Download Administrative Assistant Meeting

The use of DSM-IV-TR and
ICD-9-CM/ICD-10 in
School Settings
Alvin E. House, Ph.D.
Department of Psychology
Illinois State University
Goals of presentation
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Familiarity with basic components of DSM
Goals of presentation
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Familiarity with basic components of DSM
Understanding the structure of DSM
Goals of presentation
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Familiarity with basic components of DSM
Understanding the structure of DSM
Introduction to the use of DSM
Goals of presentation

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
Familiarity with basic components of DSM
Understanding the structure of DSM
Introduction to the use of DSM
What’s not covered:
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Concerns about medical model
Problems with categorical assessment
Everything that is wrong with DSM
Goals of presentation
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What’s not covered:
When do you play at a crooked card game?
Goals of presentation
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What’s not covered:
When do you play at a crooked card game?

When it’s the only game in town.
Goals of presentation
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What’s not covered:
When do you play at a crooked card game?
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When it’s the only game in town.
DSM-IV-TR/ICD-9-CM is the only game in
town with regard to most potential sources of
“recovered funds”, “third party carriers”,
“reimbursement”, “funding”
Two metaphors for DSM-IV-TR

A house
Two metaphors for DSM-IV-TR
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A house
Oh, isn’t that a clever play on words. What,
they’re both made from trees? I had to take
the morning off for this?
Two metaphors for DSM-IV-TR

A house

“Constructed”, not “found”
Two metaphors for DSM-IV-TR

A house
 Constructed, not “found”
 Constrained by nature of phenomenon
Two metaphors for DSM-IV-TR

A house
 Constructed, not “found”
 Constrained by nature of phenomenon
 Utility rather than truth criterion for success
Two metaphors for DSM-IV-TR
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A house
A language
Two metaphors for DSM-IV-TR
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
A house
A language
used to communicate
Two metaphors for DSM-IV-TR
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
A house
A language
used to communicate
used to capture as much information about
the case as possible
Two metaphors for DSM-IV-TR
A house
 A language
used to communicate
used to capture as much information about the case
as possible
It’s less about getting the “right answer” than getting
the clearest message across

The central role played by the
examiner in DSM

You are the most important element of a
DSM-IV-TR diagnosis
The central role played by the
examiner in DSM
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DSM is at heart a tool prepared by (mostly)
physicians for the use of (mostly) other
physicians
The central role played by the
examiner in DSM
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You are the standard by which almost all
judgments are made
The central role played by the
examiner in DSM

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You are the standard by which almost all
judgments are made
Clinical judgment and responsibility are
critical factors in DSM
The central role played by the
examiner in DSM
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Sign/symptom
Syndrome
Disorder
Disease
The central role played by the
examiner in DSM
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Sign/symptom
The central role played by the
examiner in DSM

Sign/symptom

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Sign: objective manifestation of pathological
condition observed by examiner (p. 827)
Symptom: subjective manifestation of pathological
condition reported by affected individual (p. 828)
Sources of confusion
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The complexity of the subject/task
Sources of confusion
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The complexity of the subject/task
Errors in the references
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Very first case in DSM-IV-TR Case Studies shows
a diagnosis of Mental Retardation on Axis I (p. 4)
Sources of confusion
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The complexity of the subject/task
Errors in the references
Ambiguities in the document
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What counts for a “setting” (besides “school” and
“home”) for ADHD?
Sources of confusion
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The complexity of the subject/task
Errors in the references
Ambiguities in the document
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What counts for a “setting” (besides “school” and
“home”) for ADHD?
Does an Adjustment Disorder diagnosis take
precedence over a thematic NOS diagnosis?
DSM-IV-TR Multiaxial Assessment
Axis I
Clinical Syndromes
Other Conditions That May Be a Focus of
Clinical Attention
Axis II
Mental Retardation
Borderline Intellectual Functioning (not a
mental disorder)
Personality Disorders
Personality Traits
DSM-IV-TR Multiaxial Assessment
Continued
Axis III
General Medical Conditions
Axis IV
Psychosocial & Environmental Problems
Axis V
Global Assessment of Functioning (GAF)
Scale
“DSM-IV-TR diagnosis”
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___.__
Number
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The 3-5 digit number is
the ICD-9-CM code for
the condition or disorder
being recorded
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________ Disorder
Title

