Transcript Diagnostic and Statistical Manual

Diagnostic and Statistical Manual
• Encyclopedia of current
psychiatric diagnoses in the U.S.
• Published by the American
Psychiatric Association
• The latest version is the DSM-IVTR (4th edition, text revision)
DSM-IV-TR
• Ratings are made on 5 different
dimensions, called axes
– The 5 axes describe several different features
that contribute to an individual’s presentation
and broadens the clinician’s understanding of
the individual
• This multiaxial classification system was
first implemented in the DSM-III, and
continued in subsequent editions (DSM-IV
and DSM-IV-TR)
DSM-IV-TR (cont.)
• Axis I – all psychiatric diagnostic categories, except personality
disorders and mental retardation
– E.g., posttraumatic stress disorder, anorexia nervosa, schizophrenia
• Axis II – personality disorders and mental retardation
– E.g., schizoid personality disorder, antisocial personality disorder
• Axis III – medical conditions that are relevant to the psychiatric
disorder
– E.g., cancer, AIDS, diabetes mellitus
• Axis IV – psychosocial and environmental problems
– E.g., homelessness, joblessness
• Axis V – global assessment function (GAF) is a number from 1-100
that is assigned to an individual, which determines their level of
functioning and alludes to their need for treatment, level of
treatment, as well as prognosis
– The higher the number, the higher functioning the person
Axis I Disorders
• Disorders Usually First Diagnosed in Infancy,
Childhood or Adolescence
– Intellectual, emotional, social and physical disorders
that begin at or before adolescence
• E.g., separation anxiety disorder, attention
deficit/hyperactivity disorder, learning disorders
• Delirium, Dementia, Amnestic and Other
Cognitive Disorders
– Cognition is seriously disturbed
• Delirium – clouded consciousness, wandering attention,
incoherent thinking
• Dementia – deterioration of mental capacities, especially
memory
– E.g., Dementia of the Alzheimer’s Type
• Amnesia – memory impairment without delirium or dementia
Axis I Disorders (cont.)
• Substance-Related Disorders
– dependence, abuse, intoxication, withdrawal
• Alcohol, amphetamine, caffeine, cannabis, etc.
• Schizophrenia and Other Psychotic
Disorders
– loss of contact with reality, deterioration in
functioning, language and communication
disturbance, delusions and hallucinations
• E.g., schizophrenia, schizoaffective disorder,
delusional disorder
Axis I Disorders (cont.)
• Mood Disorders
– Feelings of extreme and inappropriate
sadness or euphoria for extended periods of
time.
• E.g., major depressive disorder, bipolar disorder
• Anxiety Disorder
– Characterized by irrational or excessive fear
• E.g., phobias, panic disorder, agoraphobia,
obsessive-compulsive disorder, posttraumatic
stress disorder
Axis I Disorders (cont.)
• Somatoform Disorders
– Characterized by the presence of physical symptoms
with no known physiological cause, but which seem to
serve a psychological purpose
• E.g., pain disorder, conversion disorder, hypochondriasis,
body dysmorphic disorder
• Factitious Disorders
– Complaints of physical or psychological symptoms
where it is assumed that the individual has some
psychological need to assume a sick role
• Also known as Munchausen’s syndrome
Axis I Disorders (cont.)
• Dissociative Disorders
– Memory and identity are disrupted by a sudden
alteration in consciousness.
• E.g., dissociative amnesia, dissociative fugue, dissociative
identity disorder, depersonalization disorder
• Sexual and Gender Identity Disorders
– Three subcategories
• Paraphilias – unconventional sexual gratification
– E.g., frotteurism, exhibitionism, voyeurism
• Sexual Dysfunction – problems with sexual response
– E.g., hypoactive sexual desire disorder, premature ejaculation
• Gender Identity Disorders – discomfort with sexual anatomy
and identification as the opposite sex
– Also known as transsexualism
Axis I Disorders (cont.)
• Eating Disorders
– Abnormal eating patterns that significantly impair
functioning
• E.g., anorexia nervosa, bulimia nervosa
• Sleep Disorders
– Disturbances in the amount, quality or timing of sleep;
the occurrence of unusual events during sleep
• E.g., primary insomnia, primary hypersomnia, narcolepsy,
breathing-related sleep disorder, nightmare disorder
Axis I Disorders (cont.)
• Impulse Control Disorders Not Elsewhere
Classified
– Behavior is inappropriate and seemingly out of control
• E.g., intermittent explosive disorder, kleptomania, pyromania,
pathological gambling, trichotillomania
• Adjustment Disorders
– The development of emotional or behavioral
symptoms following a major life stressor. These
symptoms do not meet criteria for another Axis I
disorder
Axis II Disorders
• Personality Disorders
– Enduring, inflexible and maladaptive patterns of
behavior and inner experience
• E.g., paranoid personality disorder, narcissistic personality
disorder, avoidant personality disorder
• Mental Retardation
– Significantly sub-average intelligence
– Onset before age 18
– Deficits or impairment in other areas of functioning
• Found in DSM-IV-TR under Disorders Usually First
Diagnosed in Infancy, Childhood or Adolescence
• But diagnosed on Axis II
More on Personality Disorders
• Why are personality disorders placed on a
separate axis?
