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Diagnosis in the Assessment
Process
“….making diagnoses and using them
in treatment planning has become an
integral part of what all mental health
professionals do” (Neukrug & Fawcett,
2010, p. 245).
The Importance of a Diagnosis
1. Federal & state laws require that students with
severe emotional disorders be serviced in the
schools. Diagnosis helps to identify the specific
mental disorder with which a student may be
struggling and can be useful in deciding treatment
strategies.
2. A mental disorder diagnosis is usually required if
medical insurance is to reimburse for treatment.
Insurance companies will sometimes want to
monitor progress as a function of the kind of
diagnosis made.
The Importance of a Diagnosis
3. Familiarity with the wording of the DSMIV-TR has become critical to effective
communication between clinicians.
4. A definitive diagnosis that points to a
biological influence (e.g., genetics,
environmental factors such as lead paint)
can be critical for the proper treatment of an
individual.
The Importance of a Diagnosis
5. Diagnosis has become a critical aspect of
the total assessment process and can be
helpful in case conceptualization and in
treatment planning.
The DSM-IV-TR
“Diagnosis refers to the process of making an
assessment of an individual from an outside,
or objective, viewpoint” (Neukrug &
Fawcett, 2010, p. 147).
 DSM-IV-TR: Accepted diagnostic
classification system for mental disorders
developed by the American Psychiatric
Association
DSM-IV-TR: Characteristics
“The most widespread and accepted diagnostic
classification system of emotional disorders
in the world” (Neukrug & Fawcett, 2010, p.
247).
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Five axes to assist in diagnosis and treatment of
mental disorders
Many clinicians will use two or more of the axes
The five axes allow clinicians to accurately
describe their clients & communicate details
related to the client to other clinicians
DSM-IV-TR: 5 Axes
 “A diagnosis can help a clinician determine the primary
focus of counseling and assist in deciding which
interventions might be most useful” (Neukrug & Fawcett,
2010, p. 247).
1. Axis 1: Clinical disorders and other conditions that may be
a focus of clinical attention
2. Axis 2: Delineates personality disorders and mental
retardation
3. Axis 3: Explains general medical conditions
4. Axis 4: Describes psychosocial & environmental problems
5. Axis 5: Offers a global assessment of functioning
DSM-IV-TR: Usefulness
“Although all five axes can be helpful in
determining the kind of intervention and in
treatment planning, the first two axes focus
specifically on helping the clinician
determine what kind of disorder an
individual may be displaying” (Neukrug &
Fawcett, 2010, p. 247).
DSM-IV-TR: Axes 1 & 2:
Highlights
1. Each disorder listing describes:
a) The disorder’s main features
b) Subtypes and variations in client
presentations
c) The typical pattern, course, or progression
of symptoms
d) How to differentiate the disorder from other,
similar ones
DSM-IV-TR: Axes 1 & 2:
Highlights
2. Provides findings about predisposing
factors, complications, and associated
medical & counseling problems - when they
are known
3. Does not hypothesize about etiology of a
disorder when information is not known
4. Diagnoses are intended to be theory-neutral
descriptions of behavior, thoughts, mood,
physiology, functioning, and distress.
DSM-IV-TR: Axis 1 & 2: Highlights
4. Continued: Because DSM-IV-TR
categories and descriptors are designed to
be theory-neutral, clinicians are able to
apply their own theoretical orientation to
the treatment planning process
5. DSM-IV-TR offers a decision tree that
helps in distinguishing similar diagnoses
from one another
DSM-IV-TR: Axis 1 & 2:
Misconceptions
Myth: Clinicians must view all client
concerns from a very clinical,
psychopathological viewpoint.
Fact: DSM-IV-TR is used to share
information about a subset of human
experience - those conditions that meet the
“mental disorder” definition
DSM-IV-TR: Axis 1 & 2: Cultural
Issues & Mental Disorders:
Criticisms
 The DSM has been criticized as not being
cross-culturally sensitive


Minorities tend to be misdiagnosed at higher
rates than Whites
Some argue that the use of a diagnostic
criterion tends to minimize the negative
influences that external events have on clients,
such as, racism and discrimination.
DSM-IV-TR:
Addressing Cross-cultural Fairness
1. Developers made considerable effort to
address cross-cultural issues:


