By: SOPHIA F. DZIEGIELEWSKI
The purpose here is to apply the
diagnostic criteria from DSM-5
utilizing the
principal and the provisional diagnosis, along with other supporting
information, to start the process toward a comprehensive diagnostic assessment
within the parameters of current mental health practice.
Professional record keeping by all
mental health practitioners in the 21st century is characterized by
time-limited services, coordinated care requirements, cost containment
practices, and quality assurance and improvement procedures (Dziegielewski,
2008, 2013; Shlonsky, 2009).
To complete comprehensive diagnostic
assessments, learning how best to document mental disorders and supporting
information makes practitioner training mandatory in how to best utilize this system. Skill in professional documentation becomes essential for
social workers, psychologists, mental health therapists, professional
counselors, and other clinicians and practitioners.
Training in this area is a functional
building block for effective, efficient, and cost-controlled service
provision, as well as representing the legal, ethical, and fiscal
concerns inherent in all service provision (Braun & Cox, 2005;
Dziegielewski, 2010; Sheafor & Horejsi, 2012).
In addition to presenting information
on how to best complete the diagnostic assessment, this article outlines the changes from DSM-IV (APA,
1994) and DSM-IV-TR (APA, 2000) to DSM-5 (APA, 2013); awareness of these changes
enables a smoother transition in maintaining the proper application of the
diagnostic assessment. Similar to previous editions of the DSM, many of the changes are shrouded in controversy (Mallett,
2014).
This article at times outlines this
controversy but focuses primarily on how these changes relate to completion of the diagnostic assessment. Therefore, completion of the
assessment is presented with the changes between the earlier and later versions
of the DSM described. The application of this
information is highlighted, allowing practitioners to clearly identify and
apply each step of the diagnostic system.
BASICS FOR COMPLETING A COMPREHENSIVE DIAGNOSTIC ASSESSMENT
This article assumes that the diagnostic assessment begins with the first client–practitioner interaction. The information gathered provides the data-based observations and reporting to be used to determine the requirements and direction of the helping process, as well as the data collection.
The professional is expected to gather
information about the current situation, take a history of past issues, and anticipate service expectations for the future.
This diagnostic assessment should be multidimensional, include creative interpretation, and
provide the groundwork for the possible strategy for service delivery.
The information gathered follows a behavioral
bio-psychosocial approach to practice (Pearson, 2008). Utilizing the DSM-5 can provide the starting point for
accurately creating the diagnostic impression that will later provide the basis
of the treatment planning and practice strategy to follow.
Starting the Process: Gathering Information
Biomedical Information
In a comprehensive diagnostic
assessment, the biomedical factors highlighted often start with a client’s
general physical health or medical condition. (See Quick Reference 3.1.)
QUICK REFERENCE 3.1
|
Biomedical Factors
in Assessment
Medical conditions
The physical
disability or illness the client reports and what specific ways it affects
the client’s social and occupational
functioning and activities of daily living
Perceived overall health status Encourage the client to assess his or her own health status and what he or she is able to do to facilitate the change effort Maintenance and continued health and wellness Measurement of functional ability and interest in preventive health |
Such information should be considered
from both the practitioner’s and the client’s
perspective. All initial information needs to show the relationship between the
biological or medical factors and the functioning level attainable that will
allow the completion of certain behaviors that will maximize independence.
Assessing the biomedical problems
allows the practitioner to become aware of how medical conditions can either influence
or complicate mental health conditions. Although most counseling professionals
are not qualified to examine or diagnose biomedical
information, they are expected to document and note it and provide referrals as
needed to ensure comprehensive care.
All practitioners are expected to know
how some medical symptoms present and what needs to be done in the referral
process. Whether the practitioner is working collaboratively in a team or independently, the first referral for a physical exam is
given the highest priority.