– They tend to be egosyntonic
– Represent baseline functioning
– Tend to be chronic and stable
Issues in the Classification of
Mental Illness
• Some criticism of the (current) diagnostic system
– Doesn’t encompass the totality of a person
– Stigmatizing and degrading
– Our categorical classification system does not
consider the continuity of behavior from “normal” to
“abnormal”
– Subjective factors still play a role in making
diagnoses (what is included in the DSM and what a
clinician labels a person)
– Day-to-day interrater reliability is probably lower than
field trials
Issues in the Classification of
Mental Illness
• Value of the (current) diagnostic system
– Common language of mental health
professionals that conveys information about
an individual
– Allows professionals to search for causes and
treatments of particular disorders
– Facilitates research and adds to our body of
knowledge of psychopathology
– Interrater reliability has improved since the
DSM-III for most diagnostic categories
Clinical Assessment
• More or less formal approach to
understanding a person
• Results are used to diagnose and treat an
individual
• As clinicians and laypersons, we are
always assessing ourselves and others
• Psychologists use a variety of techniques
to assess cognitive, emotional,
personality, and behavioral variables
Clinical Assessment (cont.)
• The utility of an assessment instrument is
determined by its reliability and validity
• Reliability – how consistent is this measure?
– Some types of reliability include interrater reliability,
test-retest reliability, etc.
• Validity – does this instrument measure what it
purports to measure?
– Some types of validity include construct validity,
predictive criterion validity, etc.
Psychological Assessment
• Clinical Interviews
– Amount of structure varies by purpose,
setting, style of the interviewer
• E.g., Structured Clinical Interview for Axis I of
DSM-IV (SCID)
– Reliability and validity are good
– The more structure, the more confident an interviewer
can be about making diagnostic judgments and
comparisons with others who were given the same
structured interview
– Clinician pays attention to the process as well
as content of responses
Psychological Tests
– Standardized procedures to measure performance on
a given task
– Statistical norms are established by analyzing the
responses of many people
• Intelligence Tests
– E.g., Wechsler Adult Intelligence Scale (WAIS)
• Measures cognitive abilities
• Objective Personality Inventories
– E.g., Minnesota Multiphasic Personality Inventory-2
(MMPI-2)
• Self-report inventory that measures both personality and
psychopathology
Projective Personality Tests
– Based on hypothesis that a person “projects”
their thoughts and feelings on to an
ambiguous stimuli
• Rorschach Inkblot Test
– Subject describes what the inkblot might be, and then
provides an explanation for why s/he gave those
responses
• Thematic Apperception Test (TAT)
– Subjects tells a story about the picture
Behavioral Assessment
• Behavioral observation focuses on the situational
determinants of behavior
– Stimuli that precedes the problem
– Organismic factors (psychological and physiological) that affect
behavior
– Responses (the main focus of behavioral therapists)
– Consequences that seem to reinforce or punish the response
• Assessment is linked to intervention, with sequence of
events analyzed in terms of learning framework
• Self monitoring
– E.g., Ecological Momentary Assessment (EMA)
• Subject assesses their own behavior
• Problem with reactivity; behavior may be altered due to selfmonitoring
Cognitive Assessment
•
•
•
•
Methods tend to be theoretical and data driven
Get at thoughts that underlie behavior and
moods
Can be questionnaires, interviews, self-reports
–
E.g., Beck Depression Inventory (BDI)
Recollection of thoughts during assessment
procedure may not reflect thoughts during
event
–
Articulated Thoughts in Simulated Situations
(ATSS) avoids this problem
•
Subject reports thoughts on hypothetical situations
Biological Assessment
• Brain imaging
– Computerized Axial Tomography (CAT or CT scan), Magnetic
Response Imaging (MRI), Functional Magnetic Response
Imaging (fMRI), Positron Emission Tomography (PET scan)
• Neurochemical Assessment
– Postmortem studies look at the amounts of a neurotransmitter
found in specific brain regions
– Indirect assessment via analysis of metabolites of
neurotransmitters in bodily fluids
• Neuropsychological Assessment
– Neuropsychological tests assess behavioral disturbances
thought to arise from brain dysfunctions
• E.g., Halstead-Reitan and Luria Nebraska batteries
• Psychophysiological Measurement
– E.g., electrocardiogram (EKG), electroencephalogram (EEG)
Cultural Issues in Psychological
Assessment
• Assessment “paradigms” tend to be based on
the cultures of white, European-Americans
• Some psychological measures can be culturally
biased
• Cultural bias in psychological testing can lead to
“underpathologizing” or “overpathologizing”, as
well as the type of diagnosis given
• Differences between therapist and client in terms
of language, expression of symptoms, style of
test-taking, can effect the outcome of an
assessment
Avoiding or Minimizing Cultural
Bias in Assessment
• Assessor should learn about the cultures
of the population they work with
• Testing can be conducted in the client’s
preferred language
• Make certain that the subject understands
the assessment procedures and
instructions
• Always make sure that rapport is
established before proceeding with testing