DIAGNOSIS

Why diagnose? To define clinical entities

Typical symptom cluster Natural history Causes

To determine treatment

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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?

Signs, Symptoms, and Issues Signs – observable phenomena Symptoms – subjective experiences Issues – ideas about signs,

symptoms, and circumstances

Diagnostic approaches Descriptive – the “what” Psychological or inferential – the

“why” Dimensional – focuses on elements,

not categories

Diagnostic approaches - continued Categorical – implies that the

categories are discovered Observation leads to recognition of

clusters Diagnoses are labels of clusters

Limitations of a categorical approach Categories are not necessarily

homogeneous. Boundaries between classes are not

always clear. Classes are not mutually exclusive.

Two diagnostic principles Parsimony Hierarchy

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

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

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.

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.”

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.

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?

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

Major Diagnostic Categories

Disorders usually first diagnosed in infancy, childhood, or adolescence Mental Retardation Learning Disorders Motor Skills Disorder

Childhood disorders - continued

Communication Disorders Pervasive Developmental Disorders Attention Deficit and Disruptive

Behavior Disorders

Childhood disorders - continued

Feeding and Eating Disorders of Infancy and Early Childhood

Tic Disorders Elimination Disorders Other Disorders of Infancy, Childhood,

and Adolescence

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

Diagnoses - continued Mood Disorders Anxiety Disorders Somatoform Disorders Factitious Disorders Dissociative Disorders Sexual and Gender Identity

Disorders Eating Disorders

Diagnoses - continued Sleep Disorders Impulse-Control Disorders Not

Otherwise Classified Adjustment Disorders Personality Disorders

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

Other - continued Problems Related to Abuse or Neglect Additional Conditions That May Be a

Focus of Clinical Attention

Additional Codes Unspecified Mental Disorder No Diagnosis Diagnosis Deferred

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?

Childhood Depression as an Example

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

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.

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.

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.

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.

Views continued There are many psychoanalytic

views hinging on putative psychological mechanisms.

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.

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.

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.

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."

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

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

Signs and symptoms continued impaired memory and concentration suicidal thoughts irritability anxiety

Signs and symptoms continued A convenient way of thinking of

depression is that it looks like a normal grief reaction, but it lasts longer.

Types of depression:

major depression, with several subtypes;

dysthymia; depression as part of bipolar

disorder; depression as part of cyclothymia; adjustment disorders, normal

bereavement, and other normal reactions to circumstances.

Conditions that mitigate against a diagnosis

Bizarre behavior, delusions, or hallucinations in the absence of the depression

A known organic cause for the depression

Depression following the loss of a loved one

A depression of less than two weeks duration

Important considerations Depression should be formally

diagnosed only by someone with sufficient training and experience to adequately consider all of the relevant factors and to rule out other illnesses that may present as depression. This will usually mean a medical doctor with specialized training in child psychiatry.

Considerations continued Depression involves all body

systems. Depression may have behavioral

manifestations. Depression interferes with normal

thinking patterns.

Cognitive Distortions of Depression difficulty concentrating and

remembering exaggerations or misinterpretations

of events extreme or absolute judgements over generalization

Distortions continued focus on details to the exclusion of

other data draw inferences in the absence of

supporting evidence attribute personal significance to

unpleasant events

Treatment of Depression

serotonin reuptake inhibitors (Celexa, Paxil, Prozac, Zoloft)

tricyclics and heterocyclics (Anafranil, Desyrel, Pamelor, Elavil)

monoamine oxidase inhibitors (Marplan, Nardil, Parnate)

Treatment - continued Cognitive Behavioral Therapy Interpersonal Therapy