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The Diagnostic and Statistical Manual of Mental Disorders 49

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
Difficulty 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
Difficult 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 finances
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.

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 traffic 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
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50 Chapter 2 Classification 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
good functioning in all areas; no more than
everyday problems
71–80 Transient, slight symptoms that are reasonable
responses to stressful situations; no more than
slight impairment in social, occupational, or
school functioning
61–70 Mild symptoms, or some difficulty in social,
occupational, or school functioning
51–60 Moderate symptoms or moderate difficulties
in social, occupational, or school functioning
41–50 Serious symptoms or any serious impairment
in social, occupational, or school functioning
31–40 Serious difficulties in thought or communication
or major impairment in several areas of
functioning
21–30 Behavior influenced by psychotic symptoms
or serious impairment in communication or
judgment or inability to function in almost
all areas
11–20 Dangerous symptoms or gross impairment in
communication
1–10 Persistent danger to self or others or persistent
inability to maintain hygiene
0 Inadequate information
Occasional worries such as feeling understandably
anxious before taking examinations or feelings of
disappointment following an athletic loss
Concentration difficulty following an exciting day; trouble
sleeping after an argument with partner
Mild insomnia; mild depression
Occasional panic attacks; conflicts with roommates
Suicidal thoughts; inability to keep job
Illogical speech; inability to work; neglect of
responsibilities
Delusional and hallucinating; incoherent; preoccupied
with suicide; stays in bed all day every day
Suicide attempts without clear expectation of death;
muteness
Recurrent violence; serious suicidal act with clear
expectation of death

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
Copyright © 2000 American Psychiatric Association.

job promotion may encounter psychological difficulties due REVIEW QUESTIONS

to the increased responsibilities and demands associated with
the new position. 1. What is the difference between reliability and validity in
the context of psychiatric diagnosis?
Axis V: Global Assessment of Functioning
2. In the DSM-IV-TR, refers to a class of informa-
Axis V is used to document the clinician’s overall judgment of
tion such as the primary diagnosis.
a client’s psychological, social, and occupational functioning.
Ratings are made for the client’s current functioning at the 3. What DSM-IV-TR axis would be used to document a
point of admission or discharge, or the highest level of func- client’s medical conditions?
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 The Diagnostic Process
reason to hope for improvement. The prognosis may not be so
bright if a client has a lengthy history of poor adjustment. The diagnostic process involves using all relevant information
The Global Assessment of Functioning (GAF) scale, to arrive at a label that characterizes the client’s disorder. This
which is the basis for Axis V, allows for a rating of the information includes the results of any tests given to the cli-
individual’s overall level of psychological health. The full ent, material gathered from interviews, and knowledge about
scale is shown in Table 2.4. the client’s personal history. The end result of the diagnostic
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process is a diagnosis that can be used as the basis for the
client’s treatment.
Although this definition 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
insignificant 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 first
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 first 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 find
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 first 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 first 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.
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The Diagnostic Process 51
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 butterflies 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 specifics 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 simplified version. Dr. Tobin be-
gins with the mood disturbance decision tree, because she
has already decided that Peter’s symptoms might fit 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
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52 Chapter 2 Classification and Treatment Plans
Diagnostic questions
Depressed, elevated, expansive, or irritable mood?
Yes
No
Due to the direct physiological effects
of a general medical condition?
Yes
No
Due to the direct physiological effects
of a substance?
Yes
No
Manic episode: Elevated, expansive, or irritable
mood, at least 1-week duration; marked impairment?
Yes
No
Major depressive episode: At least 2 weeks of
depressed mood or loss of interest plus associated
symptoms?
Yes
No
Psychotic symptoms occur at times other than during
manic episodes?
Yes
No
Final Diagnosis: Bipolar I Disorder
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.
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 final 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
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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 confident that Peter fits
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 first 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 fit 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 final 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 final 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)
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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 influenced 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
first manic episode, which follows his first 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 confidant. 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 first sign of a disorder he was bound to inherit from
her. Her involvement in his emotional problems creates
another difficulty 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 find out that he is in
therapy, for fear that this information will confirm 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
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The Diagnostic Process 53
Clinicians go through a process of differential diagnosis
in which they consider all possible alternative diagnoses.
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 identifica-
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 influences 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 identification. 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