DIAGNOSIS

1. DIAGNOSIS

2. Why diagnose? • To define clinical entities • Typical symptom cluster • Natural history • Causes • To determine treatment

3. Arguments Against • Diagnosis is imposed from outside by an expert, not by the client. • Diagnostic categories minimize the uniqueness of each client. • Focus on signs and symptoms ignores capacity for self-healing.

4. More Arguments Against • Diagnosis is inconsistent with a strengths approach. • Diagnosis can lead to self-fulfilling prophecy and despair. • Diagnosis leads professionals to ignore significant data that do not support the diagnosis.

5. More Arguments Against • Diagnosis leads to identification of pathology as being within individuals instead of within systems. • The diagnostic system tends to ignore culture, age, gender, etc. • Many people who use the DSM are not qualified to use it.

6. Rebuttals to Arguments • If the phenomena exist, for professionals to ignore them regardless of client perception would be irresponsible. • Diagnostic categories don’t minimize client uniqueness, although people might.

7. More Rebuttals • Diagnosis does not minimize self-healing, and may facilitate it, if it is associated with good data. • The strengths perspective does not ask us to ignore the identification and definition of problems.

8. More Rebuttals • Diagnosis can lead to change and hope. • Skilled practice does not ignore data. Diagnosis helps organize data. • If some pathology does exist within individuals, to ignore the fact would not help change the system.

9. More Rebuttals • If diagnostic labels accurately describe real sets of phenomena, the prevalence rates among groups is a matter for research, not for throwing out the labels just because they fit more members of some groups than others.

10. More Rebuttals • If people don’t know how to use a tool, training on the use of the tool and limiting access to those who know how to use the tool make more sense than throwing out the tool.

11. Arguments for Diagnosis • Diagnosis is required for reimbursement. • Clear definition of problems is necessary for focused treatment . Diagnosis is a tool for definition. • To work in the field, workers must use diagnostic procedures.

12. More Arguments For • Standard diagnostic nomenclature is essential for communication with other professionals. • Diagnosis sets a path toward appropriate treatment. • The diagnostic process helps differentiate problems.

13. More Arguments For • Diagnosis helps workers screen for problems and manage client safety. • Accurate diagnosis is necessary for the research foundation of evidence-based practice.

14. Rebuttals to Arguments For • “Required for reimbursement” is not a compelling moral argument. • “Required to work in the field” is not a compelling moral argument. • Others?

15. Signs, Symptoms, and Issues • Signs – observable phenomena • Symptoms – subjective experiences • Issues – ideas about signs, symptoms, and circumstances

16. Diagnostic approaches • Descriptive – the “what” • Psychological or inferential – the “why” • Dimensional – focuses on elements, not categories

17. Diagnostic approaches - continued • Categorical – implies that the categories are discovered • Observation leads to recognition of clusters • Diagnoses are labels of clusters

18. Limitations of a categorical approach • Categories are not necessarily homogeneous. • Boundaries between classes are not always clear. • Classes are not mutually exclusive.

19. Two diagnostic principles • Parsimony • Hierarchy

20. Seven steps for diagnosis • Collect data • Identify pathology • Evaluate data reliability • Determine the distinctive feature • Arrive at a diagnosis • Check diagnostic criteria • Resolve diagnostic uncertainty

21. What is a mental disorder? • It is what we define it to be. • A clinically significant • behavioral or psychological syndrome or pattern • that occurs in an individual, • is associated with present distress or disability

22. Mental disorder - continued • or significantly increased risk of death, pain, disability • or important loss of freedom. • The behavior or pattern must not be • an expectable or culturally sanctioned • response to an event.

23. The DSM is meant to be used by people; • with appropriate training and experience, • who know how to use clinical judgment, • who have directly assessed the individual. • See the “cautionary statement.”

24. Ethnic and Cultural Considerations • Culture may influence expression of illness. Individuals have a right to define their culture. • Pathology must be diagnosed within a cultural context.

25. Ethical Considerations • Why would a social worker use psychiatric diagnoses? • Who may diagnose mental illness? • What are the implications of labeling? • Who should know what labels are being used? • What do the labels mean to the individuals?

26. The Multiaxial System • Axis I – Clinical Disorders and Other Conditions • Axis II – Personality Disorders • Axis III – General Medical Conditions • Axis IV – Psychosocial and Environmental Problems • Axis V – Global Assessment of Functioning

27. Major Diagnostic Categories • Disorders usually first diagnosed in infancy, childhood, or adolescence • Mental Retardation • Learning Disorders • Motor Skills Disorder

28. Childhood disorders - continued • Communication Disorders • Pervasive Developmental Disorders • Attention Deficit and Disruptive Behavior Disorders

29. Childhood disorders - continued • Feeding and Eating Disorders of Infancy and Early Childhood • Tic Disorders • Elimination Disorders • Other Disorders of Infancy, Childhood, and Adolescence

30. Diagnoses - continued • Delirium, Dementia, Amnestic, and Other Cognitive Disorders • Mental Disorders Due to a General Medical Condition Not Elsewhere Classified • Substance Related Disorders • Schizophrenia and Other Psychotic Disorders

31. Diagnoses - continued • Mood Disorders • Anxiety Disorders • Somatoform Disorders • Factitious Disorders • Dissociative Disorders • Sexual and Gender Identity Disorders • Eating Disorders

32. Diagnoses - continued • Sleep Disorders • Impulse-Control Disorders Not Otherwise Classified • Adjustment Disorders • Personality Disorders

33. Diagnoses - continued • Other Conditions That May Be a Focus of Clinical Attention • Psychological Factors Affecting Medical Condition • Medication-Induced Movement Disorders • Other Medication-Induced Disorder • Relational Problems

34. Other - continued • Problems Related to Abuse or Neglect • Additional Conditions That May Be a Focus of Clinical Attention

35. Additional Codes • Unspecified Mental Disorder • No Diagnosis • Diagnosis Deferred

36. Lingering Questions • Is conservative diagnosis more ethical than liberal diagnosis? • Must someone have an illness to need treatment? • Must someone have an illness to benefit from treatment? • Do we treat illness or people?

37. Childhood Depression as an Example

38. Is there such a thing as depression in children? • Some say yes. • Some say no.

39. Views of depression in children. • It is a developmental condition that disappears with time. • It is similar to adult depression, with some additional features. • It is not expressed in overt depressive symptoms but is masked by other symptoms.

40. Views continued • Young children cannot be depressed because they lack the cognitive development necessary for the psychological mechanisms involved to occur. • It is a result of the loss of the love object and may occur in infants.

41. Views continued • There is a biological basis. • It is triggered by events. • It is consequent to the difficulties imposed by other illnesses such as attention deficit problems and other learning problems.

42. Views continued • It is the consequence of faulty cognitions. • It is a behavioral response to punishment or lack of reinforcement. • It is a response to anxiety. • It is learned helplessness.

43. Views continued • There are many psychoanalytic views hinging on putative psychological mechanisms.

44. Problems • Depression is not a thing. • Depression as an illness and depression as a mood are confusing concepts. • If we define depression as a set of symptoms, we enter into circular logic.

45. Problems continued • If we define depression as a certain biochemical condition, we ignore the behavioral manifestations. There may be people with the biochemical condition who don't have symptoms, and there may be people with symptoms without the biochemical condition.

46. Problems continued • We have similar problems if we define it by its response to antidepressants. • Any definition that involves psychological mechanisms is not subject to disproof and consequently is not scientific.

47. Problems continued • "It would be unethical to assume that a child manifesting no clear signs of depression is nevertheless depressed, particularly if this resulted in the administration of antidepressant drugs. It would be unwise and unscientific, however, to assume that depression, as a primary problem, does not occur in children."

48. Common signs and symptoms of depression • persistent depressive mood for two weeks or more • inability to derive pleasure from normal activities • loss of interest in normal activities • psychomotor retardation or agitation

49. Signs and symptoms continued • sleep disturbance • loss or increase of appetite • sense of hopelessness • sense of worthlessness

50. Signs and symptoms continued • impaired memory and concentration • suicidal thoughts • irritability • anxiety