Psychopathology & DSM Diagnosis.

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.  In it, I review information from two papers, one defines the subject of psychopathology and the other is a brief overview of DSM diagnosis.  It is not intended as a substitute for mental health counseling or diagnosis…)))

An Overview of Perspectives

If there is one thing that can be taken away from this week’s readings it is that  a simplified definition of psychopathology is difficult to come by (Maddux & Winstead 2008; Patrick, 2012).   What one conceives of as a mental disorder actually depends upon how one differentiates between normal and abnormal behavior.   While abnormal can be understood as anything that deviates from what is considered “normal”, psychopathology refers to deficits in mental functioning.    These deviations from a norm, require us to first examine how this standard is define.  “Upon what basis is a diagnosis of psychopathology made?”

  1. A social constructionist perspective abnormal might be defined as a deviation from social expectations and cultural norms.  The problem with this perspective is that it does not take into account cross-cultural differences, or even longitudinal changes within an individual culture.  With this in mind, it is worth noting that the DSM manual has been written from a very westernized cultural perspective.
  2. Vernacular criteria, on the other hand, reflect’s a laymen’s perspective that reflects popular opinion, especially within the media.  This viewpoint of psychopathology is often quite disparaging and riddled with stereotypical labels like “crazy”, “nuts”, or “psycho”.
  3. Legally, psychopathology is concerned with the issue of mental competency and criminal responsibility.  This perspective here is guided by whether an individual’s psychopathology allows for the use of an insanity defense.
  4. Finally, the Diagnostic and Statistical Manual (DSM-5) utilizes a medical definition of mental health.  Overall, this perspective might be useful to asses an individual’s ability function comfortably on a daily basis.  In sum, mental health from this perspective can be thought of as an ability to deal with reality on “reality’s terms”.

A Medical Perspective of Psychopathology

The Nature of Psychopathology

Inherent, in our definition of normalcy is a valuation statement of who falls within these parameters (Maddux & Winstead, 2008; Patrick 2012).  A few notable aspects of psychopathology’s nature are worth mentioning.

What is “Abnormal” Anyway?

Acording to Maddux, et al. (2008), “Abnormal literally means away from the norm. The word norm refers to what is typical average.” (p 4).  This implies a comparison of individuals against a standard that dictates what t characterized are considered typical ina  society.   In his article titled “The Perils of ‘Adjustment Disorder’ as a Diagnostic Category”, John Daniels states that a “Disorder is a term that names any variation, perversion, or dysfunction outside the normal order, which is regarded as a proper composition of parts according to the classical scientific paradigm” (p79).

A balanced consideration of general and particular.   

Mental health diagnosis involves an assessment of individual characteristics against an objective standard.   However, behavior cannot be truly understood when separated from the perceptual meaning system of the individual.  While scientific and socially relevant standards are essential for diagnosis, a  holistic perspective of the individual from within their standpoint of understanding is also needed. (Gorostiza & Manes, 2011, p211).  This balance seems at times to reflect a Hegelian dialectic.

Multicultural Competency.

In reality, the issue of psychopathology is quite complex, involving an array of internal and external variables. Understanding the issue in absence of the social context is a disservice to patients. (Maddux & Winstead, 2008, p12).   Multicultural competency is of ever-increasing importance in the global society we live in.

Causal complexity.

The final thing to note about psychopathology, is it is not a static concept readily observed objectively. Instead, it is a continually evolving issue that develops as a result of a complex array of factors.   This creates a problem for a medical perspective that perceives symptoms, as being related to readily understood causal factors (Gorostiza & Manes, 2011, p211). In reality, the issue of cause and effect within the realm of mental health is much more complex (Gorostiza & Manes, 2011, p211).

Psychopathology – A Medical Definition.

According to the medical field, psychopathology can be defined as an inability to function on a daily basis.   Diagnosis is based on observed behavioral and psychological symptom patterns. (Maddux & Winstead, 2008).  From a medical perspective, two key requirements are essential for understanding psychopathology: “(1) concepts must unambiguously refer to observed clinical phenomena, and (2) symptoms, understood as conceptualized clinical data, must be stabilized by a causal account” (Gorostiza & Manes, 2011, p205).

When considering the issue of psychopathology from this perspective the problem of contextual blindness is immediately apparent (Daniels, 78). On the one hand, psychopathology can be best thought of as a mental construct based on personal meaning systems that are highly fluid and complex in nature (Gorostiza & Manes, 2011). On the other hand, a medical perspective very objective and rigid in focus (Gorostiza & Manes, 2011). This contextual blindness has deep historical roots in the origins of medical science.  In reality the concept of psychopathology, extends beyond the limited confines of a medical perspective (Daniels, 1009; Gorostiza & Manes, 2011; Maddux & Winstead, 2008).   To ignore this fact is to miss key “pieces of the puzzle”  In reality, “mental phenomena are referentially open” (Gorostiza & Manes, 2011, 214) as active processes that result from a dynamic interplay of complex factor.  It is in this respect that counseling is a much-needed counterpoint to the medical perspective that predominates mental health.

