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-IV- TR (4 th 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 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 self- monitoring

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