DSMIVTR

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DSM-IV-TR
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Review Operationalizing mental illness

• Why do we need diagnoses?
• Nomenclature
• Consensus
• Communication
• Organization
• Research
• Treatment

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Operationalizing mental illness

• Two Goals
• Objectivity - Must use observable phenomenon
• Physical symptoms
• Psychological symptoms
• Mood
• Behavior
• Measurability
• Validity
• Reliability

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Reliability and Validity

• Reliability
• Interrater
• Test-retest
• Validity
• Criterion
• Concurrent
• Predictive
• Construct
• Convergent
• Discriminant

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Have we been able to operationalize mental
disorders?

• Diagnostic and Statistical Manual of Mental
  Disorders, Fourth Edition, Text Revision
  (DSM-IV-TR)
• Published by the American Psychiatric Association
• Primarily used in the United States
• Includes information only on mental illnesses
• Classifies mental illnesses into different types
  of disorders (Mood disorders, psychotic
  disorders, eating disorders, etc.)
• International Classification of Diseases (ICD)
• Created by the World Health Organization
• Used throughout the rest of the world
• Includes information on both mental and physical
  illnesses

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What is the DSM-IV-TR?

• Contains
• Does not contain

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Multiaxial Classification

• Axis I
• Axis II
• Axis III
• Axis IV
• Axis V

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Assumptions of the DSM

• Each diagnosis is unique and distinct
• Homogeneity
• Sensitivity
• Specificity

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Types of Error
Does the person have the disorder?
YES
NO
False Positive Type I Error
YES
True Positive
Does the criteria identify the person as having
the disorder?
False Negative Type II Error
NO
True Negative
Which type of error is more acceptable in
medicine?
What about in psychology?
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Sensitivity vs. Specificity
Does the person have the disorder?
YES
NO
YES
True Positive
False Positive
Do the criteria identify the person as having the
disorder?
NO
False Negative
True Negative
Sensitivity
Specificity
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Sensitivity vs. Specificity
True Positives True
Positives False Negatives
Sensitivity

True Negatives True
Negatives False Positives
Specificity

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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

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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

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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

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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 cultural
  differences in presentation of symptoms

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Evaluation of the DSM-IV-TR

• Is each diagnosis unique and distinct???
• Fluidity of diagnoses
• Comorbidity
• Two or more disorders occurring in the same
  individual
• Disorders co-occur at rates greater than expected
  by chance alone

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Evaluation of the DSM-IV-TR

• Homogeneity Do all people with the disorder
  have similar symptoms, follow a similar course,
  etc?

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Evaluation of the DSM-IV-TR

• Specificity and Sensitivity Can we use these
  definitions to distinguish between people who do
  and do not have the disorder?

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Possible Alternatives

• Categorical vs. Dimensional System
• Categorical
• DSM uses a categorical system of diagnoses that
  assumes disorders are unique and discrete
• Dimensional
• A dimensional model suggests that disorders may
  be points on a continuum (or multiple continua).
  For example, researchers suggest that there may
  be an underlying factor connecting all the
  Internalizing disorders (depression, anxiety,
  etc.) and similarly, all the Externalizing
  disorders (antisocial personality disorder,
  substance use disorders, etc.).

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Assessment

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Types of Assessments

• Mental Status Examination
• Medical/Neurological Examinations
• Neuropsychological Assessment
• Clinical Interview
• Objective Tests
• Projective Tests

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Trust and Rapport

• Why is trust/rapport important?
• Clients should understand the underlying
  rationale of the assessment
• Confidentiality
• Motivation of client for being assessed
• Importance of providing feedback to client
• Assessment can work as therapy

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Mental Status Examination

• Used primarily with the psychological functioning
  of the person is unknown
• MSE assesses
• Orientation x3
• Level of Consciousness
• Appearance
• Behavior
• Affect
• Speech
• Thought Process
• Thought Content
• Perception (sensations)
• Memory
• Judgment/Insight
• Motor activity/Gait

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Medical/Neurological Examinations

• General Physical Examination
• Used when presenting problems include physical
  symptoms/ consequences
• Used when physical causes need to be ruled out
• Neurological Examination
• Anatomical
• CAT scan
• MRI
• Functional
• fMRI
• PET scan

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Neuropsychological Examination

• Used to identify behavioral or cognitive
  impairments that are due to brain pathology
• Can identify neurological impairments before the
  brain pathology is identified
• NP Exams Assess
• Orientation x3
• Ability to recognize and produce words
• Memory tasks
• Sequencing
• Verbal, Mathematical, and Spatial abilities
• Large motor movements
• Small motor movements

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Clinical Interviews

• Used to assess the person holistically in the
  context of their social environment
• Best practice get corroborating information
• Structured Interviews
• Unstructured Interviews

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Clinical Interview

• Presenting Concern/Symptoms
• Social Context
• Personality Factors
• Family History
• Cognitive Functioning
• Medical Conditions/Medications/Substance Use
• Previous Counseling
• Suicide

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Clinical Observation of Behavior

• Used to gain more objective information about the
  person
• Direct Observation by Clinician
• Subjective Assessment by the Client

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Objective Tests

• Used to gain information that is free from bias
• Questionnaires, self-report, forced choice,
  problem solving
• Surprisingly, can be more precise and reliable
  than interviews or some observational techniques
• The value of the test almost invariably depends
  on the interpretation and the competence of the
  interpreter

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Objective Testing

• Intelligence Tests
• Personality
• Interests
• Symptoms

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Advantages and Limitations to Objective
Personality Tests

• Advantages
• Disadvantages

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Projective Personality Tests

• Used to assess conflicts that are trapped in the
  unconscious
• Interpretation of these tests in generally
  subjective, unreliable, and difficult to validate
• Administering and scoring these tests is
  frequently time consuming and requires advanced
  skills
• Look for patterns of answers

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Impact of Professional Orientation

• Psychiatrists are biologically oriented
  practitioners
• Psychoanalytically oriented clinicians may use
  unstructured assessment methods and projective
  tests
• Behaviorally oriented clinicians tend to focus on
  the assessment of behaviors and their antecedents
  and consequences
• Cognitive oriented clinicians may use interview
  techniques to uncover blocked or distorted
  thoughts
• Interpersonally oriented clinicians may use
  behavioral observations to identify problematic
  relationships