[Episode 1] This is the firstly component of a two-part lecture on diagnosis in addition to assessment. The Bio-psychosocial-spiritual (BPSS) assessment in addition to the DSM diagnosis are the 2 most mutual types of assessments made yesteryear social workers. In this lecture, I briefly review the history of DSM diagnosis, from the creation of the firstly ICD inward 1900 to the most recent text revision of the DSM-IV inward 2000. I verbalize over the multiaxial organization in addition to render examples. I transition from DSM diagnosis to the BPSS assessment yesteryear discussing the similarities in addition to differences betwixt the 2 assessments.Download MP3 [24:26]
Transcript
Today’s lecture is on DSM (Diagnostic in addition to Statistical Manual of Mental Disorders) diagnosis in addition to biopsychosocialspiritual assessment. We are going to start out yesteryear distinguishing the 2 in addition to so we’re going to focus on DSM for the firstly component of the lecture. Go over a niggling scrap of the history, focus on the multi-axial system, in addition to so were going to verbalize almost biopsychosocialspiritual assessment in addition to the components that are involved inward that.
So first, what is the divergence betwixt a DSM diagnosis in addition to a biopsychosocialspiritual assessment? Well, diagnosis is the physical care for of determining whether a item job that someone reports every bit sorry really run into criteria for a psychological disorder. So it’s non plenty to exactly state “I’m feeling really stressed”, that’s non a diagnosis. Everyone feels stress. There’s goose egg abnormal almost that. In contrast, an assessment is a systematic evaluation of biological, psychological, social in addition to spiritual factors inward an private presenting amongst a possible pathological disorder. So amongst the biopsychosocialspiritual assessment you lot are looking at those iv major domains. One of those pieces of information powerfulness really aid inward the diagnosis of a disorder.
What is a diagnosis?
H5N1 diagnosis is a type of classification in addition to classifications are exactly groupings of things based on mutual characteristics. And nosotros assort things all the time. Music is a practiced example; it is fairly slowly to assort drastically dissimilar types of music such every bit opera, hip hop, jazz in addition to reggae. Most people tin hear to a few seconds of each of those in addition to categorize them fairly easily. They are all music, but they are all categories inside music. As Any classification systems similar these musical categories travel to a greater extent than similar, they travel harder to distinguish. So for example, what would last the divergence betwixt hard rock, heavy metal, decease metal, in addition to grunge? The same tin last asked almost province in addition to blue-grass; or electronica versus drums in addition to bass versus techno. Anytime you lot verbalize to a instrumentalist in addition to you lot state you’re a techno instrumentalist or you’re a jazz instrumentalist you lot run the adventure of the instrumentalist turning some in addition to maxim no I’m not, I don’t play jazz, I play music. In these situations, the musicians would last reacting to the label in addition to we’ll come upwards dorsum to this afterward but the number of labeling is ane of the criticisms of diagnosis. That is applying a full general label to a unique private in addition to this number of hoe to tease out these characteristics in addition to apply a unremarkably understood label, is some other criticism of the DSM in addition to we’ll verbalize a niggling to a greater extent than almost that later. But when you lot receive got a individual presenting amongst a multifariousness of symptoms that don’t seem to run into or stand upwards for a classification they receive got created an out. And that is a Not Otherwise Specified category. In the plain of mental health, classification is called a nosology. Now the DSM is the nosolgical classification of a cluster of symptoms, a score of impairment, in addition to a subjective score of distress.
One of the critiques of the DSM - other than the labeling nosotros mentioned before - is that the way you lot determine what is symptomatic, or impaired or distressing, is subjective. And yesteryear labeling someone amongst a disorder, you lot justify the diagnosis. And this is called a tautology. Because somebody has the symptoms they thus must receive got the diagnosis in addition to since they receive got the diagnosis they must thus receive got the symptoms. So let’s convey a quick hold back at the history of classifications of mental illness.
History of classification of mental illness
History is of import because every classification organization that has been developed is a production of the cultural, intellectual, in addition to political climate inward which it was developed. For example, ane of the earliest classifications of problems was called the iv humorous. And all problems could last traced dorsum to imbalances inward humors. And this led to bloodletting in addition to leeching in addition to other types of procedures that were intended to remainder out your humors. Probably non real humorous to the patients. The way these imbalances were determined, the types of procedures were left upwards to the devices of the people inward the specific towns or villages, or fifty-fifty streets.
