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Diagnostic and Statistical Manual • Encyclopedia of current psychiatric diagnoses in the U.S. • Published by the American Psychiatric Association • The latest version is the DSM-IVTR (4th edition, text revision) DSM-IV-TR • Ratings are made on 5 different dimensions, called axes – The 5 axes describe several different features that contribute to an individual’s presentation and broadens the clinician’s understanding of the individual • This multiaxial classification system was first implemented in the DSM-III, and continued in subsequent editions (DSM-IV and DSM-IV-TR) DSM-IV-TR (cont.) • Axis I – all psychiatric diagnostic categories, except personality disorders and mental retardation – E.g., posttraumatic stress disorder, anorexia nervosa, schizophrenia • Axis II – personality disorders and mental retardation – E.g., schizoid personality disorder, antisocial personality disorder • Axis III – medical conditions that are relevant to the psychiatric disorder – E.g., cancer, AIDS, diabetes mellitus • Axis IV – psychosocial and environmental problems – E.g., homelessness, joblessness • Axis V – global assessment function (GAF) is a number from 1-100 that is assigned to an individual, which determines their level of functioning and alludes to their need for treatment, level of treatment, as well as prognosis – The higher the number, the higher functioning the person Axis I Disorders • Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence – Intellectual, emotional, social and physical disorders that begin at or before adolescence • E.g., separation anxiety disorder, attention deficit/hyperactivity disorder, learning disorders • Delirium, Dementia, Amnestic and Other Cognitive Disorders – Cognition is seriously disturbed • Delirium – clouded consciousness, wandering attention, incoherent thinking • Dementia – deterioration of mental capacities, especially memory – E.g., Dementia of the Alzheimer’s Type • Amnesia – memory impairment without delirium or dementia Axis I Disorders (cont.) • Substance-Related Disorders – dependence, abuse, intoxication, withdrawal • Alcohol, amphetamine, caffeine, cannabis, etc. • Schizophrenia and Other Psychotic Disorders – loss of contact with reality, deterioration in functioning, language and communication disturbance, delusions and hallucinations • E.g., schizophrenia, schizoaffective disorder, delusional disorder Axis I Disorders (cont.) • Mood Disorders – Feelings of extreme and inappropriate sadness or euphoria for extended periods of time. • E.g., major depressive disorder, bipolar disorder • Anxiety Disorder – Characterized by irrational or excessive fear • E.g., phobias, panic disorder, agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder Axis I Disorders (cont.) • Somatoform Disorders – Characterized by the presence of physical symptoms with no known physiological cause, but which seem to serve a psychological purpose • E.g., pain disorder, conversion disorder, hypochondriasis, body dysmorphic disorder • Factitious Disorders – Complaints of physical or psychological symptoms where it is assumed that the individual has some psychological need to assume a sick role • Also known as Munchausen’s syndrome Axis I Disorders (cont.) • Dissociative Disorders – Memory and identity are disrupted by a sudden alteration in consciousness. • E.g., dissociative amnesia, dissociative fugue, dissociative identity disorder, depersonalization disorder • Sexual and Gender Identity Disorders – Three subcategories • Paraphilias – unconventional sexual gratification – E.g., frotteurism, exhibitionism, voyeurism • Sexual Dysfunction – problems with sexual response – E.g., hypoactive sexual desire disorder, premature ejaculation • Gender Identity Disorders – discomfort with sexual anatomy and identification as the opposite sex – Also known as transsexualism Axis I Disorders (cont.) • Eating Disorders – Abnormal eating patterns that significantly impair functioning • E.g., anorexia nervosa, bulimia nervosa • Sleep Disorders – Disturbances in the amount, quality or timing of sleep; the occurrence of unusual events during sleep • E.g., primary insomnia, primary hypersomnia, narcolepsy, breathing-related sleep disorder, nightmare disorder Axis I Disorders (cont.) • Impulse Control Disorders Not Elsewhere Classified – Behavior is inappropriate and seemingly out of control • E.g., intermittent explosive disorder, kleptomania, pyromania, pathological gambling, trichotillomania • Adjustment Disorders – The development of emotional or behavioral symptoms following a major life stressor. These symptoms do not meet criteria for another Axis I disorder Axis II Disorders • Personality Disorders – Enduring, inflexible and maladaptive patterns of behavior and inner experience • E.g., paranoid personality disorder, narcissistic personality disorder, avoidant personality disorder • Mental Retardation – Significantly sub-average intelligence – Onset before age 18 – Deficits or impairment in other areas of functioning • Found in DSM-IV-TR under Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence • But diagnosed on Axis II More on Personality Disorders • Why are personality disorders placed on a separate axis? – They tend to be egosyntonic – Represent baseline functioning – Tend to be chronic and stable Issues in the Classification of Mental Illness • Some