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DSM-IV-TR

The American Psychiatric Association's Diagnostic & Statistical Manual of Mental Disorders (DSM) Version IV & Text Revision (TR). Published in 2000

 

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DSM-IV-TR: (Categorical Approach, Polythetic Criteria Set, Multiaxial Diagnostic System)

The DSM-IV-TR is a diagnostic system that:

  1. Uses a categorical approach (divides the mental D/O's into types that are defined by a set of Dx criteria) & polythetic criteria sets (for most D/O's requires the indiv. to present only w/a subset of characteristics from a larger list);
  2. Predominantly a theoretical w/regard to etiology; &
  3. Makes use of a multiaxial classification system that involves describing a person's condition in terms of 5 dimensions.

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Categorical Approach

The DSM-IV-TR utilizes a categorical approach that divides mental D/O's into types that are defined by a set of diagnostic criteria:

  • Involves determining whether or not a person meets the criteria for a given Dx.
  • Works best when all members of each category are homogeneous, which does not always apply to people w/mental D/O's.

Used by the DSM-IV-TR

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What is the dimensional approach to diagnosis of mental disorders?

This approach conceptualizes behavior in terms of a continuum that ranges from normal/healthy to pathological & involves rating a person on each Sx or other characteristic (e.g., on a scale 1 to 10)

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Polythetic Criteria

The DSM includes a Polythetic criteria set for most D/O's to allow for heterogeneity that requires an indiv. to present w/only a subset of characteristics from a larger list.

Ex: 2 ppl can have somewhat different Sx but receive the same Dx.

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How does the DSM-IV-TR take into account potential heterogeneity within categories of diagnoses?

The DSM-IV-TR includes a polythetic criteria set.

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The DSM-IV-TR uses a multiaxial diagnostic system so that a persons condition is described in (1)__________ that promote the application of the (2)__________ model in clinical, educational, and research settings.

1. 5 dimensions or axes
2. biopsychosocial model

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GAF (Global Assessment of Functioning) Scale

The GAF scale is used to rank the indivs. psychological, social, & occupational Fx on a scale from 0 to 100 (w/100 representing superior functioning) on Axis V.

Two factors are considered when assigning a GAF score:

  1. Sx severity and
  2. Level of Fx.

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Multiaxial Diagnostic System of the DSM

(5 Axes)

The multiaxial diagnostic system describes a person's condition in terms of 5 dimensions/axes that "promote the application of the biopsychosocial model in clinical, educational, & research settings" (p. 27):

Axis I: Clinical Disorders & Other Conditions that may be a Focus of Clinical Attention (v codes).

Axis II: Personality disorders & Mental Retardation.

Axis III: General Medical Conditions

Axis IV: ​Psychosocial and Environmental Problems

Axis V: Global Assessment of Functioning (GAF scale) a scale used to rank the individuals psychological, social, and occupational functioning on a scale that ranges from 0 to 100.

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Why are Personality Disorders and Mental Retardation included on Axis II instead of Axis I?

To ensure that consideration will be given to the possible presence of Personality Disorders & Mental Retardation, NOT because pathogenis or range of appropriate Tx is fundamentally different than Axis I

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Diagnostic Uncertainty

In the DSM-IV-TR, diagnostic uncertainty about the indivs. condition is indicated by coding on Axis I or II:

  1. Dx (or Condition) Deferred - coded when there is not enough info. to make a definite Dx.
  2. Specific Dx (Provisional) - used when there is sufficient info. for a tentative, but not firm, Dx.
  3. (Class of D/O) Not Otherwise Specified - Class of Dx's used when there is adequate info. to know that a D/O belongs to a particular category but not enough info. to make a more specific Dx or when features of the D/O do not meet the criteria for a more specific Dx.

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Outline for Cultural Formulation & Glossary of Culture-Bound Syndromes

The Outline for Cultural Formulation recommends that clinicians consider five elements:

  1. The client's cultural identity;
  2. The cultural explanation for the CT's illness;
  3. Cultural factors relevant to the CT's psychosocial environment & level of Fx;
  4. Cultural factors relevant to the relationship between the client and therapist; and
  5. How cultural factors may impact the client's Dx & care.

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Know

Mental Retardation

Developmental D/O involving:

  1. Significantly subaverage intellectual Fx (IQ = 7O or below on IQ test)
  2. Impaired adaptive Fx in 2 Areas (Does not meet expected standard of personal Independence for culture/age in at least 2 areas of Fx: communication, self-care, self-direction, social skills, Fx academic skills, work or safety, etc.)
  3. An onset prior to age 18. 

