HOW PSYCHIATRIC DIAGNOSIS ARE MADE:
THE DIAGNOSTIC AND STATISTICAL MANUAL (DSM IIR)
Since 1952 with the appearance of the first American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, clinicians have had access to an official manual containing symptomatic descriptions of psychiatric diagnostic categories. Prior to this original edition, there was little in the way of organized or uniform diagnosis of psychiatric disorders. Psychiatry may be one of the more subjective areas of medical science. Both patient presentation and interpretation of presenting symptoms through the individual clinicians’ theoretical orientation have been factors which may account for variation in diagnosis of similar symptom clusters. The DSM I may be seen as an effort by the Americana Psychiatric Association to assist clinicians to view psychiatric symptom clusters more congruently. Also, psychiatry is a field where clinicians other than MD’s apply diagnostic labels, Using a nationally approved and disseminated glossary of diagnostic categories allow allied mental health professionals such as psychologists, social workers, nurses and MFCC’s the same access to psychiatric descriptions and diagnostic nomenclature.
In 1968 the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) appeared followed by the DSM-III in 1974. Continual review and updating of the SAM reflects the dynamic nature of psychiatry and the evolving knowledge base revealed through on-going research.
Currently in use since 1987 is the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-IIIR). The large, multidisciplinary work group who gathered to revise the DSM-III was charged with the task of increasing the sensitivity in certain diagnostic categories including sleep disorders, anxiety disorders, childhood psychiatric disorders and psychosis. Need for revision of diagnostic categories was based on research when well-conducted scientific studies were available; clinical experience, however, was a significant factor in diagnostic revisions. The APA recognizes that the DSM must support validity and reliability of diagnosis and that diagnosis is the foundation on which treatment and management decisions are made. Additionally, the DSM is used for educating a variety of health professionals and as a reference in many aspects of research; it must be accepted across a wide range of theoretical viewpoints and maintain compatibility with ICD-9-CM codes.
THE AXIS SYSTEM
The most current edition, the DSM-IIIR emphasizes that the text classifies mental disorders not people. A mental disorder is described as a “clinically significant behavioral or psychological syndrome or pattern that occurs in a person and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (DSM-IIIR p. XXII). The DSM-IIIR focuses on describing the clinical features of psychiatric disorders and provides guidelines including specific criteria for establishing diagnosis. A multiaxial system is utilized in DSM-IIIR which incorporates mental disorders, physical illnesses or conditions, psychosocial stressors and global level of overall functioning. This system reflects a biopsychosocial assessment focus. The 5 axis of the system are:
Axis I Clinical Psychiatric Syndromes
Axis II Developmental Disorders
Axis III Physical Disorders and Conditions
Axis IV Severity of Psychosocial Stressors
Axis V Global Assessment of Functioning (GAF)
Multiple diagnoses are acceptable on Axis I and II when this accurately reflects an individual’s conditions. Just as a person may have several medical diagnoses, it is possible to have co-existing mental disorders.
Axis I disorders are clinical syndromes. Some examples of these include Major Depression, Adjustment Disorder, Schizophrenia or Alcohol Dependence. Obviously an individual could conceivably have two or even more of these diagnoses concurrently on Axis I.
Axis II is used to list Developmental Disorders and Personality Disorders. Both of these are generally disorders which begin in early life and continue through adulthood. Developmental disorders involve a delay or a failure to progress in skill acquisition of a motor, social, cognitive or language nature. The term personality disorder is used to describe a constellation of rigid, maladaptive personality traits which cause the individual significant distress, relationship difficulties and functional impairment. Personality disorders are often recognized during adolescence and persist through adulthood.
Examples of Developmental Disorders which would appear on Axis II include:
Autistic Disorder, Developmental Expressive Writing Disorders, or Attention Deficit Hyperactivity Disorder.
Personality Disorders which would also be listed on Axis II are Antisocial Personality Disorder, Histrionic Personality Disorder or Narcissistic Personality Disorder, to name a few.
On Axis III the clinician lists any physical disorders which are known to be current or, if pertinent, by history.
Axis IV is the severity of psychosocial stressors scale. Here the clinician codes the life stressors of the past year which may have contributed to the clients current diagnosis on a 1 – 6 scale – one being none through 6 being catastrophic. Clinical judgment is exercised in rating the stress an “average” individual in similar circumstances would experience from the psychosocial stressors in the clients’ life over the preceding year.
The Global Assessment of Functioning scale allows the assessing clinician to indicate an overall impression of the client’s level of functioning currently and within the past year. The numerical value given from 90 – 1 reflects the range of optimal mental health ---- severe illness. Psychological, social and occupational function are all assessed and integrated into a numerical GAF expressed as:
Axis V: Current GAF Highest GAF, past year
The highest GAF, past year has prognostic value as it indicated the level of functioning available to the client prior to the onset of acute psychiatric illness and, for most individuals, indicates the level of function they can expect to resume after resolution of their current difficulty.
