Introduction SectionSOCW 601

Introductions• You to me• Me to you• You to the course• Introductory materials on psychopathology, assessment, and clinical

social work

My new friend is…• Partner with someone not sitting next to you• Find out the following information about them:Their nameTheir favorite cartoon, movie, and/or book as a childWhat song would be their rock anthem • You will use this information to introduce your partner to the class

and to me

My new friend is…• Partner with someone different than before• Find out the following information about them:Their nameA talent they have or something they have accomplished that they

don’t mind sharingWhat’s the furthest away they have traveled• You will use this information to introduce your partner to the class

and to me

Two Truths and a LieA. “You look suspicious…” I have traveled under a false identity. I was believed by

law enforcement to be a terrorist. I was detained for over an hour as a suspect in the 1995 Oklahoma City bombing

B. “And I was running…” I frequently run and I have completed several marathons, including the Walt Disney World Marathon. I began training for triathlons with the hope of one day competing in an Iron Man competition, but never did

C. “Do you think you are some kind of ninja? Well, yes.” I have studied various martial arts, including those associated with the historical ninja of Japan. I used to kick box competitively and won an amateur championship. I have put my hand through ten inches of concrete and have been wounded by a machete and a samurai sword

About me• Background• Thank you• My expectations• Questions• Course overview

Opening Thoughts• A word about words….• Throughout the course we will use the term diagnose• Technically Clinical Social Workers do not diagnose, we make a clinical

assessment or clinical evaluation based on the DSM• Is messy and confusing because in many agencies the clinical social

worker makes a recommended diagnosis and then this is reviewed (“staffed”) by a psychiatrist, other physician or clinical psychologist• Some payer sources require this, while at other times clinical social

workers use DSM codes on insurance reimbursement• Technically we don’t make, assign an official diagnose

Controversy• There remains a great deal of conflict within social work about

teaching and using the DSM specifically, and using a medical model of clinical social work generally

Thomas Szaz and others-mental illness does not exist, is a societal construct, one that is used by those in power in a society to control and marginalize others

The DSM, including how it is developed and utilized, is as much a social document as it is a scientific one and is subject to the influence of societal attitudes, politics, special interests (consumer groups, professional organizations, pharmaceuticals)

ControversyQuestionable science behind diagnoses, including the reliability and

validity of the conditions themselves and the ability of clinicians to diagnose, as well as their treatment

Diagnoses can be too easily made, conditions are over diagnosed, and this has a negative impact on individuals and society• All of these are valid points, important conversations to have. Still this

system is here, widely used and it is important for clinical social workers to be informed about competent in its use (Ex. Licensure, employment)

Part of the Team• These diagnoses are used throughout healthcare, including psychiatry,

psychology, and nursing• As clinical social workers it is important for us to know about diagnoses

because:We will be assessing people, recommending diagnoses, and providing

treatment and intervention services based on those diagnosesEven if we are not recommending the diagnoses, we will be providing

services for individuals with these conditions and need to know about themWe work as part of multidisciplinary team where all (or most all) members

will be working from this paradigm

What We Bring to the Team• It is important for us to remember that people are so much more than

any diagnosis they might have, and to remind others as well. People are individuals, imbued with dignity and respect, that have a medical condition

Ex. “Schizophrenic”, “Alcoholic/addict”, “Borderline”More important than the diagnosis is how it impacts their life, their

functioning, their relationships, their sense of identitySince these are individuals, important to remember the diversity of

experiences and perspectives people have, even when they have the “same” condition; not all people with the same diagnosis look the same

What We Bring to the Team• A diagnosis is not synonymous with functioning and capabilities;

someone's abilities cannot be solely determined by a diagnostic label they may have• Since individuals with certain diagnoses and with disabilities are often

vulnerable, disadvantaged populations subjected to oppression and discrimination it is important for social work to not only provide direct care services, but to advocate and protect• Our commitment is to empower people, to enhance their ability to self-

determine, so we often serve in a role of educating people about their diagnoses, informing them on treatment services, enhancing their coping capacities

