DSM Axes

DSM-IV-TR : 

DSM-IV-TR 6.16.2004

Activity : 

Activity It is 2036 and the space probe Athena has identified life on a distant planet. Using cutting edge technology, Athena has sent pictures and descriptions of the various aliens living on this planet back to Earth. You have been asked to partake in a task force designed to create a classification system for these aliens. The purpose of this classification system will be two-fold: to organize our knowledge and enhance communication through consensus.

Tasks : 

Tasks 1. Use the information about the aliens to create a classification system that uses at least 3, but no more than 5 groups (or categories). 2. Give each classified group of aliens a name and identify the characteristics that distinguish them from the other groups.

Review: Operationalizing mental illness : 

Review: Operationalizing mental illness Why do we do it? Nomenclature, consensus, communication, organization, research, treatment

Operationalizing mental illness : 

Operationalizing mental illness Objectivity and measurability Validity Reliability Must use observable phenomenon such as: Physical symptoms (eg. heart palpitations, insomnia, etc.) Psychological symptoms (eg. delusions, memory loss, etc.) Mood (eg. fear, elation, anxiety, etc.) Behavior (eg. self-mutilation, purging, etc.)

Have we been able to operationalize mental disorders? : 

Have we been able to operationalize mental disorders? “Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision” 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

What is the DSM-IV-TR? : 

What is the DSM-IV-TR? Contains: Diagnostic criteria Associated features (eg. other symptoms may be present, but which are not necessary for a diagnosis) Age of onset Typical course of illness Prevalence rates specific to age, gender, and ethnicity Does not contain: Information about etiology Information about treatment Cultural implications

Multiaxial Classification : 

Multiaxial Classification Axis I – Episodic disorders, adult onset Axis II – Chronic, pervasive disorders, childhood disorders Axis III – Medical conditions Axis IV – Sociocultural stressors Axis V – Global Assessment of Functioning 1-100 rating scale (1=bad, 100=good)

Global Assessment of Functioning : 

Global Assessment of Functioning 100 – Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, no symptoms, etc. 80 – If symptoms are present, they are transient and expectable reactions to psychosocial stressors, no more than slight impairment in functioning (falling behind in schoolwork) 60 - Moderate symptoms or moderate impairment in functioning (conflicts with coworkers, some panic attacks) 40 - Some impairment in reality testing or communication or major impairment in functioning (speech is sometimes illogical or obscure, failing school, unable to hold a job, 20 - Some danger of hurting self or others or occasionally fails to maintain minimal personal hygiene or gross impairment in communication (suicide, violent, smears feces, mute, etc.)

Examples : 

Examples Axis I: Major Depressive Disorder Alcohol Abuse Axis II: Dependent Personality Disorder Axis III: None Axis IV: Unemployment Axis V: GAF = 35 (on admission) GAF = 57 (at discharge) What does this tell us about this person? What does this not tell us about this person?

Examples : 

Examples Axis I: Post-Traumatic Stress Disorder Social Phobia Axis II: None Axis III: Hypothyroidism Axis IV: Victim of child abuse Axis V: GAF = 65 (current) What does this tell us about this person? What does this not tell us about this person?

Assumptions of the DSM : 

Assumptions of the DSM Each diagnosis is unique and distinct One diagnosis over a lifespan Little comorbidity (i.e. having one disorder shouldn’t affect the probability that a person would have another disorder) Homogeneity – the disorder manifests itself the same way in everyone (all people with the disorder have similar symptoms, follow a similar course, etc.) It should allow one to distinguish between people who do and do not have the disorder

How was the DSM developed? : 

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

How was the DSM developed? : 

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

How was the DSM developed? : 

How was the DSM developed? DSM-III: 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

How was the DSM developed? : 

How was the DSM developed? DSM-IV-TR: 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

Evolution of Diagnoses : 

Evolution of Diagnoses Example: DSM-I Borderline Personality disorder “characterized by brief but nonreactive mood swings, both depressive and hypomanic, in the context of a chronically maladaptive personality resembling hysterical character.”

Evolution of Diagnoses : 

Evolution of Diagnoses Example: DSM-IV-TR Borderline Personality disorder “A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following: Frantic efforts to avoid real or imagined abandonment Pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation Markedly and persistently unstable self-image or sense of self Impulsivity in at least two areas that are potentially self-damaging Recurrent suicidal behavior, gestures, threats, or self-mutilation Affective instability due to a marked reactivity of mood Chronic feelings of emptiness Inappropriate, intense anger, or difficulty controlling anger Transient, stress-related paranoid ideation or severe dissociative symptoms

Evaluation of the DSM-IV-TR : 

Evaluation of the DSM-IV-TR Does it do what it is supposed to? Is each diagnosis unique and distinct??? Fluidity of diagnoses – transition from one diagnosis to another 25% of AN patients develop BN Comorbidity Two or more disorders occurring in the same individual 91% of people with Schizophrenia had at least one other diagnosis 77% of people with BN had at least one other diagnosis 75% of people with MDD had at least one other diagnosis Disorders co-occur at rates greater than expected by chance alone Depression and Anxiety disorders Substance abuse and Antisocial Personality Disorder

Evaluation of the DSM-IV-TR : 

Evaluation of the DSM-IV-TR Does homogeneity occur? Do all people with the disorder have similar symptoms, follow a similar course, etc? Not necessarily. Disorders may manifest themselves differently in different people. In other words, people may have similar symptoms, but not entirely. (eg. MDD) Also, some disorders can look completely different in different people. In other words, two people can have the same diagnosis with completely different symptoms. (eg. Conduct Disorder)

Evaluation of the DSM-IV-TR : 

Evaluation of the DSM-IV-TR Can we use these definitions to distinguish between people who do and do not have the disorder? There is still the criticism that the criteria used are based on the clinical judgment of a few psychologists in the individual field and not representative There are still problems differentiating between normal and abnormal Some criteria are still based on clinical judgment

Possible Alternatives : 

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.).