DIAGNOSIS AND

ASSESSMENT
LAWRENCE D. BALANA
 DIAGNOSIS
1. the process of identifying and determining the nature of a disease or
disorder by its signs and symptoms, through the use of assessment
techniques (e.g., tests and examinations) and other available evidence.
2. the classification of individuals on the basis of a disease, disorder,
abnormality, or set of characteristics. Psychological diagnoses have been
codified for professional use, notably in the DSM–IV–TR and DSM–5.
3. the decision or statement itself that results from this process or
classification as in “She was given a diagnosis of schizoaffective disorder.”
 Advantages of Diagnosis

1. Facilitates communication among professionals

2. Advances the search for causes and treatments
3. Cornerstone of clinical care
 Brief History of DSM
• 1939- WHO added mental disorders to the ICD
• 1952- DSM was published
• 1969- DSM II
• 1980- DSM III
• 1987- DSM III-R
• 1988- DSM IV
• 2000- DSM IV-TR
• 2013- DSM V
DSM-IV-TR: Diagnostic System
 DSM-IV-TR: Diagnostic System
• Modeled on the International Classification of Diseases (9th
edition, 1978), developed by the World Health Organization and
modified for use in the United States (ICD–9–CM), but it contains
greater detail as well as a method of coding on different axes.

• Over that period, the number of identified disorders increased

from about 100 to more than 300.
 Multiaxial Classification

•A system of classifying mental disorders

according to several categories of factors (e.g.,
Social and cultural influences) as well as
clinical symptoms.
 Five Axes of DSM-IV

I- All diagnostic except personality disorders and mental

retardation
II- Personality disorders and mental retardation
III- General medical conditions
IV- Psychosocial and environmental problems
V- Global assessment of functioning scale (GAF)
 AXIS I
All diagnostic except personality disorders and
mental retardation
• Disorders Usually Diagnosed in Infancy, • Somatoform Disorders
Childhood or Adolescence • Factitious Disorders
• Delirium, Dementia and Amnestic and Other • Dissociative Disorders
Cognitive Disorders
• Sexual and Gender Identity Disorders
• Mental Disorders Due to a General Medical
Condition • Eating Disorders
• Substance-Related Disorders • Sleep Disorders
• Schizophrenia and Other Psychotic Disorders • Impulse-Control Disorders Not Else Classified
• Mood Disorders • Adjustment Disorders
• Anxiety Disorders • Other Conditions That May Be a Focus of Clinical
Attention
 AXIS II
Personality disorders and mental retardation

• Paranoid Personality Disorder • Avoidant Personality Disorder

• Schizoid Personality Disorder • Dependent Personality Disorder
• Schizotypal Personality Disorder • Obsessive-Compulsive Personality
• Antisocial Personality Disorder Disorder

• Borderline Personality Disorder • Personality Disorder Not Otherwise

Specified
• Histrionic Personality Disorder
• Mental Retardation
• Narcissistic Personality Disorder
 AXIS III
General Medical Conditions

A general medical condition is a physical problem that can potentially influence

your client's mental illness. General medical conditions may be relevant to
understanding and treating your client's mental disorder. There are three ways
that you can view general medical conditions:
1. They are directly related to your client's mental health problems.
2. They are important in creating a comprehensive diagnosis of the client.
3. There is not a significant relationship between the general medical condition
and the client's mental health problems.
 AXIS III
General Medical Conditions
• Imagine that a client comes into your office experiencing symptoms
of depression. After continuing your conversation, you find out that
the client's depressive symptoms started right after the client was
diagnosed with lung cancer.
•A review of the client's medical records also reveals that the client
has asthma. Assume that you determined that the cancer is the cause
of the client's depression.
• You decide that you should address the client's emotions
surrounding his cancer diagnosis in your sessions. Like all general
medical conditions, the client's cancer diagnosis would be recorded
on Axis III.
 AXIS III
General Medical Conditions
• Whenever you determine that a mental disorder is a direct
consequence of a general medical condition, you must record it as an
Axis I diagnosis of a mental disorder, due to a general medical
condition' and record the general medical condition on Axis III.
• In the example above, it was determined that the lung cancer was the
cause of the client's depression. Therefore, a diagnosis of 'mood
disorder due to lung cancer, with depressive features' goes on Axis I.
Lung cancer is listed again on Axis III.
 AXIS IV
Psychosocial and environmental problems
Used to describe psychosocial and environmental factors affecting the person. Factors which
might have been included here were:
• Problems with a primary support group
• Problems related to the social environment
• Educational problems
• Occupational problems
• Housing problems
• Economic problems
• Problems with access to health care services
• Problems related to interaction with the legal system/crime
• Other psychosocial and environmental problems
Axis V was a rating scale called the Global Assessment of Functioning; the GAF went from 0 to
100 and provided a way to summarize in a single number just how well the person was
functioning overall. A general outline of this scale would be as follows:

100: No symptoms
90: Minimal symptoms with good functioning
80: Transient symptoms that are expected reactions to psychosocial stressors
70: Mild symptoms or some difficulty in social occupational or school functioning
60: Moderate symptoms or moderate difficulty in social, occupation or school functioning
50: Serious symptoms or any serious impairment in social occupational or school functioning
40: Some impairment in reality testing or communication or major impairment in several areas
such as work or school, family relations, judgment, thinking or mood
30: Behavior is considerably influenced by delusions or hallucinations or serious impairment in
communication or judgment or inability to function in almost all areas
20: Some danger of hurting self or others or occasionally fails to maintain minimal personal
hygiene or gross impairment in communication
10: Persistent danger of severely hurting self or others or persistent inability to maintain
minimal personal hygiene or serious suicidal act with clear expectation of death
 Ethnic & Cultural Considerations
- Mental illness as universal
- Culture can influence:
o Risk factors
o Types of symptoms experienced
o Willingness to seek help
o Availability of treatments

- DSM-IV-TR includes:
o Enhanced cultural sensitivity
o Appendix of 25 culture-bound syndromes
• Koru (South and East Asia)
• Dhat (India)
• Hikikomori (Japan, South Korea)
• Some researchers endorse looking for commonalities rather than differences across
cultures
 Categorical vs. Dimensional Systems
Categorical
• Presence/ absence of a disorder
• Either you are anxious or you are not anxious.

Dimensional
• Rank on a continuous quantitative dimension
o Degree to which a symptom is present
o How anxious are you on a scale of 1 to 10?
o Dimensional systems may better capture an individual’s functioning

- Categorical approach has advantages for research and understanding

 Criticisms of Classification
- Stigma against mental illness
o Treated differently by others
o Difficulty finding a job
•
- Categories do not capture the uniqueness of a person.
• The disorder does not define the person.
o She is an individual with schizophrenia, not a “schizophrenic”
The DSM 5
 The DSM 5
- the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, prepared by
the DSM–5 Task Force of the American Psychiatric Association and published in 2013.
- Changes from the DSM–IV–TR include
- (1) use of a nonaxial approach to diagnosis with separate notations for psychosocial and
contextual factors and disability;
- (2) organization of diagnoses according to the period (i.e., childhood, adolescence,
adulthood, later life) during which they most frequently first manifest;
- (3) clustering of disorders within chapters according to internalizing factors (e.g.,
anxiety, depression) and externalizing factors (e.g., impulsive, disruptive conduct);
- (4) replacement of the not otherwise specified label with clinician choice of other specified
disorder or unspecified disorder;
- (5) replacement of the Global Assessment of Functioning Scale with the World Health
Organization’s Disability Assessment Schedule for further study; and
- (6) consolidation of separate diagnostic areas into spectra (e.g., autism spectrum
disorder).
 The DSM 5
- The structure and content of the DSM–5 was coordinated with that of
then forthcoming 11th revision of the International Classification of
Diseases (ICD), although the DSM–5 retains diagnostic codes from
both the ICD–9–Clinical Modification and ICD–10–CM.
- In addition, the Roman numerals used in previous DSM editions were
replaced with an Arabic numeral to allow clearer labeling of future
updates (e.g., DSM–5.1, DSM–5.2).
 The DSM 5
- Several diagnostic changes in the DSM–5 have met with controversy.
Its consolidation of Asperger’s disorder into autism spectrum
disorder, for example, has raised concerns that those who would
meet prior criteria for Asperger’s will now instead be diagnosed as
having ASD, which many consider a more serious disorder, or not
having either disorder, thereby losing eligibility for certain medical
and educational services.
- Moreover, a criticism of its immediate predecessor has been lodged
against the DSM–5 as well—that it retains some diagnostic criteria
that pathologize normal behaviors (e.g., temper tantrums, overeating)
and emotions (e.g., grief, worrying).
DSM-5- Text Revision (DSM-5-TR)
 DSM-5- Text Revision (DSM-5-TR)
• is
the first published revision of the DSM-5 since its
publication in 2013.
• Likethe previous text revision (DSM-IV-TR), the main goal
of the DSM-5-TR is to comprehensively update the
descriptive text accompanying each DSM disorder on the
basis of reviews of the literature over the past 10 years.
 DSM-5- Text Revision (DSM-5-TR)
• In contrast to the DSM-IV-TR, in which updates were confined almost
exclusively to the text, the DSM-5-TR includes many other changes and
enhancements of interest to practicing clinicians, such as:

1. The addition of diagnostic categories (prolonged grief disorder, stimulant-

induced mild neurocognitive disorder, unspecified mood disorder, and a
category to indicate the absence of a diagnosis);
2. The provision of ICD-10-CM symptom codes for reporting suicidal and
non-suicidal self-injurious behavior;
 DSM-5- Text Revision (DSM-5-TR)
3. Modifications, mostly for clarity, of the diagnostic criteria for more than 70
disorders;
4. Updates in terminology (e.g., replacing “neuroleptic medications” with
“antipsychotic medications or other dopamine receptor blocking agents”
throughout the text and replacing “desired gender” with “experienced
gender” in the text for gender dysphoria).
5. Also, the entire text was reviewed by an Ethno-racial Equity and Inclusion
Work Group to ensure appropriate attention to risk factors such as the
experience of racism and discrimination, as well as the use of non-
stigmatizing language.