DSM-IV-TR notes that schizophrenia is
sometimes diagnosed instead of bipolar disorder
in non-Whites and younger clients
DSM-IV-TR notes that somatic complaints,
such as headaches among Latinos and fatigue
and weakness among Asians, are symptoms that
could be representative of depression more
frequently in these cultural groups than in others
DSM-IV-TR:
Addressing Cross-cultural Fairness
2. The DSM-IV-TR include an appendix of
culture-specific syndromes not included
elsewhere

Although these syndromes might be problematic in
the client’s culture of origin, in the U.S., these
syndromes often get misconstrued or exaggerated by
an uninformed counselor, i.e., nervios: Common
stress disorder among Latinos. Symptoms include
emotional distress, nervousness, tearfulness, and
bodily complaints
DSM-IV-TR:
Addressing Cross-cultural Fairness
3. The DSM-IV-TR addresses expected
reactions/culturally appropriate responses to
life events:

Suggests that these are usually not diagnosable
as mental disorders, even though they may
cause the client distress
• Examples include:
– Loss of a loved one
– Expected developmental experiences (adolescence)
DSM-IV-TR:
Addressing Cross-cultural Fairness
4. DSM-IV-TR pays greater attention to
differences in symptom expression as a function
of age, gender, socioeconomic status, and culture


Age: For example, major depression is associated
with increased withdrawal in children, oversleeping
in adolescents, and memory loss in older adults
Gender: For example bipolar disorders are equally
common among men & women, but major depression
is more common among women. Obsessivecompulsive disorder is more common among men
Axis 1 Disorders
“Axis 1 disorders are considered treatable and often
temporary” (Neukrug & Fawcett, 2010, p. 249).
 Generally, Axis 1 disorders are often reimbursable by
insurance companies
 Axis 1 disorders include all disorders except those
classified as personality disorders or as mental
retardation
Axis 1 Disorders
1. Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence (may sometimes be
diagnosed in adulthood)
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Learning disorders
Motor skills disorders
Communication disorders
Pervasive developmental disorders
Attention-deficit and disruptive behavior disorders
Feeding and eating disorders of infancy or early childhood
Tic disorders
Elimination disorders
Other disorders of infancy, childhood, or adolescence
Axis 1 Disorders
2. Delirium, Dementia, Amnestic, and Other Cognitive
Disorders: Represent a significant change from past
cognitive functioning of client

Caused by a medical condition or substance (drug abuse,
medication, or allergic reaction)
3. Mental Disorders Due to a General Medical Condition:
When mental disorder is the result of a medical
condition and includes personality changes and mental
disorders not otherwise specified
4. Substance-related Disorders: Disorder is a direct result
of the use of a drug or alcohol, the effects of
medication, or exposure to a toxin
Axis 1 Disorders
5. Schizophrenia and Other Psychotic Disorders:
Psychotic symptomatology is the most distinguishing
feature.
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Schizophrenia
Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
Brief psychotic disorder
Shared psychotic disorder
Psychotic disorder due to a general medical condition
Substance-induced psychotic disorder
Psychotic disorder not otherwise specified
Axis 1 Disorders
6. Mood Disorders: Mood disturbances of the
depressive, manic, or hypomanic type.

