disorder. Examples of Axis IV stressors are shown in Table 2.3 . As you can see, Axis IV conditions include the negative life events of losing a job, having an automobile accident, and breaking up with a lover. All of these conditions are stressors that can cause, aggravate, or even result from a psychological disorder. A depressed man might get into a serious traffi c acci- dent because he is so preoccupied with his emotions that he
does not concentrate on his driving. Alternatively, a person may become clinically depressed in the aftermath of a serious car accident. As you can see, the same life event can be either the result or the cause of a psychological problem.
For the most part, the life events on Axis IV are negative.
However, positive life events, such as a job promotion, might also be considered stressors. A person who receives a major TABLE 2.3 Axis IV of the DSM-IV-TR
Problem Category Examples Problems with primary support group: childhood Death of parent
Health problems of parent Removal from the home Remarriage of parent Problems with primary support group: adult Tensions with partner
Separation, divorce, or estrangement Physical or sexual abuse by partner Problems with primary support group: parent-child Neglect of child
Sexual or physical abuse of child
Parental overprotection
Problems related to the social environment Death or loss of friend
Social isolation
Living alone
Diffi culty with acculturation
Adjustment to life cycle transition (such as retirement) Educational problems Academic problems
Discord with teachers or classmates
Illiteracy Inadequate school environment
Occupational problems Unemployment Threat of job loss Diffi cult work situation
Job dissatisfaction Job change
Discord with boss or co-workers
Housing problems Homelessness
Inadequate housing
Unsafe neighborhood
Discord with neighbors or landlord
Economic problems Extreme poverty
Inadequate fi nances Serious credit problems Problems with access to health care services Inadequate health insurance
Inadequate health care services Problems related to interaction with the legal system/crime Arrest
Incarceration Victim of crime Other psychosocial problems Exposure to disasters
Loss of important social support services
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
Copyright © 2000 American Psychiatric Association.
50 Chapter 2 Classifi cation and Treatment Plans
TABLE 2.4 Axis V: Global Assessment of Functioning Scale
Rating Level of Symptoms Examples 91–100 Superior functioning; no symptoms
81–90 No symptoms or minimal symptoms; generally Occasional worries such as feeling understandably good functioning in all areas; no more than anxious before taking examinations or feelings of everyday problems disappointment following an athletic loss
71–80 Transient, slight symptoms that are reasonable Concentration diffi culty following an exciting day; trouble responses to stressful situations; no more than sleeping after an argument with partner
slight impairment in social, occupational, or school functioning
61–70 Mild symptoms, or some diffi culty in social, Mild insomnia; mild depression occupational, or school functioning
51–60 Moderate symptoms or moderate diffi culties Occasional panic attacks; confl icts with roommates in social, occupational, or school functioning
41–50 Serious symptoms or any serious impairment Suicidal thoughts; inability to keep job in social, occupational, or school functioning
31–40 Serious diffi culties in thought or communication Illogical speech; inability to work; neglect of or major impairment in several areas of responsibilities
functioning
21–30 Behavior infl uenced by psychotic symptoms Delusional and hallucinating; incoherent; preoccupied or serious impairment in communication or with suicide; stays in bed all day every day judgment or inability to function in almost
all areas
11–20 Dangerous symptoms or gross impairment in Suicide attempts without clear expectation of death;
communication muteness
1–10 Persistent danger to self or others or persistent Recurrent violence; serious suicidal act with clear inability to maintain hygiene expectation of death
0 Inadequate information
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
Copyright © 2000 American Psychiatric Association.
The Diagnostic Process
The diagnostic process involves using all relevant information to arrive at a label that characterizes the client’s disorder. This information includes the results of any tests given to the cli- ent, material gathered from interviews, and knowledge about the client’s personal history. The end result of the diagnostic job promotion may encounter psychological diffi culties due
to the increased responsibilities and demands associated with the new position.
Axis V: Global Assessment of Functioning
Axis V is used to document the clinician’s overall judgment of a client’s psychological, social, and occupational functioning.
Ratings are made for the client’s current functioning at the point of admission or discharge, or the highest level of func- tioning during the previous year. The rating of the client’s functioning during the preceding year provides the clinician with important information about the client’s prognosis, or likelihood of recovering from the disorder. If a client has func- tioned effectively in the recent past, the clinician has more reason to hope for improvement. The prognosis may not be so bright if a client has a lengthy history of poor adjustment.
