Introduction to the
Significance of Mental Illness
DSM-IV and
Psychological Testing In any given year, how many Americans
will suffer with a diagnosable mental
illness?
How many will suffer with a “serious”
mental illness?
For Americans age 15-44, mental
disorders are the leading cause of
disability
(NIMH, 2008)
When an individual is experiencing a mental Primary care physicians frequently encounter
health problem, who does he/she see first, a Clinical Depression (19 million Americans)
psychiatrist or primary care physician? and Generalized Anxiety Disorder (4 million
(NMHA, 2001) Americans)
(America’s Mental Health Survey, 2001)
Although individuals expect their primary care It is important for chiropractors to talk to their
physician to play a significant role in their patients about mental health
recovery process, the majority of patients in
the America’s Mental Health Survey reported It is also important for chiropractors to know
that they had to bring up mental health, how to identify, monitor, treat, and refer
otherwise it was not discussed by their PCP patient’s with mental disorders
(America’s Mental Health Survey, 2001)
Abnormal Psychology (D,P,E,C)
What is abnormal? (4 Ds)
1
DSM DSM-I and DSM-II
The Diagnostic and Statistical Manuals of The DSMs have changed as the prevailing
Mental Health (DSM) are handbooks concepts of mental disorders have changed
developed by the American Psychiatric DSM-I (1952) reflected Adolf Meyer’s
Association influence on psychiatry, and classified
mental disorders as various “reactions” to
Contains listings and descriptions of stressors
psychiatric diagnoses, analogous to the DSM-II (1968) dropped the reactions
International Classification of Diseases concept, but maintained a perspective
manual (ICD) influenced by psychodynamic theory
DSM-I and DSM-II DSM-III
Both the DSM-I and DSM-II had DSM-III (1980) – A watershed event
problems with reliability in diagnosing American psychiatry
mental illness It outlined a research-based, empirical,
and phenomenologic approach to
diagnosis, which attempted to be
Both lacked standardized diagnostic atheoretical with regard to etiology
criteria and assessment instruments
(Frances, Mack, Ross, First, 2000)
DSM-IV DSM-IV
DSM-IV continues the DSM-III tradition The DSM-IV serves as:
It is characterized as the “biologic” approach Guide for clinical practice
to diagnosis
Facilitates research and improved
It contains listings and descriptions of
psychiatric diagnoses communication between clinicians and
researchers
Is a tool used to teach
psychopathology
2
DSM-V
DSM-V is currently being developed What does the term mental disorder imply?
and is tentatively due for publication in
2011 Is there really a distinction between mental
disorders and physical disorders?
“…there is much “physical in “mental” disorders
and much “mental” in “physical” disorders.”
(DSM-IV Introduction, p. xxi)
Mental Disorders
The DSM does not classify people; it A clinically significant behavioral or
classifies disorders (i.e., an individual with psychological syndrome or pattern (4 Ds)
schizophrenia vs. “the schizophrenic”) Individual is experiencing present distress or
disability (i.e., significant impairment of
functioning)
People classify people
Individual has a significantly increased risk of
suffering death, pain, disability, or an
important loss of freedom
The syndrome is not an expected cultural
response
(DSM-IV Introduction, xxii)
DSM-IV Multiaxial System DSM-IV Multiaxial System
Five-axis classification system Axis I
Axis I: Clinical disorders Clinical syndromes that generally
Axis II: Personality disorders, mental develop in late adolescence or
retardation adulthood
Axis III: General medical conditions Ex: schizophrenia, bipolar disorder,
Axis IV: Psychosocial and environmental panic disorder, posttraumatic stress
problems disorder, alcohol abuse, major
Axis V: Global assessment of functioning depression
Axis I conditions are considered
illnesses
3
DSM-IV Multiaxial System DSM-IV Multiaxial System
Axis II: personality disorders and Axis III
mental retardation Medical conditions which play a role in
the development, continuance, or
Also used to note maladaptive
exacerbation of Axis I and II Disorders
personality traits and behavior
problems Examples:
Asthma in patients with anxiety
AIDS in a patient with new-onset psychosis
(brain lesions)
Cirrhosis of the liver in a patient with alcohol
dependence
DSM-IV Multiaxial System DSM-IV Multiaxial System
Axis IV Psychosocial stressors include problems
with:
Psychosocial stressors encountered Primary support group
by the patient within the previous 12 Social environment
months that have contributed to: Education
Occupation
Development of a new mental disorder
Housing
Recurrence of a previous mental disorder Economic
Exacerbation of an ongoing mental Access to health care services
disorder Interaction with the legal system
Environmental problems
DSM-IV Multiaxial System
Psychosocial stressors should be Axis V
described in as much detail as needed Patient’s global level of functioning both
to indicate how it affects the patient’s at the time of evaluation and during the
functioning past year
Clinician consults the Global
Even mild stressors should be noted if Assessment of Functioning scale to
they figure into the clinical presentation determine the level of functioning (See
DSM-IV)
GAF is based on 0-100 scale
4
Mental Health Diagnosis
http://psyweb.com/Mdisord/DSM_IV/jsp/Axis_ Example:
V.jsp Axis I: Bipolar disorder, most recent episode
manic, 296.44
Axis II: No diagnosis
Axis III: No diagnosis
Axis IV: Loss of important relationship
Axis V: 60
A patient may have a diagnosis in all five of
the axes
Shortcomings
The DSM-IV is a categorical system based Diagnosis requires art and skill – To use DSM
on description and the symptomatolgy of correctly one needs extensive clinical training
disease
Some experts consider the DSM parochial, If you suspect someone has a mental disorder,
reductionistic, and adynamic she/he should be referred to a mental health
professional
The DSM was designed to have high
reliability among different raters, but validity
remains an issue Although people may share the same diagnosis,
this does not mean the etiology is the same or
Financial ties to pharmaceutical companies? that the treatment will be the same
Psychological Assessment Psychological Assessment
Interviews, medical/personal history Difference between testing and
taking, mental status exam, collateral assessment
information Psychological testing is different than
Projective tests psychological assessment – assessment
Nonprojective tests involves integration of all sources of
data including tests
Neuropsychological tests
Brain Imaging
5
Psychological Assessment Psychological Assessment
Projective tests Projective tests include:
Are individually administered tests Rorschach
Are used to obtain information about Thematic Apperception Test (TAT)
underlying personality traits, emotions,
attitudes, and internal conflicts Children’s Thematic Apperception
Test (CAT)
How it works: patient responds freely to
ambiguous, unstructured, and open-ended Draw-a-Person Test
situations Sentence-completion tests
Rorschach Thematic Apperception
Test (TAT)
Sentence Completion Test Psychological Assessment
I like __________
Nonprojective Techniques
The happiest time __________ Are mostly self-reporting tests
Non projective tests include:
I want to know ___________ Weschler Adult Intelligence Scale (WAIS)
Minnesota Multiphasic Personality
I am sorry for __________ Inventory-2 (MMPI-2)
Weschler Intelligence Scale for Children
I hate __________ (WISC)
Beck Depression Inventory (BDI)
I worry __________
6
Psychological Assessment Psychological Assessment
Neuropsychological testing Neuropsychological Tests
Behavioral measures are used to assess Are behavioral – they are not invasive and
brain functioning especially higher cerebral present no physical risk
functioning (cognitive skills/ability) May require reading or listening to verbal
information, viewing nonverbal visual
Measures deficits in cognitive functioning information, or palpating stimuli
(i.e., a person’s ability to think, speak, Some tasks require written responses or
reason, etc.) that may result from some verbal responses; some will require
sort of brain damage manipulation of objects, puzzles, drawing
Psychological Assessment Psychological Assessment
A patient hears the words – Brain Imaging
“Neuropsychological Tests” Used to understand the relationship
What might they think? between brain structure and functions
such as speech and memory
Increase understanding of brain
How can you prepare a patient for disorders (e.g., schizophrenia,
neuropsychological testing? depression)
Locate and treat epilepsy, brain
tumors, and other disorders with
precision
Brain imaging includes
Brain structure
Computed Tomography Scan (CT)
Psychological Assessment
Magnetic Resonance Imaging (MRI) Why Use Brain Imaging?
Brain function To detect or exclude organic factors
Single photon emission computed that could be contributing to
tomography (SPECT): psychiatric (or neurological)
Positron emission tomography (PET) symptomatology
Electrophysiologic activity:
Electroencephalography (EEG) The first signs of organic brain
lesions are often cognitive
Quantitative EEG, or brain electrical activity
dysfunctions, mood disturbances,
mapping (BEAM)
and psychotic manifestations
Functional MRI
7
How and to whom do I make a
Mental Health Professionals
referral?
Psychiatrist (Child/Adolescent Psychiatrist) To whom you refer depends on your level of
Psychiatric Nurse Practitioner concern for the patient
Psychologist Is it an acute crisis, i.e. suicide risk?
Clinical Social Worker Is it a developmental crisis, i.e. divorce, death of a
loved one?
Licensed Professional Counselor
Suicide hotline
Marital and Family Therapist
Suicide intervention listing in phone book
Certified Alcohol and Drug Abuse Counselor
Local hospitals
Pastoral Counselor
National Alliance for the Mentally Ill (NAMI)
References
American Psychiatric Association. (2008). Frances, A., Mack, A., Ross, R., & First, M. (2000).
DSM-V: The future manual. Retrieved on The DSM-IV classification and psychopharmacology
retrieved on April 6, 2008, from
August 14, 2008, from
http://www.acnp.org/g4/GN401000082/CH081.html
http://www.psych.org/dsmv.asp
National Institute of Mental Illness. (2008). The
DSM-IV. (1994). American Psychiatric numbers count: mental disorders in America.
Association. Retrieved on August 10, 2008 from
DSM-V Timeline. (n.d.). Retrieved on April 6, http://www.nimh.nih.gov/health/publications/the-
numbers-count-mental-disorders-in-
2008, from http://dsm5.org/index.cfm
america.shtml#Intro
National Mental Health Association. (2001).
America’s Mental Health Survey. Roper
Starch Worldwide Inc. Retrieved on August
13, 2008, from
http://www1.nmha.org/pdfdocs/mentalhealthr
eport2001.pdf
8