Mental Health Diagnosis

Initial Thoughts & Reactions

My beliefs about mental health diagnosis have been greatly influenced by observations in acute mental health settings. Overall, I’m pleasantly surprised by the changes made in the new DSM-5 Manual.   My assumptions and beliefs about diagnosis are listed below.

Diagnosis is a Messy Process

“In the real world, patients, like Shakespeare’s sorrows, tend to come not as single spies but battalions” (Morrison, 2014, p. 8). I love this quote from our textbook, because it summarizes my observations about mental health diagnosis. In acute care settings there is often an insufficient amount of time to gather all necessary information for a full evaluation. Currently, the idea of sorting through information in such a context seems daunting. My goal for this class is to develop a good picture of the process overall as it should occur in an ideal setting.   Realistically, learning to apply it in a real world context will come with have to come with practice.

Cultural Relativism Matters

As an individual who was raised in culturally diverse setting, I believe culture permeates every facet of our development. Culture influences not only our values and beliefs, but also how we think, behave, and feel. An assigned reading in my Social and Ccultural Diversity class provides interesting commentary relevant to this discussion. Johnson, (2013) states, “Cultural factors can influence the expression and interpretation of signs and symptoms. For example, practitioners commonly perpetuate racial biases…some examiners using the DSM-5 may function with unexamined assumptions or inadequate training.” (p. 20). On the basis of these observations, I believe it is critical for therapists to consider the influence of culture in their assessments.

Objectivity Trumps Subjectivity

In an acute care setting, diagnosis occurs according to Morrison’s (2014) observation that “signs trump symptoms” (p. 9). For example, clinical observations are used to contextualize a patient’s story. One criticism I have is the over-reliance of this viewpoint in acute care settings. Managing behaviors and assuring safety in this setting is the priority over other concerns.  Patient’s thoughts and feelings are contextualized in terms of a diagnosis. I feel when interacting with patients, time must also be taken to see beyond this diagnosis. As our textbook notes, a client’s “back story…provides meaning that illuminate(s) motives, actions, and emotions” (Morrison, 2014, p7).   While objectivity is important acknowledging a client’s subjective experiences is also critical.

Open-Mindedness is Important

            One final assumption I have about diagnosis and assessment is that they exist as a process and not an event. In this respect, I feel it is important to keep an open mind. Morrison, (2014) confirms this assumption with the following statement: “I want to encourage you to avoid a trap that any clinician can fall into: rushing headlong into diagnostic closure before having all the facts” (xii).

The Process of Diagnosis….

Diagnosis requires an understanding of etiology, the process of development, and possible treatment regimen.  Underlying this information is empirical research and “evidence-based” practice.  First in my old DSM class are notes on a plan of attack….

“The Plan of Attack”

  1. The first step is your initial diagnostic impressions. This involves creating groupings of symptoms into syndromes and simply listing them. This is allows you to form an initial diagnostic impressions, containing a potential list of relevant diagnosis.
  2. The second step is a differential diagnosis. Here, we narrow down our list of potential diagnoses. To accomplish this compare you compare observable symptoms with diagnostic criteria. This will help you decide which disorder (or disorders) best account for the symptoms. In class, we are asked to explain why we keep and reject a specific disorder and the logical underlying our decisions.
  3. The last step is a final diagnosis. Your final diagnosis reflects the decision you made, the diagnosis you feel most accurately accounts for the symptoms presented. The actual format for recording your final diagnosis will vary some depending upon the agency, insurance requirements, etc. However, at a minninum the final diagnosis should be reported with the correct code number, title (capitalized), and any necessary specifiers. Most disorders have coding notes and instructions for what specifiers are needed at the end of the Diagnostic Criteria section.

Suggestions from Morrison

Last week’s readings provided an overview of the process of diagnosis. The initial steps of this process include gathering information and identifying syndromes (Morrison, 2014). With this information in hand, therapists must construct a list of potential alternatives and determine an initial diagnosis (Morrison, 2014). A differential diagnosis “is a comprehensive list of conditions that could account for a patient’s symptoms” (Morrison, 2014, p14). Strategies that can aid in the construction of a differential diagnosis were discussed in this week’s readings (Morrison, 2014). These strategies are helpful in sorting through a complexity of symptoms as well as preventing therapists from diagnostic conclusions prematurely.

Safety Hierarchy

Morrison, (2014), suggests placing a list of potential diagnoses for consideration in a safety hierarchy. At the top of this hierarchy, are conditions that require urgent treatment and are likely to respond well (Morrison, 2014). Additionally, disorders due to physical disease or substance abuse should also be placed on top (Morrison, 2014). At the bottom of the list are conditions that are hard to treat with difficult outcomes.