The condition or disorder
being recorded (title,
criterion set, other
features) is an entry from
DSM-IV-TR
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All DSM-IV-TR diagnoses
are legitimate ICD-9-CM
and ICD-10 diagnoses
DSM-IV Conceptualization of Mental
Disorder

“In DSM-IV, each of the mental disorders is
conceptualized as a clinically significant behavioral
or psychological syndrome or pattern that occurs in
an individual and that is associated with present
distress (e.g., a painful symptom) or disability (i.e.,
impairment in one or more important areas of
functioning) or with a significantly increased risk of
suffering death, pain, disability, or an important loss
of freedom.”
DMS-IV-TR, 2000, p. xxxi
DSM-IV Conceptualization of Mental
Disorder Continued
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Clinically significant
Syndrome/pattern
Occurs in an individual
Not expectable & culturally sanctioned response to
a particular event
Conflicts between individual and society are not
mental disorders, unless the deviance or conflict is a
symptom of a dysfunction in the individual
Classified disorders that people have, not people
Clinical significance
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Distress
Clinical significance
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Distress
Impairment
Clinical significance
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Distress
Impairment
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In order to reduce false positive diagnoses almost
all DSM-IV-TR diagnoses reiterate the
distress/impairment criteria for a mental disorder
Clinical significance
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Distress
Impairment
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In order to reduce false positive diagnoses almost
all DSM-IV-TR diagnoses reiterate the
distress/impairment criteria for a mental disorder
An interesting exception is one of the few criterion
changes made in the TR revision:
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Tourette’s Disorder
Use of DSM: multiple diagnoses
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DSM-IV-TR allows/encourages multiple
diagnoses when the criteria for more than
one diagnosis are met
Use of DSM: multiple diagnoses
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DSM-IV-TR allows/encourages multiple
diagnoses when the criteria for more than
one diagnosis are met; however, there are
three general exceptions to control unbridled
comorbidity
Use of DSM: multiple diagnoses
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Three general exceptions to multiple
diagnoses:
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General Medical Condition/Substance Use
Use of DSM: multiple diagnoses

Three general exceptions to multiple
diagnoses:
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General Medical Condition/Substance Use
“not due to the direct effects of a substance (e.g.,
drugs of abuse or medication) or a general
medical condition.”
Use of DSM: multiple diagnoses
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Three general exceptions to multiple
diagnoses:
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General Medical Condition/Substance Use
Associated feature of a more pervasive disorder
Use of DSM: multiple diagnoses
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Three general exceptions to multiple
diagnoses:
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General Medical Condition/Substance Use
Associated feature of a more pervasive disorder
“has never met the criteria for . . . .”
“does not meet the criteria for . . . .”
“does not occur exclusively during the course of
. . . .”
Use of DSM: multiple diagnoses
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Three general exceptions to multiple
diagnoses:
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Associated feature of a more pervasive disorder
more pervasive diagnoses usually take
precedence over more focal or narrow diagnoses
Importance of Associated Symptoms
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Associated symptoms are not part of a
disorder’s definition or criterion set, but are
common observed in the clinical presentation
Associated symptoms tell you what else a
given diagnosis will “account for”
Associated symptoms help you decide if a
single diagnosis is sufficient to explain the
features of your case or if other diagnoses
are needed
Course and Associated Symptoms
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An concurrent diagnosis of a pattern that
normally would be as associated symptom of
a more pervasive disorder, would suggest
that you had established a history of the
independent occurrence of that set of
problems
Course and Associated Symptoms
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An concurrent diagnosis of a pattern that normally would be as associated symptom
of a more pervasive disorder, would suggest that you had established a history of the
independent occurrence of that set of problems
For example, diagnosing
• Major Depressive Disorder, Single Episode
•
and
Generalized Anxiety Disorder
Would suggest you had established a history of
GAD when the Major Depressive Disorder
wasn’t present
•
Course and Associated Symptoms
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An concurrent diagnosis of a pattern that normally would be as associated
symptom of a more pervasive disorder, would suggest that you had
established a history of the independent occurrence of that set of problems
For example, diagnosing
• Major Depressive Disorder, Single
Episode
•
and
Generalized Anxiety Disorder
Or that you had made a mistake
•
Use of DSM: multiple diagnoses

