Monday, January 22, 2007

DSM Diagnosis for Social Workers

[Episode 1] This is the first part of a two-part lecture on diagnosis and assessment. The Bio-psychosocial-spiritual (BPSS) assessment and the DSM diagnosis are the two most common types of assessments made by social workers. In this lecture, I briefly review the history of DSM diagnosis, from the creation of the first ICD in 1900 to the most recent text revision of the DSM-IV in 2000. I discuss the multiaxial system and provide examples. I transition from DSM diagnosis to the BPSS assessment by discussing the similarities and differences between the two assessments.

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Today’s lecture is on DSM (Diagnostic and Statistical Manual of Mental Disorders) diagnosis and biopsychosocialspiritual assessment. We are going to start out by distinguishing the two and then we’re going to focus on DSM for the first part of the lecture. Go over a little bit of the history, focus on the multi-axial system, and then were going to talk about biopsychosocialspiritual assessment and the components that are involved in that.

So first, what is the difference between a DSM diagnosis and a biopsychosocialspiritual assessment? Well, diagnosis is the process of determining whether a particular problem that someone reports as distressing actually meet criteria for a psychological disorder. So it’s not enough to just say “I’m feeling really stressed”, that’s not a diagnosis. Everyone feels stress. There’s nothing abnormal about that. In contrast, an assessment is a systematic evaluation of biological, psychological, social and spiritual factors in an individual presenting with a possible pathological disorder. So with the biopsychosocialspiritual assessment you are looking at those 4 major domains. One of those pieces of information might actually help in the diagnosis of a disorder.

What is a diagnosis?
A diagnosis is a type of classification and classifications are simply groupings of things based on common characteristics. And we classify things all the time. Music is a good example; it is fairly easy to classify drastically different types of music such as opera, hip hop, jazz and reggae. Most people can listen to a few seconds of each of those and categorize them fairly easily. They are all music, but they are all categories within music. As Any classification systems like these musical categories become more similar, they become harder to distinguish. So for example, what would be the difference between hard rock, heavy metal, death metal, and grunge? The same can be asked about country and blue-grass; or electronica versus drums and bass versus techno. Anytime you talk to a musician and you say you’re a techno musician or you’re a jazz musician you run the risk of the musician turning around and saying no I’m not, I don’t play jazz, I play music. In these situations, the musicians would be reacting to the label and we’ll come back to this later but the issue of labeling is one of the criticisms of diagnosis. That is applying a general label to a unique individual and this issue of hoe to tease out these characteristics and apply a commonly understood label, is another criticism of the DSM and we’ll talk a little more about that later. But when you have a person presenting with a variety of symptoms that don’t seem to meet or match a classification they have created an out. And that is a Not Otherwise Specified category. In the field of mental health, classification is called a nosology. Now the DSM is the nosolgical classification of a cluster of symptoms, a level of impairment, and a subjective level of distress.

One of the critiques of the DSM - other than the labeling we mentioned before - is that the way you determine what is symptomatic, or impaired or distressing, is subjective. And by labeling someone with a disorder, you justify the diagnosis. And this is called a tautology. Because somebody has the symptoms they therefore must have the diagnosis and since they have the diagnosis they must therefore have the symptoms. So let’s take a quick look at the history of classifications of mental illness.

History of classification of mental illness
History is important because every classification system that has been developed is a product of the cultural, intellectual, and political climate in which it was developed. For example, one of the earliest classifications of problems was called the 4 humorous. And all problems could be traced back to imbalances in humors. And this led to bloodletting and leeching and other types of procedures that were intended to balance out your humors. Probably not very humorous to the patients. The way these imbalances were determined, the types of procedures were left up to the devices of the people in the specific towns or villages, or even streets.

In 1900, the world, believe it or not, was a much smaller place that it was even 50 years earlier as a result of the invention of the telephone and telegraph. So, it became increasingly more difficult for people to use their own classification systems. So, in 1900 a group of people, met in the intellectual center of the world which was Paris. And they created the International Classification of Diseases which we now refer to as the ICD I. The ICD-I focuses mostly on diseases that killed you because back in those days, most disease did kill you. And death is also talked about as mortality. So when you see data, toy can see mortality data and that’s actually people that died. By 1936, diagnosis and treatment had improved to the point where diseases did not necessarily kill you. SO the ICD grew in scope to include diseases that made you ill. This is referred to as morbidity. In the late 1940’s the center of the intellectual world had shifted to New York City. Europe was financially and socially defeated from WWII. The United States was the victor. And the concept of disease had expanded to include mental illness. The ICD included 6 mental illnesses.

In 1952, the first Diagnosis Statistical Manual of Mental Disorders was published. The DSM I included about 106 diagnoses. Now, when we think about cultural, intellectual and political influences the diagnoses were heavily influenced by a man named Menninger who worked with Vets from WWII. He saw most problems as emanating from biological causes. And in that sense they were reactions to specific things. For example, one of the diagnoses was reaction to war. These diagnoses were not based on any scientific studies and this was through no fault of the authors of the first DSM, but without these categories in the first place there was no classification from which to do research. So this first DSM contained paragraph long descriptions of what ‘reaction to war’ looked like. Now, note that reaction to war is actually an explanation for why someone might be acting a certain way, rather than a description of how they are acting. This is important as we move along to our current Diagnostic and Statistical Manual.

