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DIAGNOSIS

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					DIAGNOSIS
Why diagnose?
   To define clinical entities
     Typical symptom cluster
     Natural history

     Causes

   To determine treatment
Arguments Against
 Diagnosis is imposed from outside
  by an expert, not by the client.
 Diagnostic categories minimize the
  uniqueness of each client.
 Focus on signs and symptoms
  ignores capacity for self-healing.
More Arguments Against
 Diagnosis is inconsistent with a
  strengths approach.
 Diagnosis can lead to self-fulfilling
  prophecy and despair.
 Diagnosis leads professionals to
  ignore significant data that do not
  support the diagnosis.
More Arguments Against
 Diagnosis leads to identification of
  pathology as being within individuals
  instead of within systems.
 The diagnostic system tends to
  ignore culture, age, gender, etc.
 Many people who use the DSM are
  not qualified to use it.
Rebuttals to Arguments
 If the phenomena exist, for
  professionals to ignore them
  regardless of client perception would
  be irresponsible.
 Diagnostic categories don’t minimize
  client uniqueness, although people
  might.
More Rebuttals
 Diagnosis does not minimize self-
  healing, and may facilitate it, if it is
  associated with good data.
 The strengths perspective does not
  ask us to ignore the identification
  and definition of problems.
More Rebuttals
 Diagnosis can lead to change and
  hope.
 Skilled practice does not ignore
  data. Diagnosis helps organize
  data.
 If some pathology does exist within
  individuals, to ignore the fact would
  not help change the system.
More Rebuttals
   If diagnostic labels accurately
    describe real sets of phenomena,
    the prevalence rates among groups
    is a matter for research, not for
    throwing out the labels just because
    they fit more members of some
    groups than others.
More Rebuttals
   If people don’t know how to use a
    tool, training on the use of the tool
    and limiting access to those who
    know how to use the tool make
    more sense than throwing out the
    tool.
Arguments for Diagnosis
 Diagnosis is required for
  reimbursement.
 Clear definition of problems is
  necessary for focused treatment .
  Diagnosis is a tool for definition.
 To work in the field, workers must
  use diagnostic procedures.
More Arguments For
 Standard diagnostic nomenclature is
  essential for communication with
  other professionals.
 Diagnosis sets a path toward
  appropriate treatment.
 The diagnostic process helps
  differentiate problems.
More Arguments For
 Diagnosis helps workers screen for
  problems and manage client safety.
 Accurate diagnosis is necessary for
  the research foundation of evidence-
  based practice.
Rebuttals to Arguments For
 “Required for reimbursement” is not
  a compelling moral argument.
 “Required to work in the field” is not
  a compelling moral argument.
 Others?
Signs, Symptoms, and
Issues
 Signs – observable phenomena
 Symptoms – subjective experiences
 Issues – ideas about signs,
  symptoms, and circumstances
Diagnostic approaches
 Descriptive – the “what”
 Psychological or inferential – the
  “why”
 Dimensional – focuses on elements,
  not categories
Diagnostic approaches -
continued
   Categorical – implies that the
    categories are discovered
     Observation leads to recognition of
      clusters
     Diagnoses are labels of clusters
Limitations of a categorical
approach
 Categories are not necessarily
  homogeneous.
 Boundaries between classes are not
  always clear.
 Classes are not mutually exclusive.
Two diagnostic principles
 Parsimony
 Hierarchy
Seven steps for diagnosis
 Collect data
 Identify pathology
 Evaluate data reliability
 Determine the distinctive feature
 Arrive at a diagnosis
 Check diagnostic criteria
 Resolve diagnostic uncertainty
What is a mental disorder?
 It is what we define it to be.
 A clinically significant
 behavioral or psychological
  syndrome or pattern
 that occurs in an individual,
 is associated with present distress or
  disability
Mental disorder - continued
 or significantly increased risk of
  death, pain, disability
 or important loss of freedom.
 The behavior or pattern must not be
 an expectable or culturally
  sanctioned
 response to an event.
The DSM is meant to be
used by people;
 with appropriate training and
  experience,
 who know how to use clinical
  judgment,
 who have directly assessed the
  individual.
 See the “cautionary statement.”
Ethnic and Cultural
Considerations
 Culture may influence expression of
  illness. Individuals have a right to
  define their culture.
 Pathology must be diagnosed within
  a cultural context.
Ethical Considerations

 Why would a social worker use
  psychiatric diagnoses?
 Who may diagnose mental illness?
 What are the implications of
  labeling?
 Who should know what labels are
  being used?
 What do the labels mean to the
  individuals?
The Multiaxial System
 Axis I – Clinical Disorders and Other
  Conditions
 Axis II – Personality Disorders
 Axis III – General Medical Conditions
 Axis IV – Psychosocial and
  Environmental Problems
 Axis V – Global Assessment of
  Functioning
Major Diagnostic
Categories

   Disorders usually first diagnosed in
    infancy, childhood, or adolescence
     Mental Retardation
     Learning Disorders

     Motor Skills Disorder
Childhood disorders -
continued
  Communication Disorders
  Pervasive Developmental Disorders

  Attention Deficit and Disruptive
   Behavior Disorders
Childhood disorders -
continued

