Impact of the DSM-5: Organization Development Strengths and Limitations

Week 2: Impact of the DSM-5: Organization, Development, Strengths, and Limitations

Social work advocates for the biopsychosocial model of mental health and illness. Therefore, when making a diagnosis a social worker should always consider biological factors such as genetics, psychological factors such as personality and strengths, and social factors such as culture and environment.

Despite dialectics between various mental health professions about the role of diagnosis, there is widespread acceptance of the practical need to have a common comparison point for different syndromes—a common language and a shared knowledge of what is known about the course of illnesses. That shared knowledge is held in the DSM-5.

This week, you explore how the DSM-5 is organized and why. This exploration begins providing the tools for its effective use.

Learning Objectives

Students will:

• Analyze use and communication of a diagnosis in a case study
• Analyze strengths and limitations of the DSM-5 diagnostic system
• Differentiate between normal behavior and diagnosable symptoms using the concepts of dimensionality and spectrum

Learning Resources

Required Readings

American Psychiatric Association. (2013j). Introduction. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.Introduction

Barsky, A. (2015). DSM-5 and the ethics of diagnosis. The New Social Worker. Retrieved from https://www.socialworker.com/feature-articles/ethics-articles/dsm-5-and-ethics-of-diagnosis/

Neukrug, E. S., & Fawcett, R. C. (2015). Diagnosis in the assessment process. In E. S. Neukrug & R. C. Fawcett, Essentials of testing and assessment: A practical guide for counselors, social workers, and psychologists (3rd ed., pp. 43–58). Stamford, CT: Cengage Learning.
Neukrug, E. S., & Fawcett, R. C. (2015). Diagnosis in the assessment process. In E. S. Neukrug & R. C. Fawcett, Essentials of testing and assessment: A practical guide for counselors, social workers, and psychologists (3rd ed., pp. 43–58). Stamford, CT: Cengage Learning.
 

Paris, J. (2015). The intelligent clinician’s guide to the DSM-5 (2nd ed.). New York, NY: Oxford University Press

Chapter 6, “Dimensionality” (pp 84–101)

Document: How to Write a Diagnosis According to the DSM-5 (PDF)

Required Media

Accessible player –Downloads–Download Video w/CCDownload AudioDownload TranscriptLaureate Education (Producer). (2018d). Impact of the DSM-5: Organization, Develpment, Strengths and Limitations [Audio podcast]. Baltimore, MD: Author.

University at Buffalo School of Social Work (Producer). (2014). Episode 139—Dr. Robert Keefe and Dr. Barbara Rittner: The Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders: A conversation [Audio podcast]. Retrieved from http://www.insocialwork.org/episode.asp?ep=139

Singer, J. B. (Producer). (2016, January 25). Critiques of the DSM-5: Interview with Jeffery Lacasse, Ph.D. [Audio podcast]. Retrieved from http://www.socialworkpodcast.com/2016/01/DSM5critique.html/p> 

Optional Resources

American Psychiatric Association. (2013o). Preface. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.x00preface

American Psychiatric Association. (2013t). Use of the manual. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.UseofDSM5

Lasalvia, A. (2015). DSM-5 two years later: Facts, myths and some key open issues. Epidemiology and Psychiatric Sciences, 24(3), 185–187. doi:10.1017/S2045796015000256

Paris, J. (2015). The intelligent clinician’s guide to the DSM-5 (2nd ed.). New York, NY: Oxford University Press

Chapter 3, “How Diagnostic Manuals Are Made” (pp. 33–55)

Wakefield, J. C. (2013b). DSM-5: An overview of changes and controversies. Clinical Social Work Journal, 41(2), 139–154. doi:10.1007/s10615-013-0445-2

Document: Suggested Further Reading for SOCW 6090 (PDF)

Note: This is the same document introduced in Week 1.

Discussion: Diagnostic Labels as Powerful Communications

A diagnosis is powerful in the effect it can have on a person’s life and treatment protocol. When working with a client, a social worker must make important decisions—not only about the diagnostic label itself but about whom to tell and when. In this Discussion, you evaluate the use and communication of a diagnosis in a case study.

To prepare: Focus on the complex but precise definition of a mental disorder in the DSM-5 and the concept of dimensionality both there and in the Paris (2015) and Lasalvia (2015) readings. Also note that the definition of a mental disorder includes a set of caveats and recommendations to help find the boundary between normal distress and a mental disorder.

Then consider the following case:

Ms. Evans, age 27, was awaiting honorable discharge from her service in Iraq with the U.S. Navy when her colleagues noticed that she looked increasingly fearful and was talking about hearing voices telling her that the world was going to be destroyed in 2020. With Ms. Evans’s permission, the evaluating [social worker] interviewed one of her closest colleagues, who indicated that Ms. Evans has not been taking good care of herself for several months. Ms. Evans said she was depressed.

The [social worker] also learned that Ms. Evans’s performance of her military job duties had declined during this time and that her commanding officer had recommended to Ms. Evans that she be evaluated by a psychiatrist approximately 2 weeks earlier, for possible depression.