Correct Dx: if ppl w/IQ of 71-75 & level of adaptive Fx is subtantially impaired.

4 degrees of severity are:

1. Mild Mental Retardation (IQ 50-55 to 70): 

2. Moderate Mental Retardation (IQ 35-40 to 50-55);

3. Severe Mental Retardation (IQ 20-25 to 35-40);

4. Profound Mental Retardation (IQ below 20-25).

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Mental Retardation - Severity Levels

4 degrees of severity are:

1. Mild Mental Retardation (IQ 50-55 to 70): 6th grade level & Adults live independently w/min. sup.;

2. Moderate Mental Retardation (IQ 35-40 to 50-55): 2nd grade level & Adult perform skilled/semi-skilled work w/reg. sup.;

3. Severe Mental Retardation (IQ 20-25 to 35-40): Basic self-care skills & Adults perform simple tasks while closely supervised; 

4. Profound Mental Retardation (IQ below 20-25): Need highly structured env. & Indiv. sup.

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What are the early signs of Mental Retardation?

1. Delays in motor development
2. Lack of age appropriate interest in environmental stimuli
a. Lack of eye contact during feeding
b. Less responsive to voice & movement than would be expected

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What are potential causes for Mental Retardation?

1. Heredity Causes - 5% (Tay-sachs, Fragile X Syndrome, PKU)
2. Early alterations of embryonic development - 30% (Down Syndrome, Damage due to toxins)
3. Pregnancy & perinatal probs - 10% (Fetal malnutrition, anoxia, HIV)
4. General medical conditions during infancy or childhood - 5% (lead poisoning, encephalitis, malnutrition)
5. Environmental factors and other mental D/O's - 15-20% (deprivation of nurturance or stimulation, Autistic Dx)
6. Unknown causes (Approx. 30-40%)

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PKU (Phenylketonuria)

A rare recessive gene syndrome due to an inability to metabolize the amino acid phenylalanine, found in high-protein foods.

If untreated, produces:

  • irreversible moderate to profound retardation,
  • impaired motor & language devel., &
  • unpredictable, erratic behaviors.

​Sx's include:

  • Mental retardation
  • Microcephaly (condition in which a person's head is significantly smaller than normal for their age and sex)
  • Vomiting & Diarrhea
  • Movement D/O's
  • Seizures

D/O can be detected at birth by a blood test & its Sx prevented by a diet low in phenylalanine (milk/dairy,meat, fish)

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Down Syndrome (“trisomy 21")

Due to the presence of an extra 21st chromosome & is estimated to be the cause of 10-30% of all cases of moderate to severe retardation.

Characterized by:

  • Moderate to severe Mental Retardation
  • Delayed motor devel. & physical growth
  • Assoc. w/physical abnormalities including:
    • Slanted, almond-shaped eyes,
    • Broad flat face
    • Cataracts,
    • Respiratory defects
    • Tend to age more rapidly than other ppl,
    • Life expectancy below normal,

At higher risk for Alzheimer‘s disease/dementia, leukemia & heart defects/lesions.

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Know

Borderline Intellectual Functioning

Approp. Dx for people with IQ’s in the 71-84 range. 

Persons who fall into this categorization have:

  • A relatively normal expression of affect for their age, though their ability to think abstractly is rather limited.
  • Reasoning displays a preference for concrete thinking.
  • Others may describe such a person as "simple" or "a little slow".
  • They are usually able to Fx day to day w/out assistance, including holding down a simple job & the basic responsibilities of maintaining a dwelling

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When is a diagnosis of Mental Retardation appropriate for persons with IQs between 71 to 75?

If s/he has substantial deficits in adaptive functioning.

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Prader-Willi Syndrome

Due to a deletion on chromosome 15

Sx's include:

  • Mental Retardation
  • Decreased muscle tone
  • Short stature
  • Insatiable appetite
  • Morbit obesity

(Etiology of MR)

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Learning Disorders

Dx when a person's:

  • Score on a measure of academic achievement is substantially below (usually 2 SD's or more) his/ her score on a(n) IQ test & the discrepancy cannot be fully explained by a sensory deficit.

The most common co-diagnosis is ADHD (20-30%); evidence that LD associated w/high risk for antisocial behavior & arrest/conviction for antisocial behaviors.

