Chapter 3: Diagnosis Flashcards
why is diagnosis important?
needed for 3rd party payments
communicate w other clinicians
helps clients understand their diagnosis and prognosis
help treatment planning
medical 203
developed by US war department; first formal classification system and became basis for DSM
DSM III
released to be compatible with ICD; 265 diagnoses, multiaxial
DSM IV
five axes
- clinical disorders
- personality disorders and mental retardation
- general medical conditions
- psychosocial and environmental factors
- global assessment of functioning
changes with DSM 5
numbers replaced roman numerals
numbers aligned with ICD 9 and 10
single axis system; combines previous axes 1, 2, and 3
expanded V code–allows one to list psychosocial and environmental stressors
ordering
first diagnosis= principal diagnosis (reason why client was referred/biggest problem)
if MH diagnosis due to medical condition, med condition is listed first
subtypes
mutually exclusive
specifiers
NOT mutually exclusive, check all that apply
provisional diagnosis types
rule out: client meets many traits but not enough to make a diagnosis at time
traits: doesn’t meet criteria BUT presents with many of features of diagnosis
by history: previous records indicate diagnosis
by self report: client claims this as a diagnosis
other specified and unspecified disorders
–used when individual’s impairment to functioning is clinically sig but doesn’t meet criteria in that category
Other specified: when clinician wants to comm why the criteria do not fit
unspecified: when clinician doesn’t wish to comm specifics
cultural formulation interview
provides an outline on how to interview clients from diverse backgrounds
mental status exam
structured assessment modeled after physician medical exams
focuses on core areas of psychiatric functioning
affect
how the client is feeling in the moment
mood
general sense of being