The Global Assessment of Functioning (GAF) scale, which is the basis for Axis V, allows for a rating of the individual’s overall level of psychological health. The full scale is shown in Table 2.4 .
REVIEW QUESTIONS
1. What is the difference between reliability and validity in
the context of psychiatric diagnosis?
2. In the DSM-IV-TR, refers to a class of informa-
tion such as the primary diagnosis.
3. What DSM-IV-TR axis would be used to document a
client’s medical conditions?
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In addition to listening to the client’s description of symptoms, the clinician also attends to the client’s behavior, emotional expression, and style of thinking. For example, a client with very severe depression may be immobilized and unable to verbalize, leaving the clinician to infer that the client is depressed.
Diagnostic Criteria and Differential Diagnosis
The next step is to obtain as clear an idea as possible of the client’s symptoms and to determine the extent to which these symptoms coincide with the diagnostic criteria of a given disorder. What does Peter mean when he says that he has
“bouts of anxiety”? After Dr. Tobin asks him this question, she listens to determine whether any of his symptoms match the DSM-IV-TR criteria for anxiety: Do his hands tremble?
Does he get butterfl ies in his stomach? Does he feel jittery and irritable or have trouble sleeping? Dr. Tobin keeps a mental tally of Peter’s symptoms to see if enough of the appropriate ones are present before she decides that his state is, in fact, anxiety and that he might therefore have an anx- iety disorder.
As she listens to Peter’s symptoms, Dr. Tobin discovers that he has also experienced severe depression within the past few months. This discovery leads her to suspect that perhaps Peter does not have an anxiety disorder after all.
Now, as she sorts through the facts of his story, she starts to see his highly energized behavior as the classic symptoms of a mood disturbance. Based on this decision, Dr. Tobin then turns to a guide that she will follow to sort through the information she has gathered. This guide takes the form of a decision tree, a series of simple yes/no questions in the DSM-IV-TR about the client’s symptoms that lead to a possible diagnosis. Like the branches of a tree, the assess- ment questions proposed by the clinician can take different directions. There are different decision trees for many of the major disorders. Dr. Tobin can use the decision tree for mood disorders to narrow down the possible diagnoses and make sure that she has considered all the options in Peter’s case.
The decision tree with the specifi cs of Peter’s case is shown in Figure 2.1 . Although there are many more steps in this tree than are represented here, you can see the basic logic of the process in this simplifi ed version. Dr. Tobin be- gins with the mood disturbance decision tree, because she has already decided that Peter’s symptoms might fi t the diag- nostic criteria for a mood disorder. Going through the steps of the decision tree, Dr. Tobin begins with the recognition that Peter has been depressed and that his mood is now both expansive and irritable. Although she will request a complete medical workup, there is no evidence at the moment that his symptoms are physiological effects of a medical condition or drugs. She then focuses on the nature of the present mood episode and concludes that Peter may be experiencing a manic episode. It also appears that Peter has experienced a major depressive episode as well. Now, the question is process is a diagnosis that can be used as the basis for the
client’s treatment.
Although this defi nition makes the diagnostic process sound straightforward, it usually is not so simple. In fact, the diagnostic process can be compared to the job of a detective trying to solve a complicated case. A good detec- tive is able to piece together a coherent picture from many bits and pieces of information, some of which may seem in signifi cant or even random to the untrained observer.
Similarly, a good clinician uses every available piece of infor- mation to put together a coherent picture of the client’s condition. Fortunately, some of this information is readily available, such as the client’s age, gender, and ethnicity. This background data can help the clinician gauge the likelihood that a client has a particular disorder. For example, if a 20-year-old were to seek treatment for symptoms that appeared to be those of schizophrenia, the clinician’s ideas about diagnosis would be different than if the individual were 60 years old. Schizophrenia often makes its fi rst appearance in the twenties, and, with a client of this age who shows possible symptoms of schizophrenia, the diagno- sis is plausible. On the other hand, if the client were 60 years old and showing these symptoms for the fi rst time, other disorders would seem more likely. Similarly, the client’s gen- der can provide some clues for diagnosis. Some conditions are more prevalent in women, so the clinician is more likely to consider those when diagnosing a woman. Finally, the individual’s social and cultural background may provide some clues in the diagnostic process. The clinician may fi nd it helpful to know about the religious and ethnic back- ground of clients if these are relevant to the kind of symp- toms they are exhibiting. For example, a client from a country in which the voodoo religion is practiced might complain that she has been “cursed.” Without knowing that such a belief is perfectly acceptable within the voodoo reli- gion, the clinician may mistakenly regard this statement as evidence of a serious psychological disorder. We will talk more about the role of culture when we examine the issue of cultural formulations later in the chapter.