Three general exceptions to multiple
diagnoses:
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Associated feature of a more pervasive disorder
more pervasive diagnoses usually take
precedence over more focal or narrow diagnoses
Conduct Disorder has precedence over ODD
Use of DSM: multiple diagnoses

Three general exceptions to multiple
diagnoses:
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Associated feature of a more pervasive disorder
more pervasive diagnoses usually take
precedence over more focal or narrow diagnoses
Conduct Disorder has precedence over ODD
Mood Disorders have precedence over Anxiety
Disorders
Use of DSM: multiple diagnoses

Three general exceptions to multiple
diagnoses:

Associated feature of a more pervasive disorder
more pervasive diagnoses usually take
precedence over more focal or narrow diagnoses
Conduct Disorder has precedence over ODD
Mood Disorders have precedence over Anxiety
Disorders
Autistic Disorder has precedence over ADHD
Use of DSM: multiple diagnoses

Three general exceptions to multiple
diagnoses:
Associated feature of a more pervasive disorder
more pervasive diagnoses usually take
precedence over more focal or narrow diagnoses
General rule: skip first chapter and diagnose from
front of text toward back
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Use of DSM: multiple diagnoses

Three general exceptions to multiple
diagnoses:
Associated feature of a more pervasive disorder
usually take precedence over more focal or
narrow diagnoses
Occasional exception to this rule: when the less
pervasive diagnosis becomes the focus of clinical
attention (when there is a specific treatment plan)
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Use of DSM: multiple diagnoses
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Three general exception of multiple
diagnoses:
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General Medical Condition/Substance Use
Associated feature of a more pervasive disorder
Boundary conditions (clinical judgment required)
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“not better accounted for by . . . .”
Use of DSM: multiple diagnoses
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With more than one diagnosis, the principal
diagnosis is the condition which leads to the
evaluation or the referral for clinical services
Use of DSM: multiple diagnoses
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With more than one diagnosis, the principal
diagnosis is the condition which leads to the
evaluation or the referral for clinical services
Unless otherwise indicated, the principal
diagnosis is the first diagnosis on Axis I
Use of DSM: multiple diagnoses
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With more than one diagnosis, the principal
diagnosis is the condition which lead to the
evaluation or the referral for clinical services
Unless otherwise indicated, the principal
diagnosis is the first diagnosis on Axis I
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Axis I: Enuresis
Axis II: Mental Retardation (reason for visit)
Use of DSM: multiple diagnoses
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With more than one diagnosis on either Axis I
or Axis II, diagnoses should be listed within
each axis in the order of clinical focus for
attention or treatment
Use of DSM: the most important
phrase in DSM
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“The essential features of . . . .”
Use of DSM: the most important
phrase in DSM
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“The essential features of . . . .”
The NOS (Not Otherwise Specified)
diagnoses have two requirements:
Use of DSM: the most important
phrase in DSM
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“The essential features of . . . .”
The NOS (Not Otherwise Specified)
diagnoses have two requirements:

The condition must meet the criteria for a “mental
disorder”
Use of DSM: the most important
phrase in DSM
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
“The essential features of . . . .”
The NOS (Not Otherwise Specified)
diagnoses have two requirements:

The condition must meet the criteria for a “mental
disorder”
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Significant function impairment
or
Significant personal distress or suffering
Use of DSM: the most important
phrase in DSM


