T3 - Therapy Basics: The DSM

One thing all therapists, psychologists, licensed clinical social workers, psychiatrists and whoever else might provide mental health services has in common is the DSM. (Oh, and health insurance and pharmaceutical companies, too.)

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (or DSM-IV-TR for short) is called the therapist's "bible," although I'm not thrilled with that association. (I've only got ONE Bible, thank you.) It's put out by the American Psychiatric Association (APA) and the list price of it is about $89, but you can get it from Amazon for $72.

The DSM lists the criteria for mental disorders. Each disorder is given a specific code (i.e. 301.13) and this code is recognized by health professionals everywhere in the US. (Like, I know 301.13 is Cyclothymic Disorder).

In addition to the criteria (list of symptoms to look for in a patient), the DSM provides a lot of other helpful information about each disorder. (Psychiatric terms in bold italics)

1. Diagnostic Features - this is the criteria written out in paragraph form, often with illustrative examples
2. Subtypes and/or Specifiers - gives whether there are different types of a disorder (like there are several types of schizophrenia); specifiers simply give more specifics on the disorder, like when the onset was, or if a certain feature is more prevalent over another
3. Associated Features and Disorders - this gives clinical features that are frequently associated with the disorder, but aren't required to make a diagnosis, as well as associated medical and physical examination findings (i.e., people with an eating disorder are likely to have dental erosion or alcoholics typically can have cirrhosis of the liver)
   
4. Specific Culture, Age, and Gender Features - sometimes people present a disorder in a way that doesn't completely add up with the description on the page, and the reason could be one of the above listed, i.e., their developmental stage or cultural setting
5. Prevalence - the section gives known information for prevalence, incidence and lifetime risk; when it's known, this information includes different settings - community, primary care, outpatient mental health clinics and inpatient psychiatric settings
6. Course - gives the typical lifetime patterns of the disorder: how it's presented, how it evolves, typical age of onset, mode of onset (was it abrupt like PTSD or gradual like Alzheimer's?), whether it's in episodes (episodic) or a continuous course, a single episode v. recurrent, the duration of the disorder, as well as the typical length of the illness and it's progression over time (stable, worsening, improving)
7. Familial Pattern - looks at the frequency of the disorder among first-degree biological relatives compared with the general population
8. Differential Diagnosis - probably one of my most favorite sections, as it gives possible other diagnoses that might be similar as far as presentation and then how to differentiate between the two (or three or five)
   

Not every disorder will include all of this information. Sometimes the information isn't known, and it might be included in the next version of the DSM (to come out in 2012, tentatively). Many times this information changes from publication to publication, as data is gathered from ongoing studies. New diagnoses emerge and some diagnoses get the chopping block or get absorbed into others.

There is talk of including internet addiction, compulsive shopping, or premenstrual dysphoric disorder--that's right, ladies. The real name for PMS, and it's not actually a diagnosis right now!--as well as getting rid of schizoaffective disorder and possible gender identity disorder to reflect the changing times. Major changes within editions usually make the news, the biggest being in 1974 when the APA took out homosexuality as a disorder. As you can imagine, new editions cause LOTS of controversy between professionals in the field as well as political and religious leaders.

But one thing remains the same: this is the therapist's manual. I never see a client when I don't break out this really large book of almost 1000 pages. You can see how this would be helpful in writing, right?

Q4U: Which of the eight sections do you think would be most helpful when writing?

Join me next Thursday as I discuss the multi-axial format of the DSM and why this is extremely useful.

T3 - Therapy Basics: Assessments

An assessment is a therapist's most basic tool. They all look different, include different questions in different orders. Some are very extensive, up to several pages long, while others are short and to the point (i.e., "Why are you here?").

The assessment I've used for years is around five pages and it includes the following:

Identifying Information Presenting Problem(s)
*Psychiatric Symptoms/Behaviors
Individual's Expectations
Developmental History
Educational History
Marital History
Work/Military History
Medical/Physical/Psychiatric History
Substance Abuse History
Legal/Incarceration History
Relevant Financial Issues
Relevant Ethnic/Cultural Considerations
History of Trauma (best to just know this up front, so I ask)
*Mental Status Exam
*Suicide Risk Assessment
*Assault Risk Assessment
Diagnostic Impressions (where a diagnosis is assigned)
Clinical Summary/Impressions (overall)
Individual Strengths and Weaknesses
*Current Areas of Functional Impairment (to focus treatment)
Treatment Referrals (either to a medical doctor for a physical; a lawyer for legal aide, etc.)
Final Plan (what client agrees to)
*Release(s) of Information Obtained
Therapist Signature

Like I said, assessments differ as widely as the therapists who use them. I happen to like this assessment because it was developed to meet state requirements for someone on MediCal (which is the equivalent of Medicare for those who don't live in California). MediCal requirements are extensive, so I know my assessment is, too.

Breaking it down isn't that difficult because most of it is self-explanatory. I put a star next to those elements that might need a bit more explanation.

As you could see by the list, most of the information I gather is history, plain and simple. I have to know where a client is coming from before I can try to help them to where they want/need to go. So history gathering is extensive, and it can take more than one session to get everything down.

Psychiatric symptoms/behaviors are what I observe to be problematic during the initial interview. What symptoms of disorders are florid (very clearly exemplified)? Are they agitated? Tearful? Which symptoms does the client self-report (it can be that a client has panic attacks that I'd never see in the office, for example)? A knowledge of the Diagnostic and Statistical Manual is imperative for this type of assessment.

A mental status exam is kind of like a mini-assessment all by itself. I basically see if the person is in their right mind or not. Do they know who they are? What year it is? Who is president? What 2+2 is? Can they remember my name five minutes into our assessment after I gave it to them at the beginning? What is their speech pattern like? How are the groomed/dressed? These types of questions, if answered incorrectly, can automatically point a therapist to severe disorders like schizophrenia.

A suicide risk assessment and an assualt risk assessment are included to protect the therapist from litigation. No one would want a client to come to see them only to kill themselves hours later. So I've developed the habit of always broaching the subject of self harm and harm to others in the first session, just to see the client's reaction (are they shocked because they are offended, or because they have had suicidal thoughts?) and be able to note in my case notes for that client their response. This shows that I have acted as a reasonable therapist and protects me should I get sued (which thankfully I have never been!).

Current areas of functional impairment is just a fancy way of saying "What areas does this client struggle with the most?" How severe is the struggle? Moderate? Mild? None? Extreme? Here are the major areas I assess for:

1. Community Living

2. Community Participation

3. Community Contribution

4. Financial

5. Relationships with Others

6. Education and Learning

7. Physical and Emotional Health

8. Legal

And the release of information section is just to know who exactly I have permission to coordinate treatment with. I did a lot of school counseling, so I always had to have a release of information for the school. If you need to be in contact with a medical doctor, their name should be on a release somewhere. Having a list of all these contacts in one place is very handy.

So, this is what all I include in an assessment. This is not to be confused with intake paperwork a client fills out when they come into your office. An assessment is a document likely no client will see. Intake paperwork asks some of the same type information I've listed, and most therapists can compare the information to what the client actually tells them, looking for consistency, as well as use the intake paperwork to help fill in the assessment after the session is over (to spark their memory, etc.). It never hurts to repeat information in different places.

Join me next week as I discuss the Diagnostic and Statistical Manual-IV-TR, also known as the DSM or therapist's "bible."

Q4U: Have you or someone you know ever gone through an assessment similar to what I've described above? What might have been some areas left out of my assessment that were on yours?