Include 5 broad categories:
•
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•
•
•
Depressive disorders
Bipolar disorders
Mood disorder due to a general medical condition
Substance-induced mood disorder
Mood disorder not otherwise specified
Axis 1 Disorders
7. Anxiety Disorders: There are many distinct types of
anxiety disorders, each with its own unique
characteristics:
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Panic disorder with or without agoraphobia
Agoraphobia without history of panic disorder
Specific phobia
Obsessive-compulsive disorder
Posttraumatic stress disorder
Acute stress disorder
Generalized anxiety disorder
Anxiety disorder due to a general medical condition
Substance-induced anxiety disorder
Anxiety disorder not otherwise specified
Axis 1 Disorders
8. Somatoform Disorders: Characterized by symptoms
that would suggest a physical cause; however, no such
cause can be found. Strong evidence exists that link
symptoms to psychological causes:
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Somatization disorder
Undifferentiated somatoform disorder
Conversion disorder
Pain disorder
Hypochondriasis
Body dysmorphic disorder
Somatoform disorder not otherwise specified
Axis 1 Disorders
9. Factitious Disorders: Intentionally feigned physical or
psychological symptoms for the purpose of assuming a
sick role:
 Two subtypes:
• Factitious disorder w/predominantly psychological signs
and symptoms
• Factitious disorder w/predominantly physical signs and
symptoms
Axis 1 Disorders
10. Dissociative Disorders: Occur when there is a
disruption of consciousness, memory, identity, or
perception of the environment:
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Dissociative amnesia
Dissociative fugue
Dissociative identity disorder (formerly called, “multiple
personality disorder”)
Depersonalization disorder
Dissociative disorder not otherwise specified
Axis 1 Disorders
11. Sexual and Gender Identity Disorders: Disorders that
focus on sexual problems or identity issues related to
sexual issues:
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Sexual dysfunctions
Paraphilias
Gender identity disorders
Sexual disorder not otherwise specified
Axis 1 Disorders
12. Eating Disorders: Focus on severe problems with the
amount of food intake by the individual that can
potentially cause serious health problems or death:
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Anorexia nervosa
Bulimia nervosa
Eating disorder not otherwise specified
Axis 1 Disorders
13. Sleep Disorders: Severe sleep-related problems:
 Four subcategories:
•
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•
•
Primary sleep disorders
Sleep disorder related to another mental condition
Sleep disorder due to a general medical condition
Substance-induced sleep disorder
Axis 1 Disorders
14. Impulse Control Disorders Not Elsewhere Classified:
Highlighted by the individual’s inability to stop himself
or herself from exhibiting certain behaviors:
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Intermittent explosive disorder
Kleptomania
Pyromania
Pathological gambling
Trichotillomania
Impulse-control disorder not otherwise specified
Axis 1 Disorders
15. Adjustment Disorders: Highlighted by emotional or
behavioral symptoms that arise in response to
psychosocial stressors.
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Probably the most common disorders clinicians see
Subtypes include:
• Adjustment disorders w/depressed mood
• Adjustment disorders w/anxiety
• Adjustment disorders w/mixed anxiety & depressed
mood
• Adjustment disorders w/disturbance of conduct
• Adjustment disorders w/mixed disturbance of emotions
& conduct
• Unspecified adjustment disorder
Axis II Disorders:
Personality Disorders & Mental Retardation
“Axis II disorders tend to be lifelong and resistant to
treatment” (Neukrug &Fawcett, 2010, p. 251).

Treatment tends to have little or no effect
 Two types of Axis II Disorders:
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Mental retardation
Personality disorders
Axis II Disorders:
Mental Retardation
Mental retardation is characterized by intellectual
functioning significantly below average (below
2nd percentile) and includes problems with
adaptive skills (daily living skills)
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Four categories of mental retardation:
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•
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Mild mental retardation (IQ of 50-55 to approximately 70)
Moderate mental retardation (IQ of 35-40 to 50-55)
Severe mental retardation (IQ of 20-25 to 35-40)
Profound mental retardation (IQ below 20 or 25)
Axis II Disorders:
Personality Disorders
Individuals with personality disorders will show
deeply ingrained, inflexible, and enduring
patterns of relating to the world that lead to
distress and impairment in functioning.
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May have difficulty understanding self & others
May be emotionally labile (changeable)
May have difficulty in relationships
May have problems with impulse control
Generally, first recognized during adolescence or
early adulthood - & may remain throughout lifetime
Axis II Disorders:
Personality Disorders
Three clusters of personality disorders:

Each cluster represents a general way of relating to the world
• Cluster A: Includes paranoid, schizoid, and schizotypal
personality disorders. Individuals exhibit characteristics
that may be considered odd or eccentric by others.
• Cluster B: Include the antisocial, borderline, histrionic,
and narcissistic personality disorders. Individuals are
generally dramatic, emotional, overly sensitive, and
erratic.
• Cluster C: Includes the avoidant, dependent, and
obsessive-compulsive personality disorders. Individuals
show anxious and fearful traits.
Axis III Disorders:
General Medical Conditions
Axis III provides the clinician the opportunity to
report relevant medical conditions of the client.
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If a medical condition is related to the cause (or
worsening) of a mental disorder, then the medical
condition is noted on Axis I & listed on Axis III.
If a medical condition is not a cause of the mental
disorder but will affect overall treatment of the
individual, then it is listed only on Axis III..
• The International Classification of Diseases, 9th revision,
is used to code the Axis III medical condition
Axis IV Disorders:
Psychosocial & Environmental Problems
Psychosocial or environmental problems that affect the
diagnosis, treatment, & prognosis of mental disorders
listed on Axis I & II.
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Generally, problems will be listed only on Axis IV
When it is believed that such stressors may be a prime cause
of the mental disorder, a reference should be made to them
on Axis I or II
Problems include problems with one’s primary support
group, problems related to the social environment,
educational problems, occupational problems, housing
problems, economic problems, problems with access to
health care services, problems related to interaction with the
legal system (crime)
Axis V Disorders:
Global Assessment of Functioning (GAF)
Axis V is a scale used by clinicians to assess a client’s
overall functioning and is based on an assessment of the
client’s psychological, social, and occupational
functioning.
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GAF scale ranges from very severe dysfunction to superior
functioning (Numeric scale ranging from 1-100)
A score of zero means there is inadequate information to make
a judgment
A clinician can report current functioning, the highest
functioning within the past year, or any other relevant GAF
ratings based on the uniqueness of the situation
Making a Diagnosis
“Making an appropriate diagnosis is critically important
because the diagnosis will affect treatment planning
and choices of psychotropic medication” (Neukrug &
Fawcett, 2010, p. 255).
 DSM-IV-TR offers decision trees to assist the clinician
in differential diagnosis

If two or more diagnoses are being considered that share
similar symptoms, the decision tree walks the clinician
through a series of steps designed to assist in choosing the
most appropriate diagnosis
 It is possible for a client to have more than one Axis I
and Axis II diagnoses (multiaxial). All diagnoses
should be reported.
The DSM-IV-TR:
One Piece of the Assessment Process
“Along with the clinical interview, the use of
tests, and informal assessment procedures,”
the DSM-IV-TR can add essential
information to the overall assessment
process (Neukrug & Fawcett, 2010, p. 255).
Scenario Time:
Applying Textbook Knowledge to Real World Situations:)
Joshua
Facts in the case:
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Joshua is 10-years-old
He is an only child
Parents have been married for 6 years
Parents have commented that Joshua has been a difficult child
since birth
Parents report that he has difficulty in school and didn’t read
until 4th grade
• Reading scores low & teacher has suggested having him tested for a
possible reading learning disability