“The essential features of . . . .”
The NOS (Not Otherwise Specified)
diagnoses have two requirements:
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
The condition must meet the criteria for a “mental
disorder”
The condition must meet the “essential features”
of the diagnosis being considered
Diagnostic Certainty
Specific Diagnosis
Meets criteria for a mental disorder?......“Yes”
Meets essential criteria for group?.........“Yes”
Meets specific criteria for diagnosis?.....“Yes”
Specific Diagnosis, Provisional
Meets criteria for a mental disorder?......“Yes”
Meets essential criteria for group?.........“Yes”
Meets specific criteria for diagnosis?.....“Not
quite”
Categorical NOS Diagnosis
Meets criteria for a mental disorder?......“Yes”
Meets essential criteria for group?.........“Yes”
Meets specific criteria for diagnosis?.....“No”
Mental Disorder NOS
Meets criteria for a mental disorder?......“Yes”
Meets essential criteria for group?.........“No”
Meets specific criteria for diagnosis?.....“No”
799.9 Diagnosis Deferred
Meets criteria for a mental disorder?......“Not
sure”
Meets essential criteria for group?.........“Not
sure”
Meets specific criteria for diagnosis?.....“No”
Use of DSM: subtypes & specifiers
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Subtypes: mutually exclusive and jointly
exhaustive subgroupings within a diagnosis
Specifiers are not mutually exclusive; provide
for more homogeneous subgroupings of
individuals who meet diagnostic criteria
Use of DSM: severity specifiers
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Severity: mild, moderate, severe
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Usually reflects the number of symptoms evident
Use of DSM: severity specifiers
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Severity: mild, moderate, severe
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Usually reflects the number of symptoms evident
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Mild: just meets or barely exceeds minimum requirement
to support diagnosis
Use of DSM: severity specifiers
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Severity: mild, moderate, severe

Usually reflects the number of symptoms evident
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Mild: just meets or barely exceeds minimum requirement
to support diagnosis

Severe: meets almost all or all diagnostic symptoms
Use of DSM: severity specifiers
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Severity: mild, moderate, severe