For example, when an older adult client
very quickly shows behaviors that are delusional and disorganized, before the
practitioner diagnoses a serious mental disorder, a good physical exam may
reveal that the individual has a urinary tract infection (UTI). This medical
condition that may mimic a mental health one would certainly be treated
differently than a neurocognitive or a type of delusional disorder. Taking the
medical condition into account is essential, and often a comprehensive physical
exam, if it is not completed at the initial assessment, should be done soon
afterwards.
Also, how does the client view his or
her own biomedical health? What is the client’s
self-reported health status, and is there any interest in preventive medical
care and intervention? Practice wisdom dictates that the professionals who are
trained in the medical area spend the most attention on the medical aspects of
a client’s health, whereas those trained in
mental health also stick with what they know best, the mental health aspects.
Special attention should always be given to recognizing these roles. In
addition, what otherwise might be considered normal human responses should not
be medicalized (Horowitz & Wakefield, 2012).
Taking the whole person into account is
well complemented by a collaborative team. To facilitate the process for non-medically trained professionals, be sure to
ascertain whether the client has had a recent physical exam. If so, does the client have a copy of
it, or is there a way to get the record so it can be reviewed? Were there any laboratory
findings, x-rays, or other tests completed
related to the symptoms experienced?
If the client has not had a recent
physical exam, suggest or take steps to make sure that one is ordered. Once the information is obtained, it needs to be shared with the
collaborative team to ensure that it is discussed in terms of how this biomedical information may influence the mental health condition presented. In addition, assess for medication side effects, substance use, or medical conditions that contribute or in some cases cause the mental health problems evident (Frances, 2013).
To provide a comprehensive biomedical
assessment and take into account the mind–body connection, all aspects of the
person must be considered, including social and environmental factors. To start
the process and address the biomedical aspects, a thorough medical checkup or
workup is always recommended as close to the initial assessment as possible.
Psychosocial Information
The second area of a comprehensive
diagnostic assessment relates directly to the psychological factors a client is
exhibiting. To start the diagnostic assessment in this area, psychological
functioning is noted. Cognitive health functioning is recorded, along with its
effects on occupational and social functioning.
Although we attempt to do so in an assessment,
separating the psychological and the social-spiritual factors can be difficult.
To facilitate the diagnostic impression, the psychological is related to the
resulting mental functioning, cognitive functioning, and the assessment of
lethality.
To start the mental health process, a mental
health status exam needs to be completed. Specific
information related to lethality for a client who may be at risk for suicide or harming others must be gathered and processed. If these behaviors exist,
immediate action is needed. (See Quick Reference 3.2.)
QUICK REFERENCE 3.2
|
Psychological
Factors in Assessment
Mental functioning Describe the client’s mental functioning.
Complete a mental
status assessment.
Learn and identify
key cultural factors related to the client.
Cognitive functioning Does the client have the ability to think and reason about what is happening to him or her?
Is the client able
to participate and make decisions in regard to his or her own best interest?
Assessment of lethality Would the client harm himself or herself or anyone else because of the perception of the problem he or she is experiencing? |
Social, Cultural, and
Spiritual Information
Behavioral-based bio-psychosocial and
spiritual approaches to assessment emphasize aspects highly influenced
by a client’s environment, such as social,
cultural, and spiritual factors.
Most professionals would agree that environmental
considerations are very important in measuring and assessing all other aspects of a client’s
needs. Identifying family, social supports, and cultural expectations are
important in helping the client ascertain the best course of action (Colby
& Dziegielewski, 2010). (See Quick Reference 3.3.)
QUICK REFERENCE 3.3
|
Social and
Environmental Factors in Assessment
Social/societal help seeking Is the client open to outside help? What support system or helping networks are available to the client from those outside the immediate family or the community? Occupational participation How does a client’s illness or disability impair or prohibit functioning in the work environment?
Is the client in a
supportive work environment?
Social support
Does the client
have support from neighbors, friends, or community organizations (e.g.,
church membership, membership in professional clubs)?
Family support
What support or
help is expected from relatives of the client?