In 1900, the world, believe it or not, was a much smaller position that it was fifty-fifty 50 years before every bit a outcome of the innovation of the telephone in addition to telegraph. So, it became increasingly to a greater extent than hard for people to occupation their ain classification systems. So, inward 1900 a grouping of people, met inward the intellectual pump of the dry reason which was Paris. And they created the International Classification of Diseases which nosotros instantly refer to every bit the ICD I. The ICD-I focuses generally on diseases that killed you lot because dorsum inward those days, most illness did kill you. And decease is also talked almost every bit mortality. So when you lot regard data, toy tin regard mortality information in addition to that’s really people that died. By 1936, diagnosis in addition to handling had improved to the betoken where diseases did non necessarily kill you. SO the ICD grew inward reach to include diseases that made you lot ill. This is referred to every bit morbidity. In the belatedly 1940’s the pump of the intellectual dry reason had shifted to New York City. Europe was financially in addition to socially defeated from WWII. The U.S. of A. was the victor. And the concept of illness had expanded to include mental illness. The ICD included half-dozen mental illnesses.
DSM I
In 1952, the firstly Diagnosis Statistical Manual of Mental Disorders was published. The DSM I included almost 106 diagnoses. Now, when nosotros think almost cultural, intellectual in addition to political influences the diagnoses were heavily influenced yesteryear a human named Menninger who worked amongst Vets from WWII. He saw most problems every bit emanating from biological causes. And inward that sense they were reactions to specific things. For example, ane of the diagnoses was reaction to war. These diagnoses were non based on whatever scientific studies in addition to this was through no mistake of the authors of the firstly DSM, but without these categories inward the firstly position at that topographic point was no classification from which to produce research. So this firstly DSM contained paragraph long descriptions of what ‘reaction to war’ looked like. Now, authorities annotation that reaction to state of war is really an explanation for why someone powerfulness last acting a sure way, rather than a description of how they are acting. This is of import every bit nosotros displace along to our electrical flow Diagnostic in addition to Statistical Manual.
DSM-II
In the 1950’s nosotros also saw the advent of psychotropics, medications that touching people’s emotional well-being. One of the most famous medications was valium, also known every bit mother’s niggling helper. It treated anxiety. Thorozine was invented to care for psychosis, schizophrenia. In lodge to effectively assay these drugs, the drug companies needed a way accurately position what it was they were treating. The DSM I in addition to the DSM II both suffered from the same problem. They had pathetic inter-rater reliability. Two clinicians could regard the same customer in addition to come upwards up amongst dissimilar diagnoses. Good inter-rater reliability would hateful that 2 clinicians would regard the same individual in addition to would come upwards up amongst the same diagnosis. They would produce that because the criteria for coming together the diagnosis were specific plenty that the determination of a diagnosis would non last subjective but would rather last based on the criteria, symptoms presented. So, the drug companies were looking for precise diagnoses in addition to the DSM I in addition to DSM II had pathetic inter-rater reliability. Now the DSM came out inward 1968, the same yr every bit the ICD–VII. The biological reactions from the DSM I were really replaced amongst psychodynamic explanations. These influences came out of Freud in addition to other psychodynamic theorists. For example, the explanation of somebody’s conduct inward the DSM I powerfulness receive got said ‘reaction to war’. In DSM II they talked almost neuroses. So the diagnosis was neurosis due to underlying conflict. Again, notice how the diagnosis is an explanation for underlying argue for someone’s problems. The DSM II did include a child’s section. And this was component of the societal recognition that children could really endure in addition to at that topographic point was also, think the 1960’s, the belatedly 1960’s inward particular, at that topographic point was a lot of teenage in addition to immature adult rebellion. Sex, drugs in addition to stone in addition to roll. Hippie counter-culture, protests, all these things that were going on in addition to the state of war generation, which Tom Brokaw called the greatest generation, inward general, didn’t empathize what was going on amongst these adolescents. They started agreement these problems every bit mental disorders. One of the diagnoses inward the DSM II was inward fact ‘adjustment to adolescence. This was a diagnosis that everyone liked, kids in addition to adults alike. In the DSM II you lot had neuroses in addition to psychoses, which inward the DSM IV receive got been updated to last called anxiety in addition to psychotic symptomology. Now the DSM II soundless didn’t address all the needs of researchers because disorders were descriptors rather than classifiers.
