DSM-IV: Symptom, Syndrome, Disorder, Disease

SYMPTOM

-refers to an observable behavior or state.

-there is no implication that an underlying problem necessarily exists or that there is a physical etiology.

-the simplest level of analyzing a presenting problem.

SYNDROME

-the next higher level of analysis

-this term is applied to a constellation of symptoms that occur together or co-vary over time.

-the term carries no direct implications in terms of underlying pathology.

-Whether, in fact, certain sets of symptoms co-vary with one another is an empirical question.

DISORDER

-like a syndrome, refers to a cluster of symptoms,

-but the concept includes the idea that the set of symptoms is not accounted for by a more pervasive condition.

-As with symptom and syndrome, there is no implication of etiology

DISEASE

-a disorder where the underlying etiology is known.

-It is the highest level of conceptual understanding.

6 ISSUES IN THE CLASSIFICATION OF ABNORMAL BEHAVIOR

1. A label leads to a loss of information and overlooks the uniqueness of the person being studied or treated.

2. While such simplification may be useful depending on the purpose of the classification system, the classified individual may be stigmatized .

3. DSM represents a categorical classification or a "yes-no" approach to classification, and does not take into account the continuity between normal and abnormal behavior ( i.e., dimensional classification whereby symptoms are rated on quantitative dimensions.) 4. Interrater reliability of diagnoses based on DSMS criteria 5. Diagnostic validity =

Whether or not accurate statements and predictions can be made from a classification

=

the extent to which accurate statements and predictions can be made about a category or construct. 6. Consequences of unreliable and invalid diagnoses are severe and include not only stigma but financial expenses

PURPOSES OF THE DSM WITH LIMITED RELIABILITY AND VALIDITY

-All classification systems function to enhance communication by summarizing observations

-Kirk and Kutchins' The Selling of DSM: The Rhetoric of Science in Psychiatry (1992, NY: Walter de Gruyter, Inc.). offer an

account of the political and social implications of the revisions of "the new bible" (DSM) includes a provocative discussion of uses for diagnosis other than the traditional ones such as planning treatment

-Considering that clinicians using the DSM have considerable discretion in deciding on a particular diagnosis, the following purposes for diagnostic decisions may apply:

1) Regulating Client Flow .

2) Protecting Clients from Harm .

3) Acquiring Fiscal Resources .

4) Rationalizing Decision-Making .

5) Advancing a Political Agenda .

Five Axes of DSM-IV

I All categories except personality disorder and mental retardation II Personality disorders and mental retardation III General medical conditions IV Psychosocial and environmental problems V Current level of functioning

D

SM-I Diagnostic Criteria for Obsessive Compulsive Reaction

In this reaction the anxiety is associated with the persistence of unwanted ideas and of repetitive impulses to perform acts which may be considered morbid by the patient. The patient himself may regard his ideas and behavior as unreasonable, but nevertheless is compelled to carry out his rituals. The diagnosis will specify the symptomatic expression of such reactions, as touching, counting, ceremonials, hand-washing, or recurring thoughts (accompanied often by a compulsion to repetitive action). This category includes many cases formerly classified as "psychasthenia." DSM-II Diagnostic Criteria for Obsessive Compulsive Neurosis

This disorder is characterized by the persistent intrusion of unwanted thoughts, urges, or actions that the patient is unable to stop. The thoughts may consist of single words or ideas, ruminations, or trains of thought often perceived by the patient as nonsensical. The actions vary from simple movements to complex rituals such as repeated hand washing. Anxiety and distress are often present either if the patient is prevented from completing his compulsive ritual or if he is concerned about being unable to control it himself. DSM-IV Diagnostic Criteria for Obsessive Compulsive Disorder A. Either obsessions or compulsions: Obsessions as defined by (1), (2), (3), and (4): (1) recurrent and persistent ideas, thought, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress (2) the thoughts, impulses, or images are not simply excessive worries about real-life problems (3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action (4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

Compulsions as defined by (1) and (2):

(1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly

(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.

C. The obsessions or compulsions cause marked distress, are time-consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.

D. If another Axis I disorder is present, the content of the obsession or compulsions is not restricted to it (e.g., the preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern about appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).

E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Outline for Cultural Formulation

Note: The following material was adapted from DSM-IV, pp. 843-844.

I. Cultural identity of the individual.

What is your ethnic background?



In what ways do you identify with your cultural group in your daily life? For example, in types of food you eat, clothing you wear, rituals you follow during the week and on holidays.



In what ways did your family of origin identify with your cultural group in your daily life growing up?



In what ways do you identify with mainstream American culture in your daily life?



What languages do you speak? Which did you speak growing up? Which do you prefer to use now, and in what situations?



For immigrants: What kind of job did you have in your country of origin? What kind of job do you have now? What was the impact of immigration on the persons financial situation and professional status?



For immigrants: What were your (or your familys) reasons for immigrating? What were the circumstances of the immigration? (Note any dangers involved.)

II. Cultural explanations of the individuals illness.

Note what words the person uses to describe their symptoms ("idioms for distress").



What is the meaning of the symptoms in relation to norms of their cultural reference group?



How does the persons family explain the persons symptoms?



What has been your past experience with mental health professionals?



What other kinds of help have you sought?

III. Cultural factors related to psychosocial environment and levels of functioning.

What kind of stressors has the person been experiencing?



What kinds of social support are available?



Explore religious or other support systems.



How do the symptoms impact the persons functioning?

IV. Cultural elements of the relationship between the individual and the clinician.