More common in Boys.

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Stuttering

(Communication D/O) is characterized by:

  • Disturbance in normal fluency and
  • Time patterning of speech that is inapprop. for the individual’s age;
  • Connot be completely explained by a speech-motor or sensory deficit.

Onset: Btwn ages of 2-7

Effective Tx: Habit reversal, which combines regulated breathing, awareness training, & social support.

Etiology: 3 times more common in males, & in 60% of cases it remits spontaneously by 16 y.o.

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What treatments have been successfully in helping people who stutter?

1. Reduction of psychological stress at home, stop reprimanding child for stuttering & teach coping strategies for frustration
2. Regulated breathing:

  • Involves reassuring the individual that s/he can speak without stuttering 
  • Incorporates breathing & vocalization exercises & graded speech assignments

3. Habit reversal, which combines regulated breathing, vocal exercises, awareness training (aware of situations words that evoke stuttering), & social support (parents encourage & reinforce childs efforts to speak w/out stuttering)

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Pervasive Developmental Disorders

Involve severe & pervasive impairments in communication & social interaction &/or the presence of stereotyped behaviors & activities.

Included in this category are:

  • Autistic Disorder,
  • Rett's Disorder,
  • Childhood Disintegrative Disorder,
  • Asperger‘s Disorder.

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Know

Autistic Disorder

(Pervasive Devel. D/O) Dx criteria includes 6 characteristic Sx's by age 3:

1. Impairment in social interactions (Min. 2 Sx's) 

  • Babies avoid eye contact; limited facial expressions (dont smile); resist physical contact

Older children have trouble interpreting meaning of gesture & facial expressions, indifferent to other ppls feelings, impaired nonverbal behavior that helps regulate social interactions, fail to devel. normal peer rel. & may seem oblivious to others).​​

2. Impairment in communication (Min. 1 Sx) (Do not speak at all or varying degree of limited speech that contains a # of abnormalities. Such as: Pronoun reversal - saying "you" insted of "I", Echolalia - echoing words/phrases of others, inappropriate tone of voice).

3. Restricted, repetitive, & stereotyped behavior, interests & activities (Min. 1 Sx) (Preoccupied w/narrow interests, parts of an object instead of entire object, & engage in repetative body movements - arm flapping or rocking).

Course/Prognosis: (poor but best) outcomes as adults assoc. with:

  • Ability to communicate verbally by age 5/6,
  • IQ over 70, &
  • Later onset of Sx. (Small % of adults able to live/work independently)

Etiology: 

  • Biogenic D/O & has a genetic component
  • Linked to CNS brain abnormalities including: A smaller-than-normal cerebellum, enlarged ventricles; corpus collosum & limbic system
  • Assoc. w/abnorm. levels of norepinephrine, serotonin, & dopamine.
  • 4-5 x more common in males

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Tx for Autistic Disorder

Most effective are:

  • Behavioral techniques (e.g., shaping & discrimination training for communication) by Lovaas.
  • improving daily living, communication, and social skills
  • Reducing undesirable behaviors

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Lovaas (1960)

Used behavioral technique for Autism, one found to be most effective:

  • Shaping & discrimination training to teach non-speaking children to immitate others verbally & improve communication skills.
  • Originally described by Lovaas (1960) & continue to be used to improve communication skills.

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Rett's Disorder

(Pervasive Devel D/O) Characteristic devel. pattern of multiple Sx following a period of normal devel. for 5 + mos. Sx's include:

  • Head growth deceleration;
  • Loss of previously acquired  purposeful hand skills
  • Loss of expressive language
  • Devel. of stereotypical movements (e.g., hand-wringing);
  • Impairments in the coordination of gait or trunk movements; -
  • Loss of interest in the social environment;
  • Severely impaired language development; and
  • Psychomotor retardation.

DSM-IV-TR states that this D/O “has been reported only in females"; yet is evidence it's occasionally occurs in males but that males w/this D/O often die shortly after birth (e.g., Kerr, 2002).

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Childhood Disintegrative Disorder

(Pervasive Developmental D/O) is characterized by distinct pattern of developmental regression after 2 yrs. of normal devel. in at least 2 areas of Fx. Sympotms include:

  • Loss of previously acuired language (expressive or receptive), motor, social skills, play, self-help skills & bowel or bladder control
  • Characteristic abnormalities in  social interactions, communication & adaptive behaviors