Lesson 4 - Assessment and the DSM-V

Diagnosis and the DSM (DSM-V)

Diagnosis (the identification of a disease from a collection of signs and symptoms) is dependent on classification. If a friend told you that a yellow rose had bloomed in his garden the other day, you would have an accurate idea of what that rose looked like - not because you actually saw the rose, but from your knowledge of the categorization of roses. With abnormal behaviour, classification involves the description of various types or groups of maladaptive behaviour. Classification is based on generalizations formed from observations. Even with the best observations, generalizations include biases and inferences and may exclude cultural variations. To illustrate, a Native American hears the voice of a recently deceased loved one calling from the grave. He or she may view this experience as normal, but a person of European descent may label this an auditory hallucination.

Gender bias may also be prevalent in the classification done by clinicians. In one study where men and women displayed the same behaviour, clinicians were more likely to diagnose the women with histrionic personality disorder and the men with anti-social personality disorder (Ford and Widiger, 1989). Psychology is not an exact science!

Diagnosis in North America is guided by the Diagnostic and Statistical Manual (DSM). The DSM has been revised many times. The original DSM, inspired by Kraepelin of the late nineteenth century, was published in 1952 by the American Psychiatric Association (APA). With each revision of this classification manual, changes are made that impact the way disorders are classified and diagnosed. The manual covers all mental health disorders for both children and adults.  It also lists known causes of these disorders, statistics in terms of gender, age at onset, and prognosis as well as some research concerning the optimal treatment approaches. The latest version of this manual DSM-V was released in 2013.  Any classification system has benefits and limitations, however, and health care practitioners must keep this in mind.

 

One of the limitations of the DSM classification system is the simplification of the definition of each type of illness. Mental illness is rarely simple and whether a person has an illness will establish whether (and how) he or she is treated. This is particularly important because with some diagnoses medication is prescribed, and the classification will determine which class of drugs will be used to treat the illness. For example, antidepressants are often used for depression, and tranquilizers are used to treat schizophrenia. An incorrect diagnosis in this example means that the incorrect medication is prescribed, which could do more harm than good. Also, diagnosis essentially labels a person. Labelling, as noted previously, can be extremely damaging. Labels describe the behaviour of a person – but not the actual “person” in his or her entirety. Note the following example, recounted by Carson, Butcher, and Coleman (1988), of how damaging a label can be.

On a more positive note, with a widely used classification system such as the DSM, individuals with observable sets of symptoms are more likely to receive the same diagnosis across the world and, thus, receive similar treatment. Despite the creation of distinct criteria for each disorder, however, diagnosis is not a clear-cut process. Mental illness may not always present itself consistently throughout the world, and the boundary between normal and abnormal is not always clear.

The DSM, based on descriptions of syndromes, identifies certain critical characteristics of a disorder that have to be met for a diagnosis to be made. The DSM also allows for some non-essential variations. For instance, in the classification of depression, five symptoms must be present, but there are nine symptoms that may be present at once. The DSM details major features of disorders, descriptions of accompanying features, and an account of the onset, course, prevalence, and sex ratio of each disorder. The manual is composed of three main components to assist the clinician: the diagnostic classification, the diagnostic criteria sets, and the descriptive text.

The first component, diagnostic classification, is the list of the mental disorders that are part of the DSM system. Forming a DSM diagnosis involves the selecting of those disorders from the classification that best reflect the signs and symptoms of the patient. The second component, diagnostic criteria, refers to the symptoms that must be present (and for how long) as well as those symptoms that must not be present for an individual to qualify for a specific diagnosis. These diagnostic criteria are useful in that they provide a concise description and summary of each disorder. The last component is the descriptive text associated with each disorder. The descriptive text guides the clinician by systematically describing each disorder under a variety of headings (e.g., diagnostic features, subtypes and/or specifiers, specific culture, age, gender features, and familial pattern).

With each revision of the DSM, clarity was added and validity and reliability were improved. For instance, in the third version of the manual, clinicians were encouraged to consider a wide range of dimensions in forming their assessment. This is referred to as a multiaxial assessment, which allows an individual to be evaluated on five different axes. The first three axes rate the individual’s present condition. The last two axes provide a broader assessment of the specific situation of the individual, one dealing with the stressors that may have contributed to the current illness, and the other dealing with how well the individual has been coping in recent months. Please refer to the table 1, below for a description of each axis.