What We Bring to the Team• We bring to diagnosing and our clinical work our appreciation for and

our emphasis on:Ecological perspectiveSystems theoryPerson-in-environmentBiopsychosocial perspective

Biopsychosocial model

Psychological (thoughts, feelings

and how we process them,

patterns of behavior)

Social (relationships, family/societal

structure/systems, social/environmental forces, oppression/discrimination)

Biological (genetics,

hormones/chemicals,

organs/structure)

Why Diagnose?• Helps in naming and describing phenomena (What is this?)• Helps communication between clinicians (Do you see the same

thing?)• Helps to better understand phenomena and guide research (What’s

this like? How does it work?)• Helps guide choice of treatment (What if we do…? What tends to

work for this is…)

Assessment (general)

AssessmentInformation acquired,

identifying what is present

Conceptualization (diagnosis)

How the information is related, connected,

interpreted; working understanding of

someone and what they are experiencing

Plan/InterventionWhat we do based on the information

and our understanding of it

Why Diagnose?• Additional reasons include:Gathering data (epidemiology)Legal/forensicInsurance/Reimbursement

Some Terms• Nosology-the study of naming, classifying conditions What we are most concerned about in this particular class• Etiology-the onset of a condition (What leads to…?)• Pathogenesis-the course of a condition over time (How does this look, change

over time?)• Differential Diagnosis-the process of determining what condition is present as

opposed to another (it’s tis, not this, and here’s why)• Comorbidity-When two (or more)conditions are present, especially if they are

often found to be present with each otherEx. Substance Use Disorders are often comorbid with mood, anxiety and trauma-

related disorders

Some Terms• Primary diagnosis-when more than one diagnosis is present this is seen as

the one that is most severe, most prominent, most contributing to their reason for presenting and current treatment• Provisional diagnosis-term used when there is a suspicion that a condition

is present and some of the criteria are met, but not enough to meet the requirements

This can be and is also often called a Rule Out diagnosis, where you note that there is data suggesting that the condition is likely there, but currently not enough information or criteria met to officially make the diagnosis

Ex. Rule out (or R/O)…..

Some Concepts• “Abnormal” behavior is often defined as behavior that:Is statistically infrequent (which by its very definition then would say

it is not normal i.e. statistically frequent because it differs from that)Violates norms (because that is behavior that is defined as “normal”)Represents a change from previous functioning (often sudden)Creates significant distressCreates an impairment in functioning

Some Concepts• “Abnormal” behavior is often defined as behavior that: Is statistically infrequent (which by its very definition then would say it is not normal i.e.

statistically frequent because it differs from that)Genius is statistically infrequent, wouldn’t necessarily call it psychopathologyViolates norms (because that is behavior that is defined as “normal”)Civil rights activists in the 1960’s who integrated restaurants and busses were violating norms (and

laws)-not psychopathologyRepresents a change from previous functioning (often abrupt, sudden)This one can be a defining feature of psychopathology, because many conditions represent a

change from previous functioning, including abrupt and sudden, but some conditions are more chronic (so no real change; always been there) and gradual as opposed to sudden

Creates significant distressCreates an impairment in functioning

Some Concepts• Creates significant distressCauses significant concern and/or distress to someone, most important client, but

also client and others in their life, but can also be to others without the client necessarily currently experiencing it as distress• Creates an impairment in functioningInterferes with and disrupts their ability to function in life, such as:Social-affects relationships, ability to form and maintain, leisureIndependent Living-ability to care for self and maintain everyday needs of living

(shopping, cleaning, budgeting, personal safety etc.)Occupational-ability to achieve and maintain employment and provide for

themselves

Some concepts• Dichotomous-vs.-continuum view of psychopathology• The dichotomous view says that you either have something or you

don’t

Some Concepts• The continuum view suggests that all conditions exist along a

continuum of expression

Some Concepts• Spectrum view-when different conditions are seen to be related to

each other, seem to exist on a continuum• Often believed to have common biological and/or environmental

etiology and common pathophysiology

Changes• Why do we need to learn about aspects of a system that are no longer

used?In the grand scheme of things the change has been rather recent

(only a few years)The changes were significant, not minor-previous revisions had

changed less, but this one has many substantial changesYou will continue to see references to the older system and older

names in the literature, and you will review records for decades that have the old system and names and codes on them, so important to at least be familiar

Changes• Used to use a multi-axial diagnostic system:Axis I: All clinical disorders except…Axis II: Personality Disorders and Mental RetardationAxis III: General medical condition, especially conditions that affect the understanding or management of the client’s mental disorder(s)Axis IV: Psychosocial and environmental problems, especially those affecting the understanding or management of the client’s mental disorder(s)Axis V: Global Assessment of Functioning (GAF)Was a 0-100 score or range of score (ex. 80-85 or 80-90) that represented the

clinician’s judgment to the person’s overall level of functioningUsually score was given for currently and highest in past year

Changes• Names of some conditions have changed, some previous conditions have been collapsed

together or deletedEx. “Mental Retardation is now Intellectual Disability (Intellectual Development Disorder)Substance abuse and substance dependence replaced by substance use disorder with

different severity specifiers• New conditions added Ex. Disruptive Mood Dysregulation Disorder• Not Otherwise Specified (NOS)-used in previous editions to say that a disorder was present,

but that it did not meet the exact criteria for a particular disorderOften used because diagnoses are often not as clear as they first seem, often hard to get

complete information due to he client, amount of time etc.Now there are other specified disorder and unspecified disorder to take the NOS place

Changes• The categories and the conditions classified in each category (what’s in the

category) have changed drastically• Conditions are now grouped in a dimensional view, suggesting that the

conditions in a category are related along a continuum/spectrumSuggests possibility of common etiology and pathophysiology that might

guide future research and understanding• Conditions are now also grouped developmentally, with conditions often first

seen in early life included with ones that present later• Conditions now generally grouped and ordered in the book as they are seen

to reflect a sense of Internalizing (anxiety, depression, somatic symptoms) versus externalizing (impulsive, disruptive conduct, substance use)

Changes• DSM is now making an effort to coincide with the International

Classification of Disease (ICD) from the World Health Organization (WHO)• The codes have changed, third party payers are changing to reflect

that, and some states and funders (Medicaid, Medicare, etc.) are considering whether to drop the DSM and just use ICD

Framework for Diagnoses• As we are learning the diagnostic process for each condition we can use

the following framework:I. Required, defined time frameII. Symptom cluster/constellation and thresholdIII. Causes distress/impairmentIV. Rule outV. Specifiers and severity indicatorsVI. ICD codeVII. Tell me more

Framework for DiagnosisI. Required, defined time frame-each condition will have specifics

about how long the difficulties need to have been present before making a diagnosis

II. Symptom cluster/constellation and threshold-each condition will have its list of symptoms for the condition and the number of symptoms that must be present to make the diagnosis

III. Causes distress/impairment-each condition has he following requirement: The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning

Framework for DiagnosisIV. Rule out-some conditions further describe and specify characteristics beyond specific symptoms that need to be present to qualify for the diagnosis and conditions that need to be ruled out, such as:If the condition is due to the effect of a general medical conditionIf condition is due to the direct physiological effect of a substanceIf symptoms can be better described or accounted for by another condition V. Specifiers and severity indicatorsSome conditions will offer specifiers to further describe the nature of the

conditionSome conditions define how many symptoms present for the condition can be

classified as mild, moderate and severe

Framework for DiagnosisVI. ICD codeEach diagnosis will have a code number attached to it VII. Tell me moreThis one is mineThere is always more information we could gain that would further

refine, clarify, enhance our understandingWhat further information would I want to know?What else might help me better understand or determine…?