We will return now to Peter’s symptoms and will discuss the diagnostic process Dr. Tobin would use to evaluate him.
You will see how she uses the tools of the detective to arrive at the diagnosis.
The Client’s Reported and Observable Symptoms
Remember that Peter fi rst describes his symptoms as involv- ing “bouts of anxiety.” When Dr. Tobin hears the word anxiety, she immediately begins thinking about the DSM-IV- TR criteria for an anxiety disorder. This is the fi rst step in the diagnostic process. Dr. Tobin listens for a key word or phrase in the client’s self-report of symptoms and observes how the client acts. That gives her a clue about what to look for next. In the process of following up on this clue, Dr. Tobin will gain more information about the symptoms that Peter reports.
52 Chapter 2 Classifi cation and Treatment Plans
whether Peter has psychotic symptoms at times other than during these episodes. Assuming he does not, it means that Peter should be diagnosed as having bipolar disorder (for- merly referred to as manic depression), a mood disorder that involves the experience of a manic episode and commonly a depressive episode. If he did have psychotic symptoms at times other than during his mood episodes, Peter would be diagnosed as suffering from another disorder related to schizophrenia.
The fi nal step in the diagnostic process is for Dr. Tobin to be sure that she has ruled out all possible alternative diagnoses, either by questioning Peter or by reviewing the
information she has already collected. This step, called dif- ferential diagnosis, will probably have been completed already, because Dr. Tobin has been through the decision tree pro- cess. However, Dr. Tobin must be confi dent that Peter fi ts the diagnostic criteria for bipolar disorder.
One question that Dr. Tobin might have is whether Peter’s symptoms might be due to drug use or to an undi- agnosed medical condition. If Peter had been abusing amphetamines, he might have had symptoms like those of a manic episode. Alternatively, a person with a brain tumor might show mood disturbances similar to those of a person with mania. In the process of differential diagnosis, the clini- cian must ensure that there is not a physiological basis for the symptoms. Virtually all the diagnoses on Axis I of the DSM-IV-TR specify that the clinician should rule out this possibility. There is an entire category of disorders on Axis I termed “mental disorders due to a general medical condi- tion.” Another category applies to disorders due to the abuse of psychoactive substances.
The diagnostic process often requires more than one ses- sion with the client, which is why some clinicians prefer to regard the fi rst few psychotherapy sessions as a period of evaluation or assessment. While some therapeutic work may be accomplished during this time, the major goal is for the client and clinician together to arrive at as thorough an understanding as possible of the nature of the client’s disor- der. This paves the way for the clinician to work with the client on an agreed-on treatment plan.
Peter’s diagnosis was fairly straightforward; however, there are many people whose problems do not fi t neatly into a diagnostic category. The problems of some individuals meet the criteria for two or more disorders. The most com- mon instance is when a person has a long-standing personal- ity disorder as well as another more circumscribed problem, such as depression or a sexual disorder. It is also possible for an individual to have two concurrent Axis I diagnoses, such as alcoholism and depression. When clinicians use mul- tiple diagnoses, they typically consider one of the diagnoses to be the principal diagnosis —namely, the disorder that is considered to be the primary reason the individual is seeking professional help.
Final Diagnosis
The fi nal diagnosis that Dr. Tobin assigned to Peter incor- porates all the information gained during the diagnostic phase of his treatment. Clinicians realize the importance of accuracy in designating a fi nal diagnosis, as this label will set the stage for the entire treatment plan. Dr. Tobin’s diagnosis of Peter appears in her records as follows:
Axis I: 296.43 Bipolar I Disorder, most recent episode manic, severe without psychotic features Axis II: Diagnosis deferred (no information yet available
on Peter’s long-standing personality traits)
Diagnostic questions
Depressed, elevated, expansive, or irritable mood?
Due to the direct physiological effects of a general medical condition?
Due to the direct physiological effects of a substance?
Manic episode: Elevated, expansive, or irritable mood, at least 1-week duration; marked impairment?
Major depressive episode: At least 2 weeks of depressed mood or loss of interest plus associated symptoms?