No obvious physical problems have been found to cause his
deficiency in reading
Scenario Time:
Applying Textbook Knowledge to Real World Situations:)
Joshua, Cont’d.
 Additional Facts:
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Joshua cries easily and often “has a fit” when he has to leave home to go to
school
Plagued by nightmares, often revolving around issues of being alone or
separated from his parents
Has frequent stomach aches and has vomited at school on numerous
occasions
His anxiety and reading problems have interfered with his ability to build
friendships, and he has no close friends and few peers he relates to at
school
His parents (who are college educated) are worried that their son will not
make it through high school & are concerned about his social relationships
Global Assessment of Functioning Scale (GAF)
For those 18 years of age and older
91-100 Superior functioning in a wide rage of activities, life's problems never seem to get out of
hand, is sought out by others because of his or her many qualities. No symptoms.
90-81 Absent or minimal symptoms, good functioning in all areas, interested and involved in a wide
range or activities, socially effective, generally satisfied with life, no more than everyday
problems or concerns.
80-71 If symptoms are present they are transient and expectable reactions to psychosocial stresses;
no more than slight impairment in social, occupational, or school functioning
70-61 Some mild symptoms OR some difficulty in social, occupational, or school functioning, but
generally functioning pretty well, has some meaningful interpersonal relationships.
60-51 Moderate symptoms OR any moderate difficulty in social, occupational, or school
functioning.
50-41 Serious symptoms OR any serious impairment in social, occupational, or school functioning.
40-31 Some impairment in reality testing or communication OR major impairment in several areas,
such as work or school, family relations, judgment, thinking, or mood.
30-21 Behavior is considered influenced by delusions or hallucinations OR serious impairment in
communications or judgment OR inability to function in all areas.
20-11 Some danger or hurting self or others OR occasionally fails to maintain minimal personal
hygiene OR gross impairment in communication.
10-1 Persistent danger of severely hurting self or others OR persistent inability to maintain
minimum personal hygiene OR serious suicidal act with clear expectation of death.
Children’s Global Assessment of Functioning Scale: Ages 6-17
100-91 Superior functioning in all areas (at home, at school and with peers); involved in a wide range of activities and has many interests
(e.g., has hobbies or participates in extracurricular activities or belongs to an organized group such as Scouts, etc); likeable,
confident; ‘everyday’ worries never get out of hand; doing well in school; no symptoms.
90-81 Good functioning in all areas; secure in family, school, and with peers; there may be transient difficulties and ‘everyday’ worries
that occasionally get out of hand (e.g., mild anxiety associated with an important exam, occasional ‘blowups’ with siblings, parents
or peers).
80-71 No more than slight impairments in functioning at home, at school, or with peers; some disturbance of behavior or emotional
distress may be present in response to life stresses (e.g., parental separations, deaths, birth of a sibling), but these are brief and
interference with functioning is transient; such children are only minimally disturbing to others and are not considered deviant by
those who know them.
70-61 Some difficulty in a single area but generally functioning pretty well (e.g., sporadic or isolated antisocial acts, such as occasionally
playing hooky or petty theft; consistent minor difficulties with school work; mood changes of brief duration; fears and anxieties
which do not lead to gross avoidance behavior; self-doubts); has some meaningful interpersonal relationships; most people who do
not know the child well would not consider him/her deviant but those who do know him/her well might express concern.
60-51 Variable functioning with sporadic difficulties or symptoms in several but not all social areas; disturbance would be apparent to
those who encounter the child in a dysfunctional setting or time but not to those who see the child in other settings.
50-41 Moderate degree of interference in functioning in most social areas or severe impairment of functioning in one area, such as might
result from, for example, suicidal preoccupations and ruminations, school refusal and other forms of anxiety, obsessive rituals, major
conversion symptoms, frequent anxiety attacks, poor to inappropriate social skills, frequent episodes of aggressive or other antisocial
behavior with some preservation of meaningful social relationships.
40-31 Major impairment of functioning in several areas and unable to function in one of these areas (i.e., disturbed at home, at school,
with peers, or in society at large, e.g., persistent aggression without clear instigation; markedly withdrawn and isolated behavior due
to either mood or thought disturbance, suicidal attempts with clear lethal intent; such children are likely to require special schooling
and/or hospitalization or withdrawal from school (but this is not a sufficient criterion for inclusion in this category).
30-21 Unable to function in almost all areas e.g., stays at home, in ward, or in bed all day without taking part in social activities or severe
impairment in reality testing or serious impairment in communication (e.g., sometimes incoherent or inappropriate).
20-11 Needs considerable supervision to prevent hurting others or self (e.g., frequently violent, repeated suicide attempts) or to maintain
personal hygiene or gross impairment in all forms of communication, e.g., severe abnormalities in verbal and gestural
communication, marked social aloofness, stupor, etc.
10-1 Needs constant supervision (24-hour care) due to severely aggressive or self-destructive behavior or gross
impairment in reality testing, communication, cognition, affect or personal hygiene.
Children’s Global Assessment of Functioning
 See:
http://depts.washington.edu/washinst/Resources/CGAS/CGAS%20Index.htm
DSM-IV-TR:
Joshua’s Assessment Outcome
Joshua
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
____________
____________
____________
____________
____________
____________
DSM-IV-TR:
Joshua’s Assessment Outcome
Joshua
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Rule Out Reading Disorder
Separation Anxiety Disorder
None
Stomach Aches
Problems relating to peers at school
GAF = 61 (Current)