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Abnormality: Past & Present
Dr Paul F Hard
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Why a Psychiatric Diagnosis?

Define clinical entities so that clinicians
have the same understanding of the
disorder, which generally has similar:
 Symptoms
 Natural history: onset, prognosis, complications
 Etiology: origins
 Pathogenesis: course of development
• Determine treatment
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How was the DSM developed?

DSM-I (1952)
– Created around the same time as ICD-6
– Purpose: “create a classification that was a
consensus of contemporary thinking”
– Diagnoses were created by committees and
revised by 10% of the members of the American
Psychological Association
– Included approximately 60 disorders
– Definitions were vague, wordy descriptions
– Based on psychoanalytic theory
How was the DSM developed?

DSM-II (1968)
– Created around the same time as ICD-8
– Purpose: “created to promote international
consensus in the realm of mental health”
– Similar to DSM-I in terms of its development
and the presentation of disorders
– 180 disorders were included
– Homosexuality was included as a
psychological diagnosis
How was the DSM developed?

DSM-III (1980) & DSM-III-R (1987):
– First attempt to use research in the
development of diagnostic categories, but still
mostly based on clinical judgment
– Definitions were changed to be more specific
– Both inclusion and exclusion criteria
– Homosexuality no longer considered a mental
disorder
How was the DSM developed?

DSM-IV (1994) & DSM-IV-TR (2000):
– Attempted to systematize the way diagnostic
criteria are developed
– 175 psychologists did literature reviews of the
research on each diagnosis
– Field trials were conducted that tested the
reliability of the diagnoses
– There is still the criticism that the diagnoses
are based on the clinical judgment of a few
psychologists in the individual field
– Added Culture Bound Syndromes to address
Why a Multi-axial Diagnosis?
Originally proposed in 1947 and incorporated into DSM in 1980

Clarify the complexities and relationships
of bio-psychosocial difficulties

Facilitate treatment planning

Distinguish between long term chronic and
stable Axis II disorders and more treatable
Axis I disorders
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Why a Multi-axial Diagnosis?

Shorthand communication between
clinicians

Attempts to assess the multiple factors
contributing to the source and treatment of
the disorder
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What Are the Five Axes?

Axis I: Clinical syndromes (mental
disorders); developmental disorders; other
conditions that may be a focus of clinical
attention

Axis II: Personality disorders and traits;
mental retardation
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What Are the Five Axes?

Axis III: General medical conditions or
symptoms that pertain to current problems

Axis IV: Psychosocial and environmental
problems

Axis V: Global Assessment of
Functioning (GAF)
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Example of Multi-axial Diagnosis

Axis I: Major Depressive Disorder,
Recurrent, Severe without
Psychotic Symptoms

Axis II: None

Axis III: Multiple Sclerosis, progressive
relapsing, remitting
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Example of Multiaxial Diagnosis

Axis IV: Occupational, acute – loss of
employment due to Axis III
Diagnosis
Primary support group, acute –
marital separation
• Axis V: GAF present: 45
Highest in last 12 months: 75
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Axis I
Disorders usually first diagnosed in
infancy, childhood, or adolescence
 Delirium, dementia, amnestic and other
cognitive disorders
 Mental disorders due to a general medical
condition
 Substance related disorders
 Schizophrenia and other psychotic
disorders

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Axis I

Mood disorders

Anxiety disorders

Somatoform disorders

Factitious disorders

Dissociative disorders
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Axis I

Sexual and gender identity disorders

Eating disorders

Sleep disorders

Impulse control disorders

Adjustment disorders
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Axis II

Paranoid Personality Disorder

Schizoid Personality Disorder

Schizotypal Personality Disorder

Antisocial Personality Disorder
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Axis II

Borderline Personality Disorder

Histrionic Personality Disorder

Narcissistic Personality Disorder

Avoidant Personality Disorder
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Axis II

Dependent Personality Disorder

Obsessive-Compulsive Personality Disorder

Personality Disorder, Not Otherwise Specified
(NOS)

Mental Retardation
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Axis III

Infectious and parasitic diseases

Neoplasm

Endocrine, nutritional, metabolic diseases

Immunity disorders

Diseases of the blood and blood forming organs
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Axis III

Diseases of the nervous system and sense
organs

Diseases of the circulatory system

Diseases of the respiratory system

Diseases of the digestive system
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Axis III

Diseases of the genitourinary system

Complications of pregnancy, childbirth and postpartum

Diseases of the skin and subcutaneous tissue

Diseases of the muscular-skeletal system and
connective tissue
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Axis III

Congenital anomalies

Certain conditions originating in the
perinatal period

Symptoms, signs and ill-defined
conditions, injury and poisoning
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Axis IV
Psychosocial and environmental problems

Problems with primary support group

Problems related to the social environment

Educational problems

Occupational problems
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Axis IV

Housing problems

Economic problems

Problems with access to health care services

Legal problems

Other psychosocial or environmental stress
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Axis V
Global Assessment of Functioning (GAF)

Why use the Axis V rating?
• Indicates client’s current OVERALL level of
social, psychological and occupational
functioning
• Does not include physical functioning and
limitations reported in Axis III
• Ascertains level of functioning in the present
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Axis V
Global Assessment of Functioning (GAF)
•
Along with Axis I, helps clinicians decide
on any immediate actions
•
Usually includes highest level of
functioning in the last 12 months to help
with prognosis issues
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The Subsections of Each DSM
Grouping of Disorders

Listing of all disorders in the group

Organization listing of the disorder section

Coding guidelines

Episode or disorder

Specifiers for coding
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Organization of One Disorder
Features
 Associated features and disorders
 Associated laboratory findings
 Culture, age and gender features
 Course of the disorder
 Prevalence of the disorder
 Differential diagnosis guidelines
 Criteria for episode or disorder

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Mood Disorders

Prevalence:
– During a six month period, 6% of the
population have a diagnosis of a mood
disorder.
– Major depressive disorder and dysthymia
affect 3% of the population.
– The actual percentages vary depending on
each survey. These seem to be accepted
numbers at present, although may believe that
numbers are higher due to undiagnosed cases.
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Mood Disorders
– There is also agreement that depression is
twice as high in women, greater in young
adults and that the overall rate of depression is
increasing.
– There is a high probability of relapse in the
future.
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Where to Get More Information

See the bibliography at the end of Module Two.

Websites:
www.samhsa.gov
www.nattc.org
www.kenminkoff.com
www.nami.org
http://faculty.washington.edu/linehan
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