Table 1:  Multiaxial Assessment

Axis I: Clinical Syndromes	The clinician checks for the presence or absence of most clinical syndromes (including schizophrenia, mood, anxiety, eating, and sexual disorders).
Axis II: Developmental and Personality Disorders	The clinician looks for the presence or absence of stable, long-term conditions including personality disorders and learning disabilities.
Axis III: Physical Conditions	Relevant information is gathered regarding the individual’s physical health (e.g., presence or absence of a brain tumor).
Axis IV: Psychosocial Stressors	Information regarding psychosocial and environmental problems is obtained. (E.g., a depressed person may find it difficult to recover if he or she does not have supportive friends or family.)
Axis V: Global Assessment of Functioning (GAF)	The clinician rates an individual’s global level of functioning (psychological, social, and occupational) using a scale from 1 to 100. A score of one indicates persistent violence, suicidal behaviour, or inability to maintain personal hygiene. A score of 100 means the person is symptom-free.

Axis IV and Axis V were added to the third version of the DSM and have the benefit of providing a framework for assessing a person’s life situation and coping skills. Please see table 2 below which highlights Axis IV, and table 3, which describes Axis V (adapted from DSM-III-R).

Table 2: Axis IV scale for rating severity of psychosocial stressors

Code	Term	Adult Examples	Child or Adolescent Example
1	None	No apparent psychosocial stressor or enduring                               circumstances	No apparent psychosocial stressor or enduring                           circumstances
2	Mild	Broke up with boyfriend or girlfriend, or child left home; family arguments or job dissatisfaction	Expelled from school or birth of a sibling; chronic parental discord or disabling illness in parent
3	Moderate	Marriage or marital separation or loss of job; marital discord or serious financial problems	Expelled from school or birth of a sibling; chronic parental discord or disabling illness in parent
4	Severe	Divorce or birth of a child; unemployment or poverty	Divorce of parents or unwanted pregnancy; harsh or rejecting parents or multiple foster home placement
5	Extreme	Death of spouse or serious physical illness diagnosed; victim of rape; ongoing physical or sexual abuse	Sexual or physical abuse or death of a parent; recurrent sexual or physical abuse
6	Catastrophic	Death of a child, suicide of spouse; hostage or concentration camp experience	Death of both parents; chronic life threatening illness
0	Inadequate Information or no change in condition

Table 3: Axis V scale for rating global assessment of functioning

Code	Description	Example
90	Good in all areas	Social, occupational (or school), and psychological functioning is without notable problems. Absent or minimal symptoms.
80	Slight impairment only	Temporary inefficiency in occupation or school work. If symptoms present, they are transient and normal for stressors experienced.
70	Some difficulty	Despite acceptable overall functioning, person has some problem in social, occupational, or school sphere. Retains some meaningful interpersonal relationships. If present, symptoms are mild.
60	Moderate difficulty	Social, occupational, or school functioning moderately disrupted, or symptoms of moderate severity, such as occasional panic attacks.
50	Serious difficulty	Any serious impairment in social, occupational, or school functioning, or serious symptoms such as suicidal ideation or severe compulsive rituals.
40	Major Impairments	Person shows major impairment in several areas such as work or school, family relationships, judgement, thinking, or mood, or some impairment of reality testing or communication.
30	Unable to function	Inability to manage in almost all areas; or behaviour considerably influenced by delusions or hallucinations; or seriously impaired judgment or communication.
20	Some danger	Person’s clinical status judged to be of some danger to self or others; or some failure to maintain minimal standards of personal hygiene; or gross communication impairment.
10	Persistent danger	Person judged to be a persistent danger to self or others; or inability to maintain minimal standards of hygiene; or recent serious suicidal act having clear expectation of death.

To illustrate multiaxial assessment, we can use Trish as an example. Trish is a rather dependent person. She works for a company that just hired an overbearing and authoritarian administrator. As a result of the harsh management practices, Trish has become anxious at work and has experienced an increase in blood pressure. Trish’s diagnosis might be as follows:

Axis I: The patient displays general anxiety disorder and has psychological factors that affect her physical condition. Axis II: The patient has dependent personality disorder. Axis III: The patient has hypertension. Axis IV: Level of psychosocial stressors ranks at two (mild). Axis V: Global functioning ranks at 60 (moderate difficulty).

A more detailed example of multiaxial assessment, summarized from the DSM-III-R Case Book, is presented in the following Case Study. The first part is a description of the patient, and the second part includes a discussion of the diagnosis made by the clinician.