In the 1950’s we also saw the advent of psychotropics, medications that affect people’s emotional well-being. One of the most famous medications was valium, also known as mother’s little helper. It treated anxiety. Thorozine was invented to treat psychosis, schizophrenia. In order to effectively test these drugs, the drug companies needed a way accurately identify what it was they were treating. The DSM I and the DSM II both suffered from the same problem. They had poor inter-rater reliability. Two clinicians could see the same client and come up with different diagnoses. Good inter-rater reliability would mean that two clinicians would see the same person and would come up with the same diagnosis. They would do that because the criteria for meeting the diagnosis were specific enough that the determination of a diagnosis would not be subjective but would rather be based on the criteria, symptoms presented. So, the drug companies were looking for precise diagnoses and the DSM I and DSM II had poor inter-rater reliability. Now the DSM came out in 1968, the same year as the ICD–VII. The biological reactions from the DSM I were actually replaced with psychodynamic explanations. These influences came out of Freud and other psychodynamic theorists. For example, the explanation of somebody’s behavior in the DSM I might have said ‘reaction to war’. In DSM II they talked about neuroses. So the diagnosis was neurosis due to underlying conflict. Again, notice how the diagnosis is an explanation for underlying reason for someone’s problems. The DSM II did include a child’s section. And this was part of the societal recognition that children could actually suffer and there was also, remember the 1960’s, the late 1960’s in particular, there was a lot of teenage and young adult rebellion. Sex, drugs and rock and roll. Hippie counter-culture, protests, all these things that were going on and the war generation, which Tom Brokaw called the greatest generation, in general, didn’t understand what was going on with these adolescents. They started understanding these problems as mental disorders. One of the diagnoses in the DSM II was in fact ‘adjustment to adolescence. This was a diagnosis that everyone liked, kids and adults alike. In the DSM II you had neuroses and psychoses, which in the DSM IV have been updated to be called anxiety and psychotic symptomology. Now the DSM II still didn’t address all the needs of researchers because disorders were descriptors rather than classifiers.

It wasn’t until 1980 that the DSM III created major changes in the way diagnoses were described, defined and how they were used. So the 3 major changes in the DSM III were: it was atheortical that is they did not 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 not distinguish between biological or psychological disorders. The DSM III also lists criteria for identifying disorders. This made it possible to study reliability and the validity of the criteria. Which means that starting in 1980 is really the first time that research has been able to over multiple studies use the same criteria and bases for determining whether or not interventions, medications, therapies, etc are reliable and valid. The DSM III also introduced the multi-axial system. The multi-axial system enabled clinicians to describe the person’s functioning on a number of different dimensions rather than just one disorder. Dimensions that extended past the primary diagnosis to include chronic personality disorders, medical conditions related to the disorder, psychosocial stress and a way of establishing functioning were the different axes. Because the process was based on committee decision, social workers were able to push for the inclusion of an axis 3 and an axis 4, the medical and ecological factors. This is interesting because the DSM was developed through committee, it was a political process, and even though there were specific criteria for disorders, those criteria were decided on by committee decision. Social workers wereable to vote and were able to have an influence on the DSM III. Some of the critiques of the DSM III include: some of the disorders had very poor inter-rater reliability and symptoms were decided by committee rather than purely by research. I should say in defense of the DSM III that most of the diagnoses had some empirical basis, but because there had been no prior ability to do research, the specifics of the diagnoses were unknown.

In 1994 we saw the publication of the DSM IV. This is our current Diagnostic and Statistical Manual. In response to the criticism that symptoms were decided by committee rather than purely by research like the DSM III, the diagnoses and symptoms were based entirely on empirical evidence, not by committee. In preparation of the DSM IV, 12 field trials were conducted to establish inter-rater reliability and validity of different sets of criteria and in some cases to establish a new diagnosis. The DSM IV also eliminated distinctions between organically based disorders and psychologically based disorders.