Ethnic or religious affiliation If the client is a member of a cultural or religious group, will this affiliation affect medical intervention and compliance issues? |
A comprehensive assessment in this area starts with the basic assumption that people are social creatures. Therefore, how the individual responds in the social environment and within his or her support system provides important information for problem identification. In defining diversity, the possibilities for defining people and how they will behave are unlimited (Dudley, 2014).
DSM-5 offers several ways to not only
recognize culture but also measure it by using focused culturally based
questions, the Cultural Formulation Interview (CFI), and definitions in the
appendix Glossary of Cultural Concepts of Distress. Therefore, DSM-5 can be helpful in assessing the
situation, which is especially important for working with certain cultures.
For example, Alegria et al. (2007) warn that living in what the client perceives as an unsafe area can clearly influence the behaviors the client exhibits. The social situation is discussed in more detail later in this article in reference to the chapter in the DSM-5 about the other disorders that may be the focus of clinical attention.
Gathering the Data
Because the client is the primary
source of data, be sure to take the time to assess the accuracy of the
information and determine whether the client may either willingly or
inadvertently withhold or exaggerate the information presented. Assessment
information is usually collected through verbal and written reports (Owen,
2011).
Verbal reports may be gathered from the
client, significant others, family, friends, or other
helping professionals. Critical information can also be derived from written
reports, such as medical documents, previous clinical assessments, lab tests,
and other clinical and diagnostic methods.
Furthermore, information about the
client can be derived through direct observation of the client’s
verbal or physical behaviors or interaction patterns with other
interdisciplinary team members, family, significant
others, or friends. When a practitioner is seeking evidence-based practice,
recognizing directly what a client is doing can be a critical factor in the
diagnostic assessment process.
Remember that in addition to verbal
reports, written reports reflective of practice effectiveness often
are expected. Background sheets, psychological tests, or tests to measure
health status or level of daily function may be used to more concretely measure
client problem behaviors.
Although the client is the first
and primary source of data, the current emphasis on evidence-based practice
necessitates gathering information from other sources. Taking a team approach
involves examining previously written information and records, as well as sharing
the responsibility for talking with the family, significant
others, and other health providers to estimate planning support and assistance.
From this perspective, task effectiveness is measured in how successful the team is in achieving its outcomes (Whyte & Brooker, 2001). As part of a team, collecting information from other secondary sources, such as the client’s medical record, is important. To facilitate assessment, the non-medically trained practitioner must work with those who are medically trained to make sure he or she understands the client’s medical situation (Dziegielewski, 2005, 2006). Knowledge of certain medical conditions and when to refer to other health professionals for continued care is an essential part of the assessment process.
DSM-5 AND COMPLETING THE DIAGNOSTIC ASSESSMENT
The information presented in this article
is not meant to include all the possibilities for use of the DSM-5. It is, however, designed to give
practitioners a practical introduction to facilitating and identifying how to
best complete the diagnosis assessment, taking into account all aspects of the
client.
Proper use of the DSM-5
requires diagnostic
classification of both the principal diagnosis
and the reason for visit, as well as other supporting information as needed.
This article describes and compares and contrasts what is required today within
the assessment process to past requirements. The intent is to use this information
to support the completion of the comprehensive diagnostic assessment that leads
to the treatment plan and practice strategy.
Elimination of the Multi-axial System
One of the most significant changes in DSM-5 is the elimination of the multi-axial assessment system. This assessment system and the five axes required for use have a long history, starting with DSM-III and DSM-III-R. Practitioners familiar with the DSM have used this system for more than 25 years. To review, the multi-axial assessment system identified five separate axes. Axes I and II had the primary mental health diagnoses, Axis III was the medical information, and Axes IV and V documented the information that supported the diagnosis. (See Quick Reference 3.4.)