On interview, Ms. Evans endorsed believing the world was going to end soon and indicated that several times she has heard an audible voice that repeats this information. She has a maternal uncle with schizophrenia, and her mother has a diagnosis of bipolar I disorder. Ms. Evans’s toxicology screen is positive for tetrahydrocannabinol (THC). The evaluating [social worker] informs Ms. Evans that she is making a tentative diagnosis of schizophrenia.

Source: Roberts, L. W., & Trockel, M. (2015). Case example: Importance of refining a diagnostic hypothesis. In L. W. Roberts & A. K. Louie (Eds.), Study guide to DSM-5 (pp. 6–7). Arlington, VA: American Psychiatric Publishing.

Study Guide to DSM-5(r), by Roberts, M.; Louie, A.; Weiss, L. Copyright 2015 by American Psychiatric Association. Reprinted by permission of American Psychiatric Association via the Copyright Clearance Center.

By Day 3

Post a 300- to 500-word response in which you discuss how a social worker should approach the diagnosis. In your analysis, consider the following questions:

• Identify the symptoms or “red flags” in the case study that may be evaluated for a possible mental health disorder.
• Should the social worker have shared this suspected diagnosis based on the limited assessment with Ms. Evans at this time?
• Explain the potential impact of this diagnosis immediately and over time if the “tentative” diagnosis is a misdiagnosis.
• When may it be appropriate to use a provisional diagnosis?
• When would you diagnosis as other specified and unspecified disorders?

By Day 6

Respond to at least two colleagues who had a different position than your own in the following way:

• Explain why you agree or disagree with whether the client meets diagnostic criteria and should be told about a “tentative” diagnosis, approach to diagnosis, or impact of diagnosis.
• Explain how the social worker could have worked with a supervisor to make an initial diagnosis.

Note: You are required to create a thread for your initial Discussion post before you will be able to view other colleagues’ postings in this forum. If you have not yet visited the weekly resources and assignments, you should visit that area now to access the complete set of directions and guidelines for this discussion.

Response 1

Meishalette Allen Week 2 DiscussionCOLLAPSE

According to the DSM-5, a “mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction disturbance in the psychological, biological, or development processes” (American Psychiatric Association, 2013, p. 20). When considering a mental health diagnosis, all clinicians should approach with caution taking into considerations all factors: physiological, biological, cultural, social and environment.

Ms. Evans exhibited “red flags” that may contribute to a possible mental health disorder diagnosis. Some of the red flags are as followed: self-diagnosed with depression; fearful appearance observed by peers; audible voices stating the world will be destroyed; decreased job performance; family history of mental health disorders; and a positive toxicology screen for the THC (Roberts & Trockley, 2015).

Based on the social workers assessment of Ms. Evans along with information provided by her peers out of concern, I believe the social worker should have shared the suspected diagnosis. We have commitment to our clients to promote their well-being (NASW, 2017). We are also required to respect and promote self determination of our clients. Informing Ms. Evans of the diagnosis will provide the opportunity to make informed choices/decisions regarding her diagnosis and future treatment from Ms. Evans. It will be unethical to request Ms. Evans to consent to treatment if she is unaware of what she is being treated for. We must abide by the National Association of Social Work Code of Ethics at all times.

Potential immediate impact of Ms. Evans tentative diagnosis is the appropriateness of immediate interventions. A diagnosis is used to guide and assist the clinician in conceptualizing the client’s identified problem(s), understand the client from holistic approach, and aide in the client and clinician collaboratively developing appropriate steps to intervention/treatment (Neukrug & Fawcett, 2015). Another impact may be the effect of insurance coverage for a specific diagnosis. According to Neukrug & Fawcett (2015), depending on the diagnosis some insurances will only be financial responsible for a specific amount of treatment which can alter the outcome for the client.

Provisional diagnosis may be appropriate to use when the clinician is certain the full criteria of diagnosis will be met once enough information is obtained (American Psychiatry Association, 2013). Provisional diagnosis is often used in cases when the client is unable to provide a history or timeline of when the symptoms began, the duration, and severity. The current DSM-5 manual provides provisions for clinicians to diagnose using other specified or unspecified. Clinicians can use other specified with a diagnosis if a client does not meet the full criteria and documenting the criteria(s) not met. Clinicians may use unspecified in the same manner with a diagnosis; however, they are not required to document the criteria not met. According to American Psychiatry Association (2013), there is no requirement placed on the clinician on which of the two they are allowed to use.

References:

American Psychiatric Association. (2013). Use of the Manual. In DIagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author

NASW. (2017). Code of Ethics. Retrieved from https://www.socialworkers.org/about/ethics/code-of-ethics/code-of-ethics-english

Neukrug, E. S., & Fawcett, R. C. (2015). Diagnosis in the assessment process. In E. S. Neukrug & R. C. Fawcett, Essentials of testing and assessment: A practical guide for counselors, social workers, and psychologist (3rd ed., pp 43-58). Stamford, CT: Cengage Learning.

Roberts, L. W., & Trockel, M. (2015). Case example: Importance of refining a diagnostic hypothesis. In L. W. Roberts & A. K. Louie (Eds.), Study guide to DSM-5 (pp. 6-7). Arlington, VA: American Psychiatric Publishing

Response 2

Nicole Martin WK2 Discussion Diagnostic LabelsCOLLAPSE

Red Flags in the case study that may be evaluated for a possible mental health disorder:

Ms. Evans work had declined. Her co-workers and friends are concerned about her and her statements that the world is coming to an end. Her friends and co-workers believe she is depressed. She has a family history of mental illness. She is using marijuana. Her self-care has been lacking.

Should the social worker have shared the suspected diagnosis based on the limited assessment with Ms. Evans at this time? 

I believe the social worker should have done a full psychosocial assessment prior to giving a tentative diagnosis. The suspected diagnosis could do more harm than good to Ms. Evans at this time. It sounds as if she is already paranoid and to label her schizophrenic would only increase the delusions and poor mental health status.

The potential impact of the diagnosis immediately and over time if the “tentative” diagnosis is a misdiagnosis:

Ms. Evans may become even more paranoid. She may have preconceived notions of what it is to be schizophrenic from seeing a family member with the disease. It could lead to her going further into depression or worsening her mental health overall. If it is a misdiagnoses and she believed she has schizophrenia it is going to be very hard to convince her that you made a mistake and it is wrong. She will lose trust in the mental health system and may stop seeking help. The trust relationship with a client is very important and should not be taken lightly.

When may it be appropriate to use a provisional diagnosis?

There may be some over diagnosing and loosely using diagnosing when behaviors may be within normal limits (Lasalvia, 2015). Using a provisional diagnosis could be used after more information is gathered but still more time is needed. So perhaps the psychosocial assessment is done but the social worker is still not 100% sure and would like to spend some more time gathering information on the client in further sessions. It’s a way of making a solid educated guess but saying I want to gather more information to be sure.

When would you diagnose as other specified and unspecified disorders?

I will be honest and say that I need to learn more about this. I believe this is when you do not find something that fits the client in the DSM-5. Then it would be unspecified until you can put more time into it and label it.

Laslavia, A. (2015). DSM-5 two year later: facts, myths and some key open issues. Epidimieology and Psychiatric Sciences, 185-187.

Submission and Grading Information

Grading Criteria

To access your rubric:
Week 2 Discussion Rubric

Post by Day 3 and Respond by Day 6

To participate in this Discussion:
Week 2 Discussion

Assignment: Video Role-Play: Strengths and Weaknesses of the DSM-5

Though the DSM-5 is the standard manual for mental illness diagnoses, it is not without weakness. In this Assignment, you analyze the strengths and limitations of the DSM-5 diagnostic system, and you differentiate between normal behavior and diagnosable symptoms using the concepts of dimensionality and spectrum.

To prepare: Review the concept of the dimensional approach with the DSM-5 and review the methods that the DSM-5 recommends to individualize where a person fits on a continuum of their illness in terms of subtypes, severity, and functional impairments. You will find these classifications in different parts of the manual and begin to be comfortable looking through it.

Next, imagine the following scenario:

You are a school social worker who has been asked to address a parent-teacher association meeting. Many parents in the audience have children who have been identified for special education services. They are confused about how to understand the diagnoses they are seeing. Others have worries about overdiagnosis. You have been advised that while these parents are generally well-informed, many don’t understand the dimensional or spectrum aspects. All are worried.

You will start your video with your introductory talk to the parents on these factors. After you provide your explanation, imagine that you open the meeting to questions. You will address the question noted below that is posed by a parent in the audience. Consider your audience, and practice explaining in terms a non-professional might understand. Do NOT read from the book.

Review the questions (in the Assignment instructions below) ahead of time and plan your answer before recording, as you will need to look up and integrate materials to answer the chosen question.

By Day 7

Submit a 3- to 5-minute video, considering the parents as your audience, in which you do the following:

• Briefly describe what the DSM-5 is and how it is organized. In your description, define the concepts of spectrum and dimensionality as explained by Paris and in the DSM-5 introduction.
• Explain why social workers and mental health professionals use diagnoses and what receiving a diagnosis means (and does not mean).
• Explain general concerns about the risks of overdiagnosis and misdiagnosis versus not diagnosing. Also explain how diagnosis is connected to services.
• Explain other details that might help your audience understand the strengths and weaknesses of the diagnostic system.
• Provide a response to the following parental questions:
  • My teenager’s best friend died by suicide this year. It’s been months, and she doesn’t seem over it. Her teachers tell me she should get help for depression, but I think it’s just grief. She talks about her friend all the time and gets very upset. I am worried about her. Is it normal for her to still be feeling this way? I don’t want to put her on medication for normal feelings. What is the difference between grief and depression?

Include a transcript and/or edit closed captioning on your video to ensure your presentation is accessible to viewers of differing abilities.