Week 1 DSM and Diagnosis

Question 1

WWII and the rise of contemporary diagnostic classification

Answer 1

• Vets came back from WWII with symptoms not seen before
• Veterans Affairs developed their own early categorization system to start diagnosing & treating these soldiers
  
  • Developed a military categorization system
• Had significant influence on the creation of the first DSM

Question 2

DSM 1 and DSM2

Answer 2

• Had three vague categories of disorders
  
  • Psychoses
  • euroses
  • Character disorders
• Not empirically based/scientific, instead had a strong psychoanalytic orientation
• Not lists of specific symptoms/criteria
  
  • Instead were vague one paragraph descriptions per disorder
• Low reliability because of poor inter-clinician agreement
• Number of Diagnoses
  
  • DSM I: 108
  • DSM II: 182

Question 3

Diagnostic Reliability

Answer 3

• Whether the same disorder is diagnosed every time
  
  • Inter-clinician reliability
    
    • Do different clinicians give the same diagnoses?
    • How objective (or subjective) is diagnostic criteria?
  • Test-restest reliability
    
    • Would you be able to diagnose a person again and get the same results every time?

Question 4

Diagnostic Validity

Answer 4

• Is the diagnosis criteria valid?
  
  • Does it measure a real pattern of symptoms?
  • Can effective treatment be given out based on those symptoms?
• Can bias affect validity?
  
  • Confirmation bias
    
    • psychiatrists emphasize on hints of the person’s disorder and overlook other factors
  • Fundamental Attribution Error
    
    • overattributing the cause of the disorder to any internal factors, while ignoring the external
  • Self fulfilling prophecy
    
    • once a patient gets a label, they may begin to act according to that label

Question 5

Feighner Criteria

Answer 5

• Identified specific criteria for 14 prominent diagnoses
  
  • Included schizophrenia, depression, anxiety neurosis, alcoholism
• Outlined 5 phases of diagnostic validity
  
  • Clinical description
    
    • Using many factors to paint a picture of the clinical disorder including a syndrome definition, and any demographics (race, age of onset, sex)
  • Laboratory Studies
    
    • Identify any correlations in disorders and possible biological causes (ex. chemical findings in the brain for depression)
  • Delimitation from other dx (disorders)
    
    • This involves an exclusion criteria to make sure that one disorder can’t also fit another disorder’s criteria to avoid comorbidity
  • Follow up research
    
    • Following the course of illness within a patient and assuring test-retest reliability by seeing if they still meet the original diagnosis
  • Family studies
    
    • Look for any heredity/genetic patterns in families since most psychiatric illnesses run in the family
• Huge impact with 1650 citations in 10 years (the average being less than 2 citations)

*

Question 6

DSM III

Answer 6

• Major revision
  
  • Introduced diagnostic criteria
    
    • had syndromes with specific symptom durations & specified distresses/impairments
  • Used an atheoretical category description
    
    • Meaning it did not apply to a particular theory of therapy in psychopathology, and dropped the psychoanalytic language
  • Informed on empirical data/research/field trails
  • Introduced a multiaxial assessment system
  • Used exclusionary criteria to minimize overlap between disorders (no comorbidity)
  • Introduced child specific diagnoses
• Jumped from 182 diagnoses to 265

Question 7

DSM III-R

How is it different from the DSM III?

Answer 7

• Removed many of the exclusionary criteria, and allowed for comorbidity (having more than one diagnosis)

Question 8

Multiaxial Assessment System

Answer 8

• Used in DSM III, III-R, IV, and IV-TR (not DSM 5)
• 5 axes
  
  1. Clinical Disorders
     
     • more episodic (with a beginning & and end)
     • Ex. Depression, Binge eating disorder, etc.
  2. Personality Disorders & Mental Retardation
     
     • more stable & long lasting disorders
     • Ex. Antisocial personality disorder
  3. General Medical Conditions
     
     • Ex. Cancer, Diabetes
  4. Psychosocial Stressors
     
     • Homelessness, problems at school/work
  5. Global Assessment of Functioning (GAF)
     
     • Client placed on a 100 point continuum describing overall level of functioning
       
       • 0-10 danger to yourself
       • 100 perfect, no problems

Question 9

Polythetic vs. Monothetic

approaches to diagnosis

Answer 9

• Polythetic
  
  • A lot of different ways to diagnosis
  • Ex. Having 2 out of 6 symptoms
    
    • People can experience different symptoms out of the list but still have the same diagnosis
• Monothetic
  
  • One way to diagosis
  • Everyone must be experiencing the same symptoms to get the same diagnosis

Question 10

DSM IV and DSM IV-TR

Answer 10

• Jumped from 265 to 368 disorders
• Was informed by empirical research & field tested
  
  • Improved reliability & validity
• Paid more attention to gender, race, ethnicity, and culture
• Working groups (authors of the DSM) were predominantly researchers that didn’t practice at all, so the DSM IV worked on representing different disciplines in working groups
• DSM IV-TR- what’s the difference?
  
