For my first post in the 31 Days of Mental Health series, I will discuss how mental health conditions are diagnosed. As you probably know, there is no objective test for mental illness, like a blood or urine test. The diagnosis of mental illness is based on the symtpoms and signs a patient presents with.
The main classification system for mental disorders in use in th United States and elsewhere is the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. In 2013, the fifth edition, DSM-5, was published. However, some countries, like the Netherlands, still use the previous edition, DSM-IV.
DSM-IV uses a multi-axial system of diagnosing mental disorders. There are two axes for mental disorders: Axis I for clinical disorders like depression, schizophrenia and ADHD, and axis II for intellectual disability and personality disorders. The reason for the existence of axis II is that the creators of DSM-IV felt that intellectual disability and personality disorders are particularly hard to treat and relatively stable over time. Later research found this is not necessarily the case for certain personality disorders in particular. In DSM-5, personality disorders and intellectual disabiltiy are listed under the same section as other mental disorders.
In DSM-IV, there are three more axes for diagnostic classificaiton: Axis III for physical disorders, axis IV for psychosocial and environmental factors, and axis V for one’s global assessment of functioning (GAF) score. This score indicates how well or ill a person is in general. A GAF score of 100 indicates excellent mental health, while a GAF score of 50 indicates severe symptoms or severe impairments in one area of functioning (eg. work, school, social life). A GAF socre of 1, the lowest score, indicates persistent danger of seriously harming self or others. My GAF socre is 40, meaning some problems in reality testing or communication or significant impairments in more than one area of functioning.
The GAF score is, as the name suggests, a global scale. As such, it does not determine how severe each disorder a person may be diagnosed with is. Also, if a person has problems in maintaining their personal hygiene, they automatically get a lower GAF score than those who have problems functioning at work or school. It is apparently thought that, if you neglect your personal hygiene, you will be unable to function at school or work. This at least hasn’t been the case with me. In DSM-5, the GAF scale was dropped and severity can be coded for each disorder a person has been diagnosed with. The World Health Organization (WHO) Disability Assessment Schedule is included in the assessment tools section of DSM-5.
You may’ve noticed that I mostly refer to mental disorders, not mental illnesses. The word “mental illness” is not used within the DSM, rather, DSM uses the word “mental disorder” to encompass all conditions listed in their classification system (with some exceptions, eg. medication-induced movement disorder). A mental disorder is defined in DSM-5 as a syndrome characterized by clinically significant disturbance in a person’s cognition, emotion regulation or behavior. It reflects a dysfunction in the psychological, biological or developmental processes underlying mental functions. Mental disorders are usually associated with significant distress or disability in social, occupational or other important activities. An expected or culturally approved response to a stressor, such as the loss of a loved one, is not a mental disorder. Religious, political or sexual deviance or conflicts between the individual and society are not mental disorders, unless the conflict originates primarily within the individual.
A mental disorder is not the same as a need for treatment. Need for treatment is determined through a complex process of assessment of symptom severity, presence of certain symptoms (eg. suicidal ideation), the person’s distress or disability related to their symptoms, risks and benefits of available treatment, and possibly other factors (eg. if a person’s mental disorder impacts another illness). Because of this, people who do not meet all criteria for a diagnosable mental disorder but who demonstrate a clear need for care, may be taken into treatment.
Section II of the DSM-5 describes all mental disorders that are currently being recognized by the American Psychiatric Association. Mental disorders, for clarity’s sake, include neurodevelopmental and neurocognitive disorders (eg. autism or dementia), addictions, as well as those disorders more commonly thought of as mental illnesses. Personality disorders are not always seen as mental illnesses. For example, in the UK’s Mental Health Act, they are called “psychopathic disorders”. Nonetheless, I see both personality disorders and disorders such as schizophrenia and depression, as mental illnesses.