Psychologists use classification systems to diagnose mental disorders.   But these systems have also come under criticism.   The most popular classification system is the DSM-IV. It contains over 250 disorders in 17 of the following categories: Adjustment Disorders, Anxiety Disorders, Delirium, Dementia, and Amnestic and Other Cognitive Disorders, Disorders Usually Diagnosed in Infancy, Childhood, or Adolescence, Dissociate Disorders, Eating Disorders, Factitious Disorders, Impulse-Control Disorders, Mental Disorders Due to a General Medical Condition, Mood disorders, Other Conditions That May Be a Focus of Clinician, Personality Disorders, Schizophrenia and Other Psychotic Disorders, Sexual and Gender Identity Disorders, Sleep Disorders, Somatoform Disorders, and Substance-Related Disorders. The five multiaxial dimensions are used to classify the disorders and help clinicians and psychiatrists evaluate the client’s overall level of functioning.

Axis I is used for clinical syndromes that are the focus of clinical attention. Axis II is used for personality disorders and mental retardation. Axis III is where general medical conditions that may be potentially relevant to understanding the case are listed. Axis IV is where psychosocial/environmental problems are listed; ones, which may contribute to the disorder. Axis V is to record the Global Assessment of Functioning (GAF). Here, clinicians indicate how well a client is coping at the present time on a scale of 1-100. Some clinicians may even include a separate score for best GAF in the past year or 6 months to denote the difference in functioning from now to the past. One benefit of the DSM-IV is that it provides consistency. Professionals dealing with individuals that have mental illness use the same classification system, so that everyone understand what a certain disorder means. For example, if someone is diagnosed with borderline personality disorder, this means the same thing to any professional using the DSM-IV. Another benefit to using the DSM-IV is that it is backed by research, which can lead directly to treatment planning. For example, knowing that a high percentage of individuals with OCD have a tic disorder could help a clinician better understand a client’s presentation, so as to develop an effective treatment plan. One disadvantage of the DSM-IV is that it is a categorical system, which forces clinicians to place people into categories. Many times symptoms overlap, so people end up with more than one diagnosis.

The case study of Jennifer C. exemplifies how DSM-IV categories can be used to make diagnoses. Jennifer C. initially went to see here therapist because she was beginning to lose focus and neglect her responsibilities as a student. She felt as though she could not keep up with the demands of her schedule at school and “do what needed to be done for peace of mind.” Although Jennifer C. did describe some flashbacks of her sister’s death in a bike accident, the three symptoms that seem to be most important in reaching a diagnosis of Jennifer C.’s disorder are
frequent crying spells, great difficulty falling asleep at night, and lack of general interests. Jennifer C. seems to be suffering from Major Depressive Disorder, Mild. In additional to the three aforementioned symptoms she is also described as “extremely thin” and also as having trouble with concentration, which makes up 5 of the symptoms needed to make this diagnosis.

One difficulty in using the DSM-IV is that the different disorders may hare similar symptoms. In the case study of Jennifer C. at least one other diagnosis is possible on the basis of her symptoms. Another possible diagnosis for Jennifer C. would be Post Traumatic Stress Disorder (PTSD). The first fact that would lead me to this conclusion is that she was exposed to a traumatic event (Criterion A), which was the death of her sister in the bike accident. Flashbacks would satisfy Criterion B, while the avoidance of bikes, flat affect, and diminished interests would satisfy Criterion C. Criterion D would be satisfied by her diminished sleep and trouble concentrating. One implication of attaching another disorder to the same symptoms would be that she would likely be considered “more ill” than she really is. She may be given more medications than she really needs and also her treatment plan may not be as focused and effective.

Although the DSM-IV is used only for classification purposes, a DSM-IV diagnosis can have implications for the therapy used to treat the disorder.   In the case study of Jennifer C. the original diagnosis I made suggests a certain therapeutic approach, which depends on the specific theoretical orientation of the therapist. A psychodynamic therapist would focus on trying to get Jennifer C. to explore here emotions, especially those that she is not consciously aware of. By bringing these thoughts and feelings to consciousness, the therapist could help Jennifer C. understand how her behaviors and mood are affected by her unresolved issues and unconscious feelings. He would likely focus on her unresolved issues regarding her father’s abandonment and sister’s death. Through talk therapy, he would help her work through these feelings so that she can better understand how they are affecting her life. He may also focus on defense mechanisms and use dream interpretation. He may also use the therapeutic relationship (e.g., transference and countertransference) to produce change (e.g., model appropriate behavior, use her behaviors in therapy to point things out to her in the moment, or use how she makes him feel in session to help her). A cognitive therapist would focus on how Jennifer C.’s thoughts, feelings, and behaviors are intertwined to produce her current symptoms.

The therapist would gather background information, but would focus on the here and now. The therapist would be interested in several of Jennifer C.’s maladaptive cognitions: feelings of guilt regarding the fact that she survived and her sister did not, feeling like her life could end at any moment, and feelings of giving up at school in the sense that she feels as though she cannot handle the situation. She also has some maladaptive behaviors: likely poor eating/diet habits due to extreme thinness, poor sleep (maybe anxiety), and crying spells. These are all likely driven by dysfunctional thoughts, which the therapist would work on in therapy to uncover. The therapist could use any number of cognitive questioning techniques to uncover these maladaptive cognitions: Socratic questioning, self-monitoring, homework, and role-playing. The therapist will be able to produce therapeutic change by restructuring negative and inaccurate thoughts (in lieu of more positive and accurate thoughts), so that Jennifer C.’s mood will change to also be more positive. He may also help her with sleep strategies (e.g., progressive muscle relaxation) and eating habits. As a result, her behaviors will change and she will be able to concentrate better and complete her studies with success.

A therapist from a client-centered approach would focus on the client’s needs and employ such strategies as empathy, unconditional positive regard, and genuineness. The therapist would let the client guide most of the therapy, acting more as a friend or collaborator (versus being directive). Person-centered therapists help clients grow and achieve self-actualization because they believe that clients make conscious decisions for themselves. The therapist would; therefore, employ such techniques as listening, accepting, understanding, and sharing. Empathy would involve the therapist conveying to Jennifer C. that he understands where she is coming from and that he can feel what she feels (i.e., therapist puts himself in the clients shoes). Unconditional positive regard would involve the therapist making Jennifer C. feel valued and deeply cared about. The therapist would be accepting of Jennifer as she is, versus passing judgment. Genuineness would involve “congruence with Jennifer C.,” where the therapist would allow Jennifer C. to experience her therapist as he is…as an authentic individual. It is that unique, strong, and positive relationship between client and therapist that will help empower and motivate Jennifer to fulfill her own potential.

The treatment plan that I think would be most effective would be client-centered therapy. While all three approaches would have some benefits, this approach seems best in that she seems to have suffered a lot of traumas related to relationships (e.g., father, losing sister, boyfriend, and with mother). It seems as though developing a positive, trusting, and genuine relationship with a therapist would help her heal some of these wounds. She would gain some confidence, which would help her get motivated and back on track with school. Hopefully, she would translate this positive relationship to other relationships in her life, which would also improve her overall quality of life. Immediate relief is just as important as long-term effects. If Jennifer C. is suffering to a point that it is significantly affecting her quality of life, it would be important to give her some immediate relief, which may be in the form of medication. It would be difficult for her to do any quality “work” in therapy if she was in too much acute distress. Long-lasting results are equally important so that she can lead a happy and successful life and so that she has all of the proper tools (e.g., coping skills) to help her overcome crises in the future.