Usually reflects the number of symptoms evident

Mild: just meets or barely exceeds minimum requirement
to support diagnosis
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Moderate: number of symptoms intermediate between
mild and severe
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Severe: meets almost all or all diagnostic symptoms
Use of DSM: severity specifiers
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Severity: mild, moderate, severe
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Usually reflects the number of symptoms evident
For some disorders specific criteria are provided
for severity specifiers (e.g., Mental Retardation,
Conduct Disorders, Manic Episode, Major
Depressive Episode)
Use of DSM: course specifiers
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Course: (present), in partial remission, in full
remission, prior history
Use of DSM: course specifiers
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Course: (present), in partial remission, in full
remission, prior history
In general “In Partial Remission” means full
criteria were previously met and only some of
the symptoms remain currently
Use of DSM: course specifiers
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Course: (present), in partial remission, in full
remission, prior history
In general “In Partial Remission” means full
criteria were previously met and only some of
the symptoms remain currently
“In Full Remission” refers to complete
absence of any current symptoms
Use of DSM: course specifiers
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
In general “In Partial Remission” means full
criteria were previously met and only some of
the symptoms remain currently
“In Full Remission” refers to complete
absence of any current symptoms
No absolute demarcation between In Full
Remission and Recovered (when the
disorder would no longer be noted)
Use of DSM: course specifiers
Again, there are specific criteria for In Partial
Remission and In Full Remission for some
disorders (manic episode, major depressive
disorder, substance abuse)
Use of DSM: “mental disorders”
Axis I and Axis II comprise the “mental
disorders”: diagnostic categories on both
must meet the criteria for a mental disorder
(V codes and personality traits do not meet
criteria for mental disorders; these are listed
on Axis I or Axis II also)
Use of DSM: conditions that are not
“mental disorders”
Other Conditions That May Be a Focus of
Clinical Attention
316 Psychological Factor Affecting Medical
Condition
Medication-Induced Movement Disorders
995.2 Adverse Effects of Medication Not
Otherwise Specified
cont.
Use of DSM: conditions that are not
“mental disorders”
Other Conditions That May Be a Focus of
Clinical Attention
Relational Problems
Problems Related to Abuse or Neglect
Additional Conditions That May Be a Focus of
Clinical Attention
Other Conditions that May Be a Focus
of Clinical Attention
Relational Problems
V61.9 Relational Problem Related to a Mental
Disorder or General Medical Condition
V61.20 Parent-Child Relational Problem
V61.10 Partner Relational Problem
V61.8 Sibling Relational Problem
V62.81 Relational Problem Not Otherwise
Specified
Other Conditions that May Be a Focus
of Clinical Attention
Problems Related to Abuse or Neglect
V61.21 Physical Abuse of Child
965.54 focus of clinical attention is victim
V61.21 Sexual Abuse of Child
995.53 focus of clinical attention is victim
V61.21 Neglect of Child
995.52 focus of clinical attention is victim
there are also adult codes
Other Conditions that May Be a Focus
of Clinical Attention
Additional Conditions That May be a Focus of
Clinical Attention
V15.81 Noncompliance With Treatment
V65.2 Malingering
V71.01 Adult Antisocial Behavior
V71.02 Child or Adolescent Antisocial
Behavior
V62.89 Borderline Intellectual Functioning
IQ 71-84
Other Conditions that May Be a Focus
of Clinical Attention
Additional Conditions That May be a Focus of
Clinical Attention
780.9 Age-Related Cognitive Decline
V62.82 Bereavement
V62.3 Academic Problem
V62.2 Occupational Problem
313.82 Identity Problem
V62.89 Religious or Spiritual Problem
V62.4 Acculturation Problem
V62.89 Phase of Life Problem
Additional Codes
300.9
V71.09
799.9
V71.09
799.9
Unspecified Mental Disorder
No Diagnosis or Condition on Axis I
Diagnosis or Condition Deferred on
Axis I
No Diagnosis on Axis II
Diagnosis Deferred on Axis II
Use of DSM: “Disorders usually first
evident . . . .”
The first grouping of diagnoses in DSM-IV-TR
is labeled, "Disorders Usually First Evident in
Infancy, Childhood, or Adolescence." It is an
unusual grouping because it is not
thematically defined, as are most diagnostic
groupings in DSM or etiologically defined
(such as the OBS, general medical condition,
and drug categories). Caution is necessary
because:
Use of DSM: “Disorders usually first
evident . . . .”
Caution is necessary because: 1) not all
children with mental disorders have mental
disorders found in this first grouping
Use of DSM: “Disorders usually first
evident . . . .”
Caution is necessary because: 2) adults may
be diagnosed with the disorders from the first
grouping of diagnoses
Use of DSM: “Disorders usually first
evident . . . .”
Caution is necessary because: Also, there is no
clear logical or thematic sequencing of the
subsections
Finally, recall that Mental Retardation (and
Borderline Intellectual Functioning) are
diagnosed on Axis II
Most of the subsections in the first grouping of
disorders have "The essential feature(s)"
Use of DSM: “Disorders usually first
evident . . . .”
Finally, recall that Mental Retardation (and
Borderline Intellectual Functioning) are
diagnosed on Axis II
Most of the subsections in the first grouping of
disorders have "The essential feature(s)"
Use of DSM: “Disorders usually first
evident . . . .”
It is therefore useful to train yourself not to
speak or think of the first grouping as "the
child section", "the child disorders", etc.
Use of DSM: Axis III
Axis III: General Medical Conditions
Physical disorders and conditions pertinent to
understanding or managing the youth’s
situation are recorded on Axis III
May be judged to be etiologically relevant
(dementia due to brain injury) or may be
important to clinical management of case
(diabetes precluding use of food reinforcer)
Use of DSM: Axis III
Skolol (1989) discussed issue of use of Axis III
by nonmedical mental health professionals
He opined that notation on Axis III does not
indicate diagnosis was made by person
recording the multiaxial evaluation
He suggests that nonmedical clinicians indicate
the source of their information on Axis III
Use of DSM: Axis III
Best Practice Recommendation: If you indicate
an Axis III diagnosis always also indicate the
source of the information or determination
“mother reports child has juvenile onset
diabetes”
“genetic karyotype indicates trisomy 21”
“seizure disorder diagnosed by child’s
pediatrician”
Use of DSM: Axis IV
Psychosocial and Environmental Problems
problems with primary support group
problems related to social environment
educational problems
occupational problems
housing problems
economic problems
problems with access to health care services
problems related to interaction with legal system
other psychosocial and environmental problems
Use of DSM: Axis IV
Psychosocial and Environmental Problems
positive stressors are usually not listed
usually past year is reference period
may also be recorded on Axis I if focus of
clinical attention
Use of DSM: Axis V
Global Assessment of Functioning
0 - 100 rating of “overall level of functioning”
“rated with respect only to psychological, social, and
occupational [school] functioning”
usually for current period; may also be made for
other time periods (“highest level of functioning for at
least a few months during the past year”)
Use of DSM: Axis V
100-91 superior functioning
90-81 no symptoms, good functioning
80-71 transient/expected reactions; slight impairment
70-61 mild symptoms or difficulty
60-51 moderate symptoms or moderate difficulty
50-41 serious symptoms or serious impairment
40-31 impaired reality testing/comm. or major impairment in
several areas
30-21 impaired comm./judgment or inability to function
20-11 some danger to self or others or impaired hygiene
10-1 persistent danger to self or other or impaired self care or
serious suicide attempt with clear expectation of death
0 inadequate information
The process of mental health diagnosis