criticism of the (current) diagnostic system – Doesn’t encompass the totality of a person – Stigmatizing and degrading – Our categorical classification system does not consider the continuity of behavior from “normal” to “abnormal” – Subjective factors still play a role in making diagnoses (what is included in the DSM and what a clinician labels a person) – Day-to-day interrater reliability is probably lower than field trials Issues in the Classification of Mental Illness • Value of the (current) diagnostic system – Common language of mental health professionals that conveys information about an individual – Allows professionals to search for causes and treatments of particular disorders – Facilitates research and adds to our body of knowledge of psychopathology – Interrater reliability has improved since the DSM-III for most diagnostic categories Clinical Assessment • More or less formal approach to understanding a person • Results are used to diagnose and treat an individual • As clinicians and laypersons, we are always assessing ourselves and others • Psychologists use a variety of techniques to assess cognitive, emotional, personality, and behavioral variables Clinical Assessment (cont.) • The utility of an assessment instrument is determined by its reliability and validity • Reliability – how consistent is this measure? – Some types of reliability include interrater reliability, test-retest reliability, etc. • Validity – does this instrument measure what it purports to measure? – Some types of validity include construct validity, predictive criterion validity, etc. Psychological Assessment • Clinical Interviews – Amount of structure varies by purpose, setting, style of the interviewer • E.g., Structured Clinical Interview for Axis I of DSM-IV (SCID) – Reliability and validity are good – The more structure, the more confident an interviewer can be about making diagnostic judgments and comparisons with others who were given the same structured interview – Clinician pays attention to the process as well as content of responses Psychological Tests – Standardized procedures to measure performance on a given task – Statistical norms are established by analyzing the responses of many people • Intelligence Tests – E.g., Wechsler Adult Intelligence Scale (WAIS) • Measures cognitive abilities • Objective Personality Inventories – E.g., Minnesota Multiphasic Personality Inventory-2 (MMPI-2) • Self-report inventory that measures both personality and psychopathology Projective Personality Tests – Based on hypothesis that a person “projects” their thoughts and feelings on to an ambiguous stimuli • Rorschach Inkblot Test – Subject describes what the inkblot might be, and then provides an explanation for why s/he gave those responses • Thematic Apperception Test (TAT) – Subjects tells a story about the picture Behavioral Assessment • Behavioral observation focuses on the situational determinants of behavior – Stimuli that precedes the problem – Organismic factors (psychological and physiological) that affect behavior – Responses (the main focus of behavioral therapists) – Consequences that seem to reinforce or punish the response • Assessment is linked to intervention, with sequence of events analyzed in terms of learning framework • Self monitoring – E.g., Ecological Momentary Assessment (EMA) • Subject assesses their own behavior • Problem with reactivity; behavior may be altered due to selfmonitoring Cognitive Assessment • • • • Methods tend to be theoretical and data driven Get at thoughts that underlie behavior and moods Can be questionnaires, interviews, self-reports – E.g., Beck Depression Inventory (BDI) Recollection of thoughts during assessment procedure may not reflect thoughts during event – Articulated Thoughts in Simulated Situations (ATSS) avoids this problem • Subject reports thoughts on hypothetical situations Biological Assessment • Brain imaging – Computerized Axial Tomography (CAT or CT scan), Magnetic Response Imaging (MRI), Functional Magnetic Response Imaging (fMRI), Positron Emission Tomography (PET scan) • Neurochemical Assessment – Postmortem studies look at the amounts of a neurotransmitter found in specific brain regions – Indirect assessment via analysis of metabolites of neurotransmitters in bodily fluids • Neuropsychological Assessment – Neuropsychological tests assess behavioral disturbances thought to arise from brain dysfunctions • E.g., Halstead-Reitan and Luria Nebraska batteries • Psychophysiological Measurement – E.g., electrocardiogram (EKG), electroencephalogram (EEG) Cultural Issues in Psychological Assessment • Assessment “paradigms” tend to be based on the cultures of white, European-Americans • Some psychological measures can be culturally biased • Cultural bias in psychological testing can lead to “underpathologizing” or “overpathologizing”, as well as the type of diagnosis given • Differences between therapist and client in terms of language, expression of symptoms, style of test-taking, can effect the outcome of an assessment Avoiding or Minimizing Cultural Bias in Assessment • Assessor should learn about the cultures of the population they work with • Testing can be conducted in the client’s preferred language • Make certain that the subject understands the assessment procedures and instructions • Always make sure that rapport is established before proceeding with testing