Psychotic symptoms occur at times other than during manic episodes?
Final Diagnosis: Bipolar I Disorder Yes
No
Yes No
Yes No
Yes No
Yes No
Yes No
FIGURE 2.1 Dr. Tobin’s decision tree for Peter Decision trees provide choices for the clinician based on the client’s history and symptoms. Follow the choices made by Dr. Tobin throughout the tree for mood disturbances, the area that seems most appropri- ate for Peter.
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Axis III: No physical conditions reported
Axis IV: Problems with primary support group (divorce) Axis V: Current Global Assessment of Functioning: 43
Highest Global Assessment of Functioning (past year): 80
Case Formulation
Once the formal diagnosis is made, the clinician is still left with a formidable challenge—to piece together a picture of how the disorder evolved. A diagnosis is a categorical judg- ment, and, although it is very informative, it does not say much about the client as an individual. To gain a full ap- preciation of the client’s disorder, the clinician develops a case formulation: an analysis of the client’s development and the factors that might have infl uenced his or her current psy- chological status. The formulation provides an analysis that transforms the diagnosis from a set of code numbers to a rich piece of descriptive information about the client’s per- sonal history. This descriptive information helps the clini- cian design a treatment plan that is attentive to the client’s symptoms, unique past experiences, and future potential for growth.
Let’s return to Peter’s case. Having diagnosed Peter as having bipolar disorder, Dr. Tobin uses the next two therapy sessions with him to obtain a comprehensive review of his presenting problem as well as his life history. Based on this review, Dr. Tobin makes the following case formulation:
Peter is a 23-year-old divorced White male with a diagnosis of bipolar disorder. He is currently in the middle of his fi rst manic episode, which follows his fi rst major depressive episode by about 4 months. The precipitant for the onset of this disorder several months ago seems to have been the turbulence in his marriage and the resulting divorce.
Relevant to Peter’s condition is an important fact about his family—his mother has been treated for a period of 20 years for bipolar disorder. Peter’s diagnosis appears to be a function of both an inherited predisposition to a mood disorder and a set of experiences within his family.
The younger child of two boys, Peter was somehow singled out by his mother to be her confi dant. She told Peter in detail about her symptoms and the therapy she was receiving. Whenever Peter himself was in a slightly depressed mood, his mother told him that it was probably the fi rst sign of a disorder he was bound to inherit from her. Her involvement in his emotional problems creates another diffi culty for Peter in that it has made him ambiv- alent about seeking therapy. On the one hand, he wants to get help for his problems. Counteracting this desire is Peter’s reluctance to let his mother fi nd out that he is in therapy, for fear that this information will confi rm her dire predictions for him.
This case formulation gives a more complete picture of Peter’s diagnosis than does the simple diagnosis of bipolar disorder. Having read this case formulation, you now know
some important potential contributions to Peter’s current dis- order. In effect, in developing a case formulation, a clinician proposes an hypothesis about the causes of the client’s dis- order. This hypothesis gives the clinician a logical starting point for designing a treatment and serves as a guide through the many decisions yet to be made.
Cultural Formulation
As American culture becomes increasingly diverse, experi- enced clinicians must broaden their understanding of ethnic and cultural contributions to psychological problems. To middle-class White clinicians, some conditions might seem strange and incomprehensible without an awareness of the existence of these conditions within certain other cultures.
Consequently, with clients from culturally diverse back- grounds, it is important for clinicians to go beyond the multi- axial diagnostic process of the DSM-IV and to evaluate conditions that might be culturally determined. In these cases, a cultural formulation is developed. This is a formula- tion that takes into account the client’s degree of identifi ca- tion with the culture of origin, the culture’s beliefs about psychological disorders, the ways in which certain events are interpreted within the culture, and the cultural supports available to the client.
The individual’s degree of involvement with the cul- ture is important for the clinician to know, because it indi- cates whether the clinician should take into account cultural infl uences on the client’s symptoms. Clients who do not identify with their culture of origin would not be expected to be as affected by cultural norms and beliefs as would those who are heavily involved in their culture’s tra- ditions. First, the client’s familiarity with and preference for using a certain language is an obvious indicator of cultural identifi cation. Second, assuming that the client does identify with the culture, it is necessary to know about cultural explanations of the individual’s symptoms. In certain
Clinicians go through a process of differential diagnosis in which they consider all possible alternative diagnoses.