  Feeding and Eating Disorders of Infancy
   and Early Childhood
  Tic Disorders

  Elimination Disorders

  Other Disorders of Infancy, Childhood,
   and Adolescence
Diagnoses - continued
 Delirium, Dementia, Amnestic, and
  Other Cognitive Disorders
 Mental Disorders Due to a General
  Medical Condition Not Elsewhere
  Classified
 Substance Related Disorders
 Schizophrenia and Other Psychotic
  Disorders
Diagnoses - continued
 Mood Disorders
 Anxiety Disorders
 Somatoform Disorders
 Factitious Disorders
 Dissociative Disorders
 Sexual and Gender Identity
  Disorders
 Eating Disorders
Diagnoses - continued
 Sleep Disorders
 Impulse-Control Disorders Not
  Otherwise Classified
 Adjustment Disorders
 Personality Disorders
Diagnoses - continued
   Other Conditions That May Be a
    Focus of Clinical Attention
     Psychological Factors Affecting
      Medical Condition
     Medication-Induced Movement
      Disorders
     Other Medication-Induced Disorder

     Relational Problems
Other - continued
  Problems Related to Abuse or Neglect
  Additional Conditions That May Be a
   Focus of Clinical Attention
Additional Codes
  Unspecified Mental Disorder
  No Diagnosis

  Diagnosis Deferred
Lingering Questions
 Is conservative diagnosis more
  ethical than liberal diagnosis?
 Must someone have an illness to
  need treatment?
 Must someone have an illness to
  benefit from treatment?
 Do we treat illness or people?
Childhood
Depression as an
Example
Is there such a thing as
depression in children?
 Some say yes.
 Some say no.
Views of depression in
children.
 It is a developmental condition that
  disappears with time.
 It is similar to adult depression, with
  some additional features.
 It is not expressed in overt
  depressive symptoms but is masked
  by other symptoms.
Views continued
 Young children cannot be depressed
  because they lack the cognitive
  development necessary for the
  psychological mechanisms involved
  to occur.
 It is a result of the loss of the love
  object and may occur in infants.
Views continued
 There is a biological basis.
 It is triggered by events.
 It is consequent to the difficulties
  imposed by other illnesses such as
  attention deficit problems and other
  learning problems.
Views continued
 It is the consequence of faulty
  cognitions.
 It is a behavioral response to
  punishment or lack of
  reinforcement.
 It is a response to anxiety.
 It is learned helplessness.
Views continued
   There are many psychoanalytic
    views hinging on putative
    psychological mechanisms.
Problems
 Depression is not a thing.
 Depression as an illness and
  depression as a mood are confusing
  concepts.
 If we define depression as a set of
  symptoms, we enter into circular
  logic.
Problems continued
   If we define depression as a certain
    biochemical condition, we ignore the
    behavioral manifestations. There
    may be people with the biochemical
    condition who don't have symptoms,
    and there may be people with
    symptoms without the biochemical
    condition.
Problems continued
 We have similar problems if we
  define it by its response to
  antidepressants.
 Any definition that involves
  psychological mechanisms is not
  subject to disproof and consequently
  is not scientific.
Problems continued

   "It would be unethical to assume
    that a child manifesting no clear
    signs of depression is nevertheless
    depressed, particularly if this
    resulted in the administration of
    antidepressant drugs. It would be
    unwise and unscientific, however,
    to assume that depression, as a
    primary problem, does not occur in
    children."
Common signs and
symptoms of depression
 persistent depressive mood for two
  weeks or more
 inability to derive pleasure from
  normal activities
 loss of interest in normal activities
 psychomotor retardation or agitation
Signs and symptoms
continued
 sleep disturbance
 loss or increase of appetite
 sense of hopelessness
 sense of worthlessness
Signs and symptoms
continued
 impaired memory and concentration
 suicidal thoughts
 irritability
 anxiety
Signs and symptoms
continued
   A convenient way of thinking of
    depression is that it looks like a
    normal grief reaction, but it lasts
    longer.
Types of depression:

  major depression, with several
  subtypes;
 dysthymia;
 depression as part of bipolar
  disorder;
 depression as part of cyclothymia;
 adjustment disorders, normal
  bereavement, and other normal
  reactions to circumstances.
Conditions that mitigate
against a diagnosis
 Bizarre behavior, delusions, or
  hallucinations in the absence of
  the depression
 A known organic cause for the
  depression
 Depression following the loss of a
  loved one
 A depression of less than two
  weeks duration
Important considerations
   Depression should be formally
    diagnosed only by someone with
    sufficient training and experience to
    adequately consider all of the
    relevant factors and to rule out
    other illnesses that may present as
    depression. This will usually mean a
    medical doctor with specialized
    training in child psychiatry.
Considerations continued
 Depression involves all body
  systems.
 Depression may have behavioral
  manifestations.
 Depression interferes with normal
  thinking patterns.
Cognitive Distortions of
Depression
 difficulty concentrating and
  remembering
 exaggerations or misinterpretations
  of events
 extreme or absolute judgements
 over generalization
Distortions continued
 focus on details to the exclusion of
  other data
 draw inferences in the absence of
  supporting evidence
 attribute personal significance to
  unpleasant events
Treatment of Depression

 serotonin reuptake inhibitors
  (Celexa, Paxil, Prozac, Zoloft)
 tricyclics and heterocyclics
  (Anafranil, Desyrel, Pamelor, Elavil)
 monoamine oxidase inhibitors
  (Marplan, Nardil, Parnate)
Treatment - continued
 Cognitive Behavioral Therapy
 Interpersonal Therapy

				
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posted:11/2/2011
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