An example from my own life experiences proves the utility of this strategy. As an infant, my son went into shock at home. This is a medical condition in which there is a lack of blood flow throughout the body. Causes of shock include: hypovolemic shock, cardiogenic shock, anaphylactic shock and septic shock. When I rushed him to the hospital, doctors recognized the condition immediately. They utilized a safety hierarchy similar to what is discussed in our textbook. Starting with the easiest to treat diagnoses, they assessed for dehydration and infection. After ruling out all possible alternatives it was finally determined my son had a congenital heart defect and required surgery. This process very much falls in line with the logic utilized in our textbook.

Decision Tree

Another strategy for differential diagnosis includes the decision tree. “A decision tree is a device that guides the user through a series of steps to arrive at some goal, such as diagnosis or treatment” (Morrison, 2014, p19). While not included in the DSM-5, the differential discussion sections under each diagnosis provide a similar logic. For example, the DSM-5 states the following regarding major neurocognitive disorder:

“[cognitive] difficulties must represent changes rather than lifelong patterns…[therapists must also] differentiate between [cognitive deficits] and motor or sensory limitations” (American Psychiatric Association, 2013, p608)

This insight suggests therapists must ask if observe deficits are the byproduct of recent events or symptoms of lifelong developmental patterns (American Psychiatric Association, 2013). Additionally, can cognitive deficits be explained by any sensory limitations, (American Psychiatric Association,

Diagnostic Uncertainty

The final bit of information I’d like to remember for future reference pertains to the issue of diagnostic uncertainty.   What follows are suggestions from our instructor in class:

First you have “Rule Out

There is not a code for this but you write out “Rule Out” followed by a specific disorder.  This means you have some evidence to suggest there could be a specific disorder, but not enough information to confirm or deny. For example, if parents suspect their son is using marijuana, you could record “Rule out Cannabis Use Disorder”.  This essentially says you should be on the look out for more information. I would list something as “rule out” in my final diagnosis if questions still remain after going through the differential process.

Then you have “Provisional Diagnosis”. 

This is given when you have a clear theory about a specific disorder, but need additional information to confirm.  This would be appropriate if you need results from a specific test (blood levels to see if it is medication induced) or a physician’s verification of a physical condition.  Perhaps you suspect substance use and the individual was not very cooperative, you may have a pretty good idea that they have a substance use disorder, but want this confirmed by another source such as a urine analysis.  With Rule Out I am not as confident about the disorder, but there is some evidence to suggest it should be explored.

Finally There is “Other/Unspecified”  

This is an actual diagnosis with the number determined by the class of disorders indicated.  These cases are tricky and rely heavily on clinical judgment.   “Other specified” is used when the presentation does not meet official criteria for a specific disorder within a specific a diagnostic class,  but the clinician communicates or “specifies” the specific reason why this is the case.  “Unspecified” also means the diagnosis does not meet the specific criteria but allows the clinician to choose not to explain the reason(s) why criteria are not met.  The unspecified/other diagnoses are given when you have enough information to be confident that the client has a disorder in a specific class.   This may occur because you do not have the complete picture of the symptoms or it may just be that this individual is experiencing the disorder in an atypical way so their pattern of symptoms does not quite match up.  The key is that the symptoms clearly indicate a class of disorders.   If you want to specify why they don’t quite match then use “Other specified”, if you don’t want to explain or cannot give a clear explanation then use “Unspecified”.  However, please understand that you are giving a diagnosis with a code when you do this.  You are saying they have a disorder.

References

Daniels, J. (2009). The perils of ‘adjustment disorder’ as a diagnostic category. Humanistic Counseling, Education and Development. 48(1). 77-90
Gorostiza, P.R. & Manes J.A. (2011). Misunderstanding psychopathology as medical semiology: An Epistemological inquiry. Psychopathology. 44, 205-215. doi: 10.1159/000322692.
Johnson, R. (2013) Forensic and Culturally Responsive Approach for the DSM-5: Just the FACTS. Journal of Theory Construction & Testing, 17(1), 18-22.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental healthclinicians, 2nd ed. New York, NY: The Guilford Press.
Maddux, J. & Winstead, B. (Eds.). (2008). Psychopathology: Foundations for a contemporary understanding (2nd ed.). New York, NY: Routledge. ISBN 978-0-8058-6169-3. (M&W)
Patrick, C (2012). Bellevue University – Defining Abnormality Video. Available from: https://cyberactive.bellevue.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_278013_1%26url%3D
Warren, J. (2012) Psychopathology defined in context. [Class handout, HS-513, Dr. Jane Warren, Bellevue, University]

 

 

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