Mental Health Problems

Excerpted from the Introduction to Concurrent Disorders: A Guide for Counsellors .

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) lists 16 major diagnostic classes of psychiatric disorders. Differential diagnosis requires that the therapist fit mental health problems into one or more categories based on whether the problems meet a defined set of criteria. This can be a difficult task, particularly when behaviours are the result of a complex interaction between substance use and mental health problems. In the first stages of a treatment relationship, it may be useful to take a dimensional approach that looks at problems on a continuum of severity. One advantage of this approach is that it includes symptoms that may be causing distress but that might not meet DSM criteria.

In our clinical work we find it useful to group behaviours into four dimensions:

• psychosis: involving problems of cognitive and perceptual organization
• impulsivity: including problems of anger and aggression, including risk of harm to self and others
• mood: including depression and affective instability
• anxiety: involving the problematic inhibition of responses.

Personality disorders (called Axis II disorders in DSM) can also be accommodated in this model. The DSM-IV identifies three clusters of personality disorders:

• Cluster A (called the “odd” cluster in earlier versions of the DSM) belongs in the psychosis dimension, and includes diagnoses of schizoid, schizotypal and paranoid personality disorders.
• Cluster B (previously called the “dramatic” or “impulsive” cluster) belongs in the impulsive dimension, and includes antisocial, narcissistic, histrionic and borderline personality disorders.
• Cluster C (previously called the “anxious” cluster) can be found in the anxiety dimension, and includes compulsive, avoidant and dependent personality disorders.

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