QUICK REFERENCE 3.4
|
DSM-IV-TR:
Multi-axial
Assessment
Axis I: Clinical disorders, pervasive developmental disorders, learning, motor skills, and communication disorders
Other conditions
that may be the focus of clinical attention
Axis II: Personality disorders; Mental retardation Axis III: General medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning (GAF) |
In many practice settings in the 1980s
and 1990s, the first three axes were considered sufficient
as the formal diagnostic process. The practitioner completed a diagnostic impression
of the client that involved Axes I, II, and III, leaving the use of Axes IV and
V as optional. With the later editions of the DSM (DSM-III
and DSM-III-R),
it was recommended that all five axes be addressed as part of the
diagnostic assessment. In the multi-axial system in DSM-IV and DSM-IV-TR, the
first three axes alone were not
considered acceptable as a practice standard, and working with that multi-axial
framework required using all five axes.
The APA (2000) has always clearly said
that the first three axes, although separate in
documentation, were unrelated, and diagnoses were placed on either Axis I or II
just to facilitate coding. The multi-axial system was simply a system of
convenient systematic documentation, yet many professionals did not feel that
way.
For example, the diagnosis of a
personality disorder, coded on Axis II, was avoided, as its lifelong behaviors were often avoided for diagnostic coding because it could
hamper reimbursement. There were also times when using the multi-axial
diagnostic assessment was not appropriate. For example, with special population
groups (e.g., troubled youth) or in specialized settings (e. g., assisted
residential care with elderly persons), having such a formal diagnostic
assessment did not seem appropriate and was considered unnecessary.
It could also be problematic in other
settings, such as some counseling agencies that focused directly on problem
solving, which entails helping individuals gain the resources needed to improve
functioning. In this type of setting, use of the multi-axial system was
considered disadvantageous and optional.
In updating the manual, despite widespread
use of the multi-axial system, the work groups decided to eliminate it in favor
of a format more relevant to simply writing the diagnosis and the supporting
information.
In DSM-5, coding
diagnostic impressions on a multi-axial system has been eliminated and is no
longer an option. It now emphasizes only the free listing of the mental health
diagnosis without the restrictions of utilizing the multi-axial system.
DSM-5: The Diagnostic
Impression
With the elimination
of Axes I, II, and III that were used in earlier versions of the DSM, the replacement requires all three of these axes to be combined by simply listing
the relevant diagnosis as either the replacement requires all three of these axes to be combined by simply listing
the relevant diagnosis as either the principal
diagnosis or in some cases adding
a provisional diagnosis
(see Quick Reference
3.5).
QUICK REFERENCE 3.6
|
Helpful Tips for Documenting the Principal Diagnosis
■ Principal diagnosis is most ofen the reason for the visit and is generally listed first. ■ If there are multiple diagnoses, the reason for the visit should always be listed first. ■ For the principal diagnosis, use the phrase (principal diagnosis) or (reason for visit). ■ If there are multiple diagnoses, list them after the principal diagnosis in terms of focus and attention. ■ If there is a medical condition or disorder that appears to be the cause of the mental health disorder, according to the ICD, the medical disorder should be listed before the mental disorder. ■ List the mental disorders that interfere with functioning first, and then list other medical condition(s) that are complicating or are directly or indirectly related to the mental health condition but not the direct cause. |
Both DSM-IV and DSM-IV-TR offered two ways of coding: the multi-axial system and simply listing the diagnosis, similar to what is now required in DSM-5. In DSM-5, listing the mental disorders and the relevant medical conditions are combined, thereby avoiding the artificial distinction suggested by listing them on separate axes. The diagnostic assessment starts with identifying either the principal or the provisional diagnosis.
Listing the principal diagnosis
eliminates the need for Axes I and II. Also, combining any medical conditions and listing them with the principal diagnosis eliminates
the need for Axis III, which included any related medical conditions.
Eliminating Axes I, II, and III helped to clarify that Axis II specifically
was never meant to be a separate set of diagnoses, nor was it the intent of the
multi-axial system to separate medical and mental health conditions in
assessment or treatment. What many professionals do not realize is that this
new coding system presented in DSM-5
is not completely
new.
References
SOPHIA F. DZIEGIELEWSK, 2015, DSM-5TM in Action, by John Wiley & Sons,
Inc.
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