In summary, a complete multiaxial assessment based on the DSM-IIIR will result in a 5 axis diagnosis including:
DIAGNOSIS |
EXAMPLE |
Axis I Axis II
Axis III (Medical) Axis IV
Axis V |
Major Depression
Narcissistic Personality
Status Post CVA
Current GAF: 35 |
Most of the DSMIII-R is dedicated to describing psychiatric syndromes and developmental disorders. Consistent information is provided for each diagnostic label. Information includes essential features; associated features; typical age at onset; typical course of the illness; typical impairment; complications; predisposing factors; prevalence in the general population and sex ratio; familial pattern; and differential diagnosis.
COMMON PSYCHIATRIC DIAGNOSIS
Certain psychiatric diagnoses occur more frequently in the general population than others. Diagnoses that are prevalent in our culture include:
Axis I Depression Disorder 3 – 9%
(Major depression)
Schizophrenia .2 – 1%
Bipolar Disorder .4 – 1.2%
Alcohol Abuse or
Dependence 13%
Adjustment Disorders
Axis II Personality Disorders of all types
As the stigma associated with mental illness diminishes and general understanding of psychiatric problems increases, patients with psychiatric diagnosis utilizing psychiatric medications will be seen more frequently in the medical hospital, the physician’s office, medical clinics and other health care settings. Nurses can frequently enhance patient care by assuring integration of care.
This section will conclude with two case examples of patients with current acute medical problems who also have secondary psychiatric diagnosis which require on-going attention.
CLINICAL PRESENTATIONS
EXAMPLE 1
Mrs. Drew is a 47 year old married woman who is admitted to 3 North post-op after orthopedic surgery. She was injured in a MVA and brought to surgery after assessment in the ERD. Her physical condition is stable – she is awake and alert but is quiet, rather withdrawn, has little variance in facial expression or tone of voice, and her eye contact with you is minimal. When you interact with her she answers questions rather abruptly and makes no attempt to converse or be social. You notice that you feel somewhat uncomfortable or anxious around her. Later in the shift, Mrs. Drew’s husband comes in to visit. You observe their interaction and notice that the quality of Mrs. Drew’s interaction with her husband is quite similar to her interactional style with you. As Mr. Drew leaves, you ask if you can speak with him for a moment and question him about his wife’s interpersonal style and subdued affect. In attempting to thoroughly assess your patient’s emotional state you might ask: “Is this her usual personality style? Or “Is Mrs. Drew subdued as a consequence of the physical and emotional trauma associated with her accident?” or “Could her behavior be part of her reaction to pain medication?” These are some of the differentiating questions that occur to you. Mr. Drew is receptive to your inquiry and states, “My wife is schizophrenic. She was diagnosed many years ago. This information needs to be in her chart as she must be maintained on anti-psychotic medication. As a matter of fact, I plan to notify her psychiatrist of her hospitalization tomorrow and hope she can visit my wife soon.” You request the name and phone number of Mrs. Drew’s psychiatrist as well as the names and dosages of her psychiatric medication. You also ask Mr. Drew for any suggestions he has which could assist the nursing staff and Mrs. Drew cope with the stress of her hospitalization. Then you report the information you have gathered to the nurse manager and Mrs. Drew’s primary care physician. You may suggest that Mr.. Drew contact Mrs. Drew’s primary care physician with this information as well.
EXAMPLE 2
Mr. Johns, a 52 year old male is admitted to your med-surg unit after several days in CCU. His cardiac condition is stable and in reporting his treatment, the CCU nurse notes that he is on 20 mg of Prozac each morning. You ask why he’s receiving Prozac and are told he’s been on it for 5 months since being hospitalized for major depression. In interviewing Mr. Johns you inquire about his depression. He relates he was hospitalized at age 35 for depression after losing a young son in an accident. At that time, he was in the hospital for 5 ½ weeks after a suicide attempt. He took 2 different anti-depressants as the first one was ineffective. More recently, Mr. Johns’ became depressed when he believed his job to be threatened by company downsizing and after the marriage of his youngest daughter who moved to Hawaii. Although Mr., Johns was not suicidal 5 months ago, he experienced early morning awakening; obsessive negative thoughts related to his fears of job loss; anorexia; lack of motivation and slowing of his speech. His wife insisted he seek psychiatric care after he refused to get out of bed for an entire weekend. He was hospitalized for 5 days. Prozac was begun immediately and he’s continued at 20 mgs every AM. He is willing to discuss how his current illness has affected his depression, denies any suicidal ideas and agrees when you suggest that his psychiatrist should be notified of his current health problems. Mr. Johns thanks you for your interest and understanding. He feels somewhat embarrassed by his psychiatric illness but is relieved to have his “cards on the table”.
In both of these situations, adverse consequences could result from the discontinuation of psychiatric medications or the avoidance of the psychosocial component of the patients total health picture. Each patient’s medical condition, length of stay, and response to treatment could be negatively impacted if the psychiatric history were ignored or undiscovered.
Next: ASSESSMENT SKILLS IN A CRISIS SITUATION