Before we go on, let’s talk a little about the multi-axial system. Axis I is clinical disorders and other conditions that may my focus of clinical attention For example, personality disorders were moved to Axis II. Now a personality disorder is defined as consistent behaviors that are extreme. For example, there is a difference between being neat and orderly and being compulsive. There is also a severity and length of problem with functioning or happiness that is not present in a person who is having personality issues, but does not actually have a personality disorder. In fact, that idea of impairment in functioning in at least one domain of your life, whether that is home, school, job, environmental is key to deciding if something is actually a disorder. Now also coded on Axis II is mental retardation. You have borderline intellectual functioning and mental retardation, both of which are decided on by IQ. In Axis III we code general medical conditions. These are any medical conditions that might impact the disorder. The mind and the body have a connection. For example, cancer can be discovered because the patient presents with symptoms of depression. In fact, one of the symptoms of cancer is depression. So you want to code anything that is a general medical condition that is related to the disorder on Axis III. This wouldn’t be allergies, specifically. Say your client came in and was talking about having a runny nose. That’s not a general medical condition that is specifically related to a mental illness. Therefore, you would not have to code on that. Axis IV is psychosocial and environmental problems which is another way of saying, what’s stressing this person? These stressors might affect the diagnosis treatment and prognosis of Axis I and Axis II diagnoses. So again, they’re related to each other. Axis IV information should be specific to the last year and pertinent to the mental illness. For example, prior combat experience would be pertinent to a diagnosis of PTSD. There are a number of categories that are typically listed on Axis IV and they include: problems with primary social support groups, problem with social environment, problems with education, occupation, housing, economy, health care, legal system, or other.

Finally, Axis V, that’s the global assessment of functioning. This establishes single, global, uni-dimensional level of functioning. It’s useful for planning, treatment, predicting and evaluating outcomes. For example, if a client comes in, and their current functioning is defined as the lowest level of functioning within the last week and that was a 40 and you don’t need to know what these numbers mean, the range from 1 to 100, but let’s say it’s a 40, and when they leave, their functioning is a 60. This can be very useful in deciding the success of the treatment because ultimately we’re interested in how well our client functions, regardless of the severity of their symptoms. For example, if we think about it in terms of physical health, Stephen Hawking is confined to a wheelchair, cannot communicate except through a computer, has very severe symptoms; however, his level of functioning is very high. Level of functioning only relates to psychological, social or occupational functioning, not physical or environmental limitations. So for Hawking, the limitations are physical and environmental, but emotionally, socially, psychologically, and certainly in terms of his job, his functioning is at a very high level. Now there are qualifiers you can use for the GAF score. Those would be, next to the score you would put in parentheses, current highest in past year, or at discharge. In 2000, the DSM-IV-TR (text revision) was published. It did clarify the current definition of impairment on Axis IV. It clarified the timeframe for major depressive disorder specifiers and also clarified the concept of poly-substance dependence. But again, it did not change any of those diagnoses. The DSM V is slated to come out in 2011 [UPDATE: 2013]. And there are a number of proposed changes, but since this is not a DSM class, we’re not going to spend time on that. Just know that you have quite a few years to work with the DSM IV, before things change, wither radically, or not so radically.

Cultural Issues with the DSM-IV

Cultural issues are always of concern to social workers. We tend to see things from a systemic viewpoint and we understand that culture play a significant role both in the presentation of symptoms, the access to treatment, and response to treatment. These are all influenced by culture. For the first time in the DSM IV, cultural issues were included. They were relegated to the appendix and that was called the outline for cultural formulation and glossary of culturally based syndromes. Of course, the hope is we’ll move these cultural issues from the back of the bus right up to the front with the diagnoses themselves. But basically what the DSM said was that you have to take cultural factors into account. If in your culture it is acceptable to do what they call cupping, which is to place heated cups on the body, to draw out negative energy, or harmful energy and it leaves bruises, it doesn’t necessarily fit our Western definition of abuse.

This is an important thing to think about when we talk about cultural implications. Some of the benefits of diagnosis include: establishing a baseline, narrowing the scope of treatment, diagnoses allow for the evaluation of presenting problems and provides a common language for service providers. Some of the problems include labeling, such as when Kermit said, “It’s not easy being green”. The reason why labeling is an issue because we tend to take one thing and make it the whole like skin color or cognitive functioning. For example, labels such as moron, idiot and imbecile, are today considered major insults. We would never apply those labels to our clients, or our friends, unless we’re just playing around with them. But in fact, when they were introduced, they were fairly neutral and benign categories of cognitive functioning. But as time passed, they picked up negative connotations and were truly understood to be insults. Of course, there were some people who were overjoyed to find out that they have a diagnosis. That there is some explanation for what is wrong with them. In the same way, some parents are overjoyed that when they find out that their child does have ADHD. For example, this label provides them with an explanation for these behavior problems and it suggests a possible solution for addressing these problems. Finally, as we mentioned in the beginning, one of the problems of diagnosis is that it establishes a tautology. Because the symptoms are present, the person has the diagnosis and because the person has the diagnosis, they must have the symptoms.

So, that is a brief overview of the history of the DSM and of diagnosis. And next we’re going to talk a bit about the biopsychosocialspiritual assessment in Episode 2.


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Corey, G. (2008). Theory and practice of counseling and psychotherapy(8th ed). Belmont, CA: Wadsworth/Thomson.

Jordan, C., & Franklin, C. (2003). Clinical assessment for social workers: Quantitative and qualitative methods, Third edition. Chicago: Lyceum.

Lukas, S. (1993). Where to start and 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: A learning companion to the Diagnostic and 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, January 22). DSM diagnosis for social workers [Episode 1]. Social Work Podcast [Audio podcast]. Retrieved from

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