The fundamental questions:

What are the problems?
The process of mental health diagnosis

The fundamental questions:


What are the problems?
What are the domains involved?
The process of mental health diagnosis

The fundamental questions:


What are the problems?
What are the domains involved?
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Cognitive
Behavior
Emotion
Interpersonal
Environmental
The process of mental health diagnosis

The fundamental questions:



What are the problems?
What are the domains involved?
Is there a Mental Disorder?
The process of mental health diagnosis

The fundamental questions:



What are the problems?
What are the domains involved?
Is there a Mental Disorder?

What diagnosis best accounts for the available data?
The process of mental health diagnosis

The fundamental questions:



What are the problems?
What are the domains involved?
Is there a Mental Disorder?


What diagnosis best accounts for the available data?
Are there remaining important features of the case that
need accounting for?
The process of mental health diagnosis

The fundamental questions:



What are the problems?
What are the domains involved?
Is there a Mental Disorder?



What diagnosis best accounts for the available data?
Are there remaining important features of the case that
need accounting for?
Are there any other diagnoses that need to be made?
Ethical & Legal Issues

Mental health diagnosis using DSM-IV-TR is
a process of professional, clinical judgment.
The activity is regulated by law and by
professional practice boards within states.
Agencies, school units, and organizations
may have additional or supplemental
guidelines governing diagnostic practices but
these cannot supercede the legal statutes of
the state you practice in
Ethical & Legal Issues

Diagnostic classification can have multiple,
far ranging, and long lasting consequences
for your clients and students
Ethical & Legal Issues

Diagnostic consequences:


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

Educational (stigma, accommodation)
Vocational (ADHD and the military)
Financial (mood diagnoses and insurance)
Personal esteem and identity
Treatment
Ethical & Legal Issues

Maintain a clear definition of your
professional role: Your job is to provide
psychological services as indicated by your
client’s situation--not to obtain health care
benefits for the client or to recover fees for
your agency
Ethical & Legal Issues

We do not usually get into trouble for making
mistakes
Ethical & Legal Issues


We do not usually get into trouble for making
mistakes
We can and will get into trouble for not
playing by the rules
Ethical & Legal Issues



We do not usually get into trouble for making
mistakes
We can and will get into trouble for not
playing by the rules
Being “helpful” and fudging a diagnosis so
your client can get coverage from their health
care policy (that they are not actually entitled
to) is viewed by the insurance company as
“fraud” and treated as a crime
Ethical & Legal Issues
Base your diagnosis on your best
understanding of the data available regarding
the youth’s behavior, feelings, thoughts, and
adjustment
If new data (or further consideration) changes
your mind, change your diagnosis
Practice in this manner and you will have no
problems signing your name to your reports
Practice cases

