Diagnosis in the Assessment Process

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Chapter 3
Diagnosis in the Assessment Process

Updated and Revised by

Katherine A. Heimsch & Gina B. Polychronopoulos

In Essentials of Testing and Assessment

By Ed Neukrug and Charlie Fawcett

Desk copies can be obtained at: www.cengage.com

Diagnosis in the Assessment Process

Chapter 3

It was 1975, and part of my job as an outpatient therapist at a mental health center entailed answering the crisis counseling phones every ninth night. I would sleep at the center and answer a very loud phone that would ring periodically throughout the night, usually with a person in crisis on the other end. Every once in a while, a former client of the center would call in and start to read aloud from his case notes, which he had stolen from the center. Parts of these notes were a description of his diagnosis from what was then the second edition of the Diagnostic and Statistical Manual (DSM-II). In a sometimes angry, sometimes funny tone, he would read these clinical terms that were supposed to be describing him. I could understand his frustration when reading these notes over the phone, as in some ways, the diagnosis seemed removed from the persona label. “Was this really describing the person, and how was it helpful to him?” I would often wonder.

Ed Neukrug

An important aspect of the clinical assessment and appraisal process is skillful diagnosis. Today, the use of diagnosis permeates the mental health professions, and although there continues to be some question as to its helpfulness, it is clear that making diagnoses and using them in treatment planning has become an integral part of what all mental health professionals do. Thus, in this chapter we examine the use of diagnosis.

We begin this chapter by discussing the importance of diagnosis in the assessment process and then provide a brief overview of the history of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and its evolution over the past several decades. We then introduce the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and note some of the differences from previous versions, such as the use of a single axis and factors that now come into play when making and reporting diagnosis. Next, we highlight the DSM-5 diagnostic categories and follow up with other important considerations when making a diagnosis, such as medical concerns, psychosocial and environmental concerns, and cross-cultural issues. There are several case studies and exercises that will help to hone some of your diagnostic skills. At the end of the chapter, we relate the importance of formulating a diagnosis within the overall assessment process.

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