Assessing when a patient problem or symptom elevates to the severity required to diagnose a psychiatric condition can be a difficult task, particularly for inexperienced practitioners. The “Four Ds” (deviance, dysfunction, distress and danger) can be a valuable tool to all practitioners when assessing reported traits, symptoms, or conditions in order to ascertain the point of at which these factors might represent a DSM IV-TR disorder. This article summarizes the “Four D’s” and provides the practitioner with examples of each “D” utilizing a DSM IV-TR diagnosis.
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One of the inherent difficulties in diagnosing a mental disorder is determining at whatever level a particular trait or problem becomes a clinical diagnosis. An old joke serves well to illustrate this point. Question: “What is the difference between someone who is crazy and someone who is eccentric?” Answer: “About ten million dollars”. This joke is humorous because it reflects the grey lines that define when symptoms rise to the point of classification as a disorder. As such, it also speaks to the difficulty of mental health diagnosis. An individual with many resources may not experience a similar set of behaviors as a problem since it is likely that the person will be afforded latitude that someone with limited resources will not. Every human being experiences a range of emotions and problems across the life span. When does a problem become a disorder? To answer the question in part, mental health professionals can utilize the “four Ds”, danger, deviance, dysfunction and distress to define disorders (Comer, 2010).
This article will explore in some detail the four “Ds” and how they contribute to psychiatric disorders. Each “D” will be explored through one of the Axis I disorders of the Diagnostic and Statistical Manual fourth text revised edition [DSM IV-TR] (APA, 2000).
Before illustrating diagnoses with Axis I disorders, it may be helpful to discuss broadly what the four “Ds” are commonly defined as encompassing. Wilmhurst (2005) states that she believes the four “Ds” are essential to differentiate abnormal behavior from normal behavior. She continues to explain that deviance can be understood through formal classification schemes such as those provided in the DSM IV-TR diagnostic criteria. Apart from these, other tests which provide norms for the general population can be helpful to determine degree of deviation from the norm. Further, clinical interviews can collect information helpful in both these examples. She cautions that many disorders share common patterns of deviance and need to be examined in a differential diagnostic model.
She continues to state that dysfunction is important in order to determine the presence of a problem large enough to classify as a diagnosis. This dysfunction must be significant enough to interfere in the individual’s life in some major way. In addition, it is important to look for dysfunction across life domains as they may exist in obvious places as well as less likely places.
Distress is similar to dysfunction in that it becomes an important way to grade the dysfunction in a person’s life. This relationship is not always linear. A person can experience a great deal of dysfunction and very little distress or vice versa. The essential component of distress is the extent to which the issue distresses the individual, not the objective measure of the severity of the dysfunction.
The last of the four “Ds” is danger. To outline this concept more specifically, the danger component consists of two broad themes, danger to self and danger to others. Diagnostically speaking, there is a wide continuum of danger. There is some element of danger in every diagnosis and within each diagnosis there is a continuum of severity. Once these have been explained in broad strokes one can explore how these are played out in a specific diagnostic picture.
The first “D” is that of deviance. This “D” will be examined using 302.2 Pedophilia, a DSM IV-TR diagnosis in which deviance is the hallmark of the disorder (APA, 2000). Pedophilia is a specific paraphilia, a class of disorders characterized by recurrent intense, sexually arousing fantasies, behaviors or urges. Pedophilia is characterized by recurrent urges, fantasies or behaviors existing over at least 6 months and directed at children 13 years of age or younger. These symptoms must present significant distress or impairment. The individual must be over the age of 16 and 5 years older than the subject of the desire. Seto (2004) surveyed a number of studies and found that anywhere from three to nine percent of males report some interest in underage children and a number of these studies demonstrated that this interest could be turned into action if the circumstances were right. Thus, those who have the thoughts are either in the minority or in a small minority of males. In addition, he points out that the actual number of males who meet the other criteria of time and intensity is very likely much less than the three to nine percent figure. Given the legal and social attitudes concerning pedophilia, the number of individuals who can be diagnosed with the disorder is difficult to ascertain. The fact that up to nine percent of males may have sexual interest in children may set an upper limit to the prevalence. This however may still be questionable given a potential bias against reporting (e.g., potential respondents would find it taboo to admit to certain tendencies/feelings/thoughts). Females with these propensities are even rarer in the literature as Seto demonstrates. These factors taken together illustrate the statistically deviant nature of pedophilia.
To examine dysfunction, the diagnosis of 296.33 Major Depressive Disorder, Recurrent, without Psychotic Features is chosen (APA, 2000). This disorder is characterized by two or more episodes of a major depressive episode. When the classification of severe is used, it indicates that this episode has elevated to the point where many it markedly interferes with the individual’s occupational or social life. This interference must be defined by the presence of a minimum number of the symptom classifications outlined in the criteria. The person will experience a depressed mood for most of the day which will interfere with relationships with others, as easily perceived by outside observers. He/she has a great decrease in pleasure in almost all of the activities of life which will likely make the person avoid many of these, resulting in more dysfunction. The individual may experience insomnia or hypersomnia to the point of interfering with daily tasks. He/she will experience marked energy loss and may not have the motivation or energy to do common tasks. The person may have a diminished ability to concentrate which interferes with the ability to complete tasks. When this diagnosis is made, it is likely that the individual has experienced some dysfunction in almost every area of life and severe dysfunction in many areas. In fact, in an inquiry by Remick (2002), many areas of dysfunction were identified in the research. He found that depressive disorders and poor work productivity are related as demonstrated by a threefold increase in the number of sick days in the months preceding the illness for workers with depression compared with coworkers who did not show increases in sick days preceding illness that was not depression. There is evidence that children of women with depression have higher rates of dysfunction in school, are less socially competent, and display lower self-esteem than their classmates mothers whose mothers who are not depressed. Finally, the leading cause of disability among people aged 18 to 44 years is depression and this diagnosis is expected to become the second leading cause of disability for people of all ages by 2020.
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The third “D”, that of distress, will be explored using the diagnosis of 300.7 Hypochondriasis (APA, 2000). The features of Hypochondriasis consist of a preoccupation with the fear of having, or the idea that one has, a serious disease. This fear is based on the misinterpretation of an individual’s bodily symptoms. Currently this diagnosis is classified as a somatoform disorder. However, it also features elements of an anxiety disorder. The distress of the preoccupation of the disorder persists in spite of medical evaluations and reassurance. Salkovskis, Warwick and Deale (2003) found that these individuals tend to use considerably more medical resources and tend to be rather intractable in terms of their prognoses. Further, although reassurance