Take a few minutes and look at the material
on the practice cases
DSM-IV ADHD
“The essential feature of AttentionDeficit/Hyperactivity Disorder is a persistent
pattern of inattention and/or hyperactivityimpulsivity that is more frequently displayed
and more severe than is typically observed in
individuals at a comparable level of
development (Criterion A)” (p.85)
A(1) 6 or more have persisted for 6 month to a degree
which is maladaptive and inconsistent with
development level
(a) Inattention details/careless errors
(b) Difficulty sustaining attention
(c) Does not seem to listen
(d) Poor follow through (not oppositional)
(e) Difficulty organizing
(f)
Dislikes/avoids tasks needing sustained effort
(g) Often loses things
(h) Easily distracted
(i)
Often forgetful
A(2)
(a) Fidgets
(b) Leaves seat
(c) Often runs/climbs inappropriately
(d) Difficulty playing quietly
(e) Often “on the go”, as if “driven by a motor”
(f) Talks excessively
(g) Blurts out answers
(h) Difficulty waiting turn
(i) Interrupts/intrudes on others
B.
C.
D.
E.
Some symptoms have caused impairment
before age 7
Some impairment from symptoms in 2 or
more settings
Clinically significant impairment in social,
academic, or occupational functioning
Does not occur exclusively during course of:



Pervasive developmental disorder
Schizophrenia
Psychotic Disorder
Not better accounted for by another Mental
Disorder
Sally
Axis I: Attention-Deficit/Hyperactivity Disorder,
Predominantly Inattentive Type








Failure to attend/careless errors
Difficulty sustaining attention
Doesn’t seem to listen
Doesn’t follow through
Difficulty organizing
Loses things
Easily distracted
Forgetful
Reading Disorder


Reading achievement below expectation
Interferes with academic achievement
[poor spelling, difficulty sounding words out,
history of speech delay, early articulation
problems]

Axis II: No Disorder on Axis II

Axis III: No medical problems reported

Axis IV: Academic problems
Problems with peer relationships

Axis V: 55-60

Axis I:






314.00 Attention-Deficit/Hyperactivity Disorder,
Predominantly Inattentive Type
315.00 Reading Disorder
Axis II: V71.09 No disorder on Axis II
Axis III: No medical problems reported
Axis IV: Academic problems
Problems with peer relationships
Axis V: Global Assessment of Functioning:
60
George
Axis I: Tourette’s Disorder











Motor and vocal tics
Two year duration
Attention-Deficit/Hyperactivity Disorder, Predominantly HyperactiveImpulsive type
Fidgets
Problems remaining seated
Climbs excessively
Difficulty engaging in quiet activities
“Driven”
Talks excessively
Blurts out answers
Difficulty awaiting turn
Interrupts others

Axis II: No Disorder on Axis II

Axis III: Treatment with CNS stimulant

Axis IV: Problems with peer relationships

Axis V: 45-60

Axis I:






307.23 Tourette’s Disorder
314.01 Attention-Deficit/Hyperactivity Disorder,
Predominantly Hyperactive-Impulsive Type
Axis II: V71.09 No disorder on Axis II
Axis III: Treatment with CNS stimulant
Axis IV: Problems with peer relationships
Axis V: Global Assessment of Functioning:
53 [45-60]
Maude
Axis I: Oppositional Defiant Disorder








Loses temper
Argues with adults
Noncompliance
Provokes others
Blames others
Easily annoyed
Angry/resentful
Vindictive

Axis II: No disorder on Axis II

Axis III: No medical problems reported

Axis IV: Problems with peer relationships
Problems with parents

Axis V: 45-60

Axis I: 313.81 Oppositional Defiant Disorder

Axis II: V71.09 No disorder on Axis II

Axis III: Problems with peer relationships
Problems with parents

Axis IV: Global Assessment of Functioning:
52 [45-60]
Lucy
Axis I: Alcohol Dependence, With
Physiological Dependence





Withdrawal
Increased drinking
Unsuccessful efforts to cut down
Great deal of time spent
Activities given up

Axis II: No disorder on Axis II

Axis III: No medical problems reported

Axis IV: Other psychosocial problems:
adjustment to adolescence and high
school

Axis V: 35-45

Axis I: 303.90 Alcohol Dependence, With
Physiological Dependence

Axis II: V71.09 No disorder on Axis II

Axis III: No medical problems reported
History of withdrawal symptoms
reported

Axis IV: Other psychological problems:
adjustment to adolescence and high
school

Axis V: Global Assessment of Functioning:
40 [35-45]
Fred
Axis I: Specific Phobia, Blood-Injury Type






Fear: marked, persistent, excessive,
unreasonable
Exposure produces anxiety response
Insight
Avoidance
Duration of avoidance 12 months
Not better accounted for
[family history of anxiety problems]

Axis II: No disorder on Axis II

Axis III: Dental problems reported

Axis IV: Problems with access to health care

Axis V: 45

Axis I: 309.29 Specific Phobia, Blood-Injury
Type

Axis II: V71.09 No disorder on Axis II

Axis III: Dental problems reported

Axis IV: Problems with access to health care

Axis V: Global Assessment of Functioning: 45
Danny
Axis I: Dysthymic Disorder






Depressed several years, without sustained relief
Low self-esteem
Feelings of hopelessness
No Major Depressive Episodes, no Manic Episodes,
no Hypomanic Episodes, not during Psychotic
disorder, not result of substance or general medical
condition
Clinically significant distress [suicidal]
Not better accounted for
History of alcohol abuse
History of cannabis abuse

Axis II: No disorder on Axis II

Axis III: No medical problems reported
[family history of mood disorder]

Axis IV: None

Axis V: 15

Axis I: 300.4 Dysthymic Disorder

Axis II: V71.09 No disorder on Axis II

Axis III: No medical problems reported
[family history of mood disorder]

Axis IV: None

Axis V: Global Assessment of Functioning:
15
Take Home Points
1)
2)
DSM-IV-TR is a categorical classification
system of mental disorders and other
clinically relevant phenomena
In DSM-IV-TR mental disorders are
recurrent patterns of behavior (syndromes)
which persist over at least minimal periods
of time and cause clinically significant
distress to the client of impairment of the
client’s adjustment and functioning
Take Home Points Continued
3)
The practicing clinician makes the
determination as to whether symptoms are
present and whether the client’s distress or
impairment meets the criterion of clinically
significant; she/he assumes primary
responsibility for these decisions and is
accorded a great deal of confidence within
this framework
Take Home Points Continued
4)
5)
DSM-IV-TR allows/encourages multiple
diagnoses in order to capture as much
information as possible about the client,
their problems, and their situation; with
certain restrictions
More pervasive diagnoses usually take
precedence over less pervasive diagnoses
a)
b)
Unless the less pervasive diagnosis is independent of
the more pervasive diagnosis
Unless, in some instance, the less pervasive diagnosis
become the focus of a treatment plan
Take Home Points Continued
6)
7)
8)
Medical and substance induced mental
disorders take precedence over other DSM
diagnoses
There are a number of issues of ambiguity
that are not resolved by the available texts
There are few “child” or “adult” specific
diagnoses and the first chapter should not
be considered the “child” section of DSM
Take Home Points Continued
9)
10)
Most specific diagnoses take precedence
over Adjustment Disorder diagnoses
(regardless of etiology); Adjustment
Disorder diagnoses (if criteria are met)
appear to take precedence of NOS
diagnoses
DSM-IV-TR allows the clinician to indicate
their level of confidence/certainty regarding
the diagnosis made
Take Home Points Continued
11)
Diagnoses should always and only be
based on your best understanding of the
data available regarding the youth’s
behavior, feelings, thoughts, and adjustment
QUESTIONS?