  • Simply an update on reseach in the field

Question 11

DSM 5

Major Changes

Answer 11

• Major revision since the DSM III
• Became compatible with the ICD (International Classification of Diseases) which is used by the rest of the world
• Changed the roman numerals in order to create a modifiable “living document” (5.1, 5.2, 5.3, etc)
• Removed Multiaxial Assessment System & GAF
• Disorders with Onset in Childhood & Adolescence are no longer seperated from other disorders
  
  • Autism Spectrum Disorder
    
    • Merged all the pervasive development disorders
  • Specific Learning Disorder
    
    • Merged reading, written expression, & mathematics disorders
  • Intellectual Disabilities
    
    • Used instead of mental retardation
• Introduced a few new disorders & revised several current disorders (lowered thresholds)

Question 12

DSM 5

Major Considerations

(that didn’t make the cut)

Answer 12

• Remember these did NOT make the cut!
• More emphasis on biological bases of disorder
  
  • rejected because many disorders don’t have those biological markers like a positive/negative test
  • may become known through future research, but not clear enough yet
• More emphasis on dimensional models of disorder
  
  • Considered especially for personality disorders, but found to be too complicated and have little clinical utility so was put in emerging measures and models section
  • DSM 5 still uses a categorical model but there are specifiers such as severity levels

Question 13

DSM 5

Major Areas of Controversy

Answer 13

• Diagnostic Overexpansion
  
  • too inclusive
  • So many diagnoses still aren’t reliable
• Too opaque
  
  • authors remained vague and selective on what they shared during the process; ideas/decisions made behind closed doors
• Too empirical & elitist
  
  • authors predominantly researchers that have never been in practice
• Too eurocentric & male
  
  • Focuses on Western norms, made predominantly by White males
• Too arbitrary (random)
  
  • Categorical system creates arbitrary cutoffs for whether patients meet diagnostic criteria
  • Ex. Experienced these symptoms for 2 weeks. Why not 3?
  • • Too expensive
  • essentail reference for all mental health professionals and students
  • ICD is free online
  • Do profits influence price of the book? Do they influence decisions made creating it?

Question 14

Categorical vs. Dimensional

Approaches to diagnosis

Answer 14

• Categorical
  
  • Viewing disorders in a either you have it or you don’t way
• Dimensional
  
  • Viewing disorders on a continuum
  • Rating symptoms on a scale
  • Highly considered for personality disorders
  • Ex. Autism Spectrum Disorder

Question 15

Emerging Measure and Models section of the DSM-5

Answer 15

• Creates a “living document”
• Prompts researchers & clinicans to consider conditions that have not yet been officially included in DSM but may after more attention, be included in future editions
• Contains “proposed criteria sets” for specific new disorders that may have been proposed but were rejected to enable researchers to conduct studies on them and determine if they can make the cut one day into the DSM
• DSM 5 proposals
  
  • Attentuated Psychosis syndrome
    
    • “mild schizophrenia” which doesn’t involve losing touch with reality
  • Mixed anxiety-depressive disorder
    
    • Does not feature enough of either symptom to qualify for an existing disorder
  • Internet gaming disorder
    
    • excessive/disruptive Internet game playing

Question 16

Differential Diagnosis

Answer 16

• A method used to determine what disorder a client has
• Comparing and contrasting disorders with similar symptoms, and using a process of elimination through clinical interviews, psychological assessments, case history, etc.
• Ruling out substance related causes, medical conditions, etc. to find the primary disorder
  
  • Ex. Differential diagnosis might be depression, but with more information turns out to be bipolar disorder with a depressive episode

Question 17

Specifiers

Answer 17

• Extensions to a diagnosis that further clarify the course, severity, or special features of a disorder
• Especially used in mood disorders
• Ex. Bipolar disorder
  
  • Current or most recent episode
    
    • Specifiers: Manic, Mixed, or Major Depressive

Question 18

Diagnostic Overexpansion

Answer 18

• Diagnoses were seen as too inclusive and covered too much of normal life
• Takes any difficult life experience and labels it as a mental disorder
• Runs risk of being labeled mentally ill and misdiagnosed