Making a DSM-5 Diagnosis

Making a DSM-5 Diagnosis

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Making a DSM-5 Diagnosis

Skillful medical diagnosis is a vital part of the clinical evaluation and appraisal process. The DSM-5 is the newest diagnostic approach, presenting a one-axis approach unlike its predecessor, which had a multiaxial approach. First published in 2013, the DSM-5 approach attempts to unify the diagnostic as well as the billing methods between psychological and medical professionals (American Psychiatric Association, 2013). This paper reviews the medical intake report of a client; Ricardo to come up with a DSM-5 diagnosis of the same client.

Questions that would elicit information to make a principal diagnosis

Some of the important questions that I would ask Ricardo to gather information to make a principal diagnosis include the following. A) How would you describe your general health for the past few days leading to today? This question is important in getting to know the patient’s perception of his health and his health problems in his words (Karyn, 2010). B) When did you start experiencing headaches, stomach pains, nightmares, fears, and worries? Was there a given time when you felt worse or better? Was there any particular pattern? These portions of the questions aim to establish the onset and course of Ricardo’s health problems. C) Do you believe that some external factors or events caused your problems? Are there any stressful life events associated with your health concerns?

Getting a detailed history of the presenting complaint is essential in establishing a principal diagnosis. For instance, the signs and symptoms of major depressive disorder and dysthymic disorder have identical symptoms, but differences in their onset, duration and severity (Karyn, 2010).

Identifying other conditions that may be the focus of clinical attention of Ricardo

When diagnosing a patient, it is also important to rule out other conditions, which could be the focus of clinical attention (V and Z codes). Therefore, the following questions will elicit important information that could be the focus of the clinical attention of Ricardo. The questions would shed light to Ricardo’s psychosocial as well as any environmental stressors (Beach, Marianne, Nadine, & Richard, 2006). A) Describe some of the problems, if any, in developing and sustaining relationships. Did you experience any violence in your past relationships? B) Why do you feel reluctant in making friends and joining social activities? C) Are you taking any medications related to a medical problem? D) How would you describe your coping mechanisms to stress at work and home or in life?

The social, cultural and family factors needed to assess Ricardo

Some of the social, cultural and family factors I would assess in Ricardo include the following. The client’s immediate relatives and their mental history. Medical history as well as any history of traumatic experiences. I would also want to know how the client spends his free time and where he gets advice and emotional care when having social issues according to their culture at home and presently. Besides, I would asses any history of substance abuse back at home and currently.

The importance of considering medical conditions in the assessment

It is vital to assess and consider medical conditions in Ricardo because some medical issues and medications have subsequent psychiatric symptoms. Moreover, others could worsen prevailing mental illnesses. Addressing a client’s medical condition would ensure a holistic care approach; therefore, promote quality of care for the patient (Rashid & Ostermann, 2009).

Additional assessment and diagnostic procedures required to gather information

Additional assessment instruments and processes that I would consider in gathering enough information for a DSM-5 diagnosis in Ricardo include the following. One of them is the mental status examination tool (MSE). The DSM-5 diagnosis is a screening and evaluation tool that is essential in areas dealing with the patient’s emotional as well as cognitive ability. Usually centered on the observations of the patient’s perception of his or her subjective experiences. It includes the client’s appearance, behavior, language, and speech, thought content, thought process, mood and affected as well as the cognitive functioning (Ericksen & Kress, 2006). Although a separate tool, most elements of the MSE are concurrently evaluated as the structured clinical interview is in progress. Another diagnostic procedure would be a thorough head to toe physical examination to rule out any medical condition that Ricardo could be having. The technique is essential in picking any other problems the client may not be aware of, and address them early enough. This is important in ensuring a holistic care to the patient (Florence & Terence, 2006).

Assessing Ricardo’s strengths and coping skills

Another important element of Ricardo’s psychiatric assessment would be his strengths and coping skills. I would seek to understand how Ricardo copes with stress and establish what works and what does not work for him in the past. Other key areas would be the client’s support system, including support from the family, accessibility of financial resources, the community as well as the professional support network. Ricardo stays alone; all his family members are far away from him. He does not have friends and does not involve himself in social activities. The best way would start to make friends and get professional help.

The impact of diagnosing Ricardo as having a mental disorder

Diagnosing Ricardo as having a mental disorder would be the initial step towards the road of recovery. Although it may be unfortunate for him at first because he would have to devote some of his time in seeing a counselor and other support systems, in the end, it would be best for him. He would need to accept that he has a problem and therefore, seek help and treatment for him to be safe.


American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th Ed.). Washington, D.C: Author.

Beach, S. R., Marianne, W., Nadine, K., & Richard, H. (2006). Describing Relationship Problems in DSM–V: Toward Better Guidance for Research and Clinical Practice. Journal of Family Psychology, Vol. 20, No. 3, 359–368.

Ericksen, K., & Kress, V. (2006). The DSM and Professional Identity: Bridging the gap. Journal of Mental health counseling, 202, 217.

Florence, K., & Terence, P. (2006). Relational Diagnosis: A Retrospective Synopsis. Contemp Fam Ther, 28:269–284.

Karyn, D. J. (2010). The Unstructured Clinical Interview. Journal of Counseling &c Development, 1-8.

Rashid, T., & Ostermann, R. (2009). Strength-based assessment in clinical practice. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, V o l . 6 5 ( 5 ), 488-498.

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