DSM-III
It wasn’t until 1980 that the DSM III created major changes inward the way diagnoses were described, defined in addition to how they were used. So the iii major changes inward the DSM III were: it was atheortical that is they did non give causes for people’s mental illnesses. For example, ‘reaction to war’ or neurosis due to underlying conflict was no longer legitimate diagnoses. They did non distinguish betwixt biological or psychological disorders. The DSM III also lists criteria for identifying disorders. This made it possible to study reliability in addition to the validity of the criteria. Which agency that starting inward 1980 is really the firstly fourth dimension that query has been able to over multiple studies occupation the same criteria in addition to bases for determining whether or non interventions, medications, therapies, etc are reliable in addition to valid. The DSM III also introduced the multi-axial system. The multi-axial organization enabled clinicians to depict the person’s surgical operation on a number of dissimilar dimensions rather than exactly ane disorder. Dimensions that extended yesteryear the primary diagnosis to include chronic personality disorders, medical weather related to the disorder, psychosocial stress in addition to a way of establishing surgical operation were the dissimilar axes. Because the physical care for was based on commission decision, social workers were able to force for the inclusion of an axis iii in addition to an axis 4, the medical in addition to ecological factors. This is interesting because the DSM was developed through committee, it was a political process, in addition to fifty-fifty though at that topographic point were specific criteria for disorders, those criteria were decided on yesteryear commission decision. Social workers wereable to vote in addition to were able to receive got an influence on the DSM III. Some of the critiques of the DSM III include: some of the disorders had real pathetic inter-rater reliability in addition to symptoms were decided yesteryear commission rather than purely yesteryear research. I should state inward defence of the DSM III that most of the diagnoses had some empirical basis, but because at that topographic point had been no prior powerfulness to produce research, the specifics of the diagnoses were unknown.
DSM-IV
In 1994 nosotros saw the publication of the DSM IV. This is our electrical flow Diagnostic in addition to Statistical Manual. In answer to the criticism that symptoms were decided yesteryear commission rather than purely yesteryear query similar the DSM III, the diagnoses in addition to symptoms were based exclusively on empirical evidence, non yesteryear committee. In grooming of the DSM IV, 12 plain trials were conducted to found inter-rater reliability in addition to validity of dissimilar sets of criteria in addition to inward some cases to found a novel diagnosis. The DSM IV also eliminated distinctions betwixt organically based disorders in addition to psychologically based disorders.
Before nosotros travel on, let’s verbalize a niggling almost the multi-axial system. Axis I is clinical disorders in addition to other weather that may my focus of clinical attending For example, personality disorders were moved to Axis II. Now a personality disorder is defined every bit consistent behaviors that are extreme. For example, at that topographic point is a divergence betwixt existence neat in addition to orderly in addition to existence compulsive. There is also a severity in addition to length of job amongst surgical operation or happiness that is non nowadays inward a individual who is having personality issues, but does non really receive got a personality disorder. In fact, that thought of impairment inward surgical operation inward at to the lowest degree ane domain of your life, whether that is home, school, job, environmental is cardinal to deciding if something is really a disorder. Now also coded on Axis II is mental retardation. You receive got borderline intellectual surgical operation in addition to mental retardation, both of which are decided on yesteryear IQ. In Axis III nosotros code full general medical conditions. These are whatever medical weather that powerfulness impact the disorder. The hear in addition to the torso receive got a connection. For example, cancer tin last discovered because the patient presents amongst symptoms of depression. In fact, ane of the symptoms of cancer is depression. So you lot desire to code anything that is a full general medical status that is related to the disorder on Axis III. This wouldn’t last allergies, specifically. Say your customer came inward in addition to was talking almost having a runny nose. That’s non a full general medical status that is specifically related to a mental illness. Therefore, you lot would non receive got to code on that. Axis IV is psychosocial in addition to environmental problems which is some other way of saying, what’s stressing this person? These stressors powerfulness touching the diagnosis handling in addition to prognosis of Axis I in addition to Axis II diagnoses. So again, they’re related to each other. Axis IV information should last specific to the terminal yr in addition to pertinent to the mental illness. For example, prior scrap experience would last pertinent to a diagnosis of PTSD. There are a number of categories that are typically listed on Axis IV in addition to they include: problems amongst primary social back upwards groups, job amongst social environment, problems amongst education, occupation, housing, economy, wellness care, legal system, or other.
Finally, Axis V, that’s the global assessment of functioning. This establishes single, global, uni-dimensional score of functioning. It’s useful for planning, treatment, predicting in addition to evaluating outcomes. For example, if a customer comes in, in addition to their electrical flow surgical operation is defined every bit the lowest score of surgical operation inside the terminal calendar week in addition to that was a xl in addition to you lot don’t demand to know what these numbers mean, the make from 1 to 100, but let’s state it’s a 40, in addition to when they leave, their surgical operation is a 60. This tin last real useful inward deciding the success of the handling because ultimately we’re interested inward how good our customer functions, regardless of the severity of their symptoms. For example, if nosotros think almost it inward damage of physical health, Stephen Hawking is confined to a wheelchair, cannot communicate except through a computer, has real severe symptoms; however, his score of surgical operation is real high. Level of surgical operation only relates to psychological, social or occupational functioning, non physical or environmental limitations. So for Hawking, the limitations are physical in addition to environmental, but emotionally, socially, psychologically, in addition to sure enough inward damage of his job, his surgical operation is at a real high level. Now at that topographic point are qualifiers you lot tin occupation for the GAF score. Those would be, side yesteryear side to the score you lot would set inward parentheses, electrical flow highest inward yesteryear year, or at discharge. In 2000, the DSM-IV-TR (text revision) was published. It did clarify the electrical flow Definition of impairment on Axis IV. It clarified the timeframe for major depressive disorder specifiers in addition to also clarified the concept of poly-substance dependence. But again, it did non alter whatever of those diagnoses. The DSM V is slated to come upwards out inward 2011 [UPDATE: 2013]. And at that topographic point are a number of proposed changes, but since this is non a DSM class, we’re non going to pass fourth dimension on that. Just know that you lot receive got quite a few years to piece of work amongst the DSM IV, before things change, wither radically, or non so radically.
Cultural Issues amongst the DSM-IV
Cultural issues are ever of business organization to social workers. We tend to regard things from a systemic viewpoint in addition to nosotros empathize that civilization play a pregnant role both inward the presentation of symptoms, the access to treatment, in addition to answer to treatment. These are all influenced yesteryear culture. For the firstly fourth dimension inward the DSM IV, cultural issues were included. They were relegated to the appendix in addition to that was called the outline for cultural formulation in addition to glossary of culturally based syndromes. Of course, the promise is we’ll displace these cultural issues from the dorsum of the coach correct upwards to the front end amongst the diagnoses themselves. But basically what the DSM said was that you lot receive got to convey cultural factors into account. If inward your civilization it is acceptable to produce what they telephone shout out upwards cupping, which is to position heated cups on the body, to pull out negative energy, or harmful liberate energy in addition to it leaves bruises, it doesn’t necessarily fit our Western Definition of abuse.
This is an of import matter to think almost when nosotros verbalize almost cultural implications. Some of the benefits of diagnosis include: establishing a baseline, narrowing the reach of treatment, diagnoses allow for the evaluation of presenting problems in addition to provides a mutual linguistic communication for service providers. Some of the problems include labeling, such every bit when Kermit said, “It’s non slowly existence green”. The argue why labeling is an number because nosotros tend to convey ane matter in addition to come inward the whole similar pare color or cognitive functioning. For example, labels such every bit moron, idiot in addition to imbecile, are today considered major insults. We would never apply those labels to our clients, or our friends, unless we’re exactly playing some amongst them. But inward fact, when they were introduced, they were fairly neutral in addition to benign categories of cognitive functioning. But every bit fourth dimension passed, they picked upwards negative connotations in addition to were genuinely understood to last insults. Of course, at that topographic point were some people who were overjoyed to honour out that they receive got a diagnosis. That at that topographic point is some explanation for what is incorrect amongst them. In the same way, some parents are overjoyed that when they honour out that their kid does receive got ADHD. For example, this label provides them amongst an explanation for these conduct problems in addition to it suggests a possible solution for addressing these problems. Finally, every bit nosotros mentioned inward the beginning, ane of the problems of diagnosis is that it establishes a tautology. Because the symptoms are present, the individual has the diagnosis in addition to because the individual has the diagnosis, they must receive got the symptoms.
So, that is a brief overview of the history of the DSM in addition to of diagnosis. And side yesteryear side we’re going to verbalize a scrap almost the biopsychosocialspiritual assessment inward Episode 2.
References
Andrews, A. B. (2007). Social history assessment
. Thousand Oaks, CA: Sage PublicationsCorey, G. (2008). Theory in addition to do of counseling in addition to psychotherapy
(8th ed). Belmont, CA: Wadsworth/Thomson.Jordan, C., & Franklin, C. (2003). Clinical assessment for social workers: Quantitative in addition to qualitative methods, Third edition
. Chicago: Lyceum.Lukas, S. (1993). Where to start in addition to what to ask: An assessment handbook
. New York: W. W. Norton & Company.Spitzer, R. L., Gibbon, M., Skodol, A. E., Williams, J. B. W., & First, M. B. (1994). DSM-IV casebook: H5N1 learning companion to the Diagnostic in addition to Statistical Manual of Mental Disorders
(DSM-IV). Washington, D. C.: American Psychiatric Press, Inc.APA (6th ed) citation for this podcast:
Singer, J. B. (Producer). (2007, Jan 22). DSM diagnosis for social workers [Episode 1]. Social Work Podcast [Audio podcast]. Retrieved from /search?q=bio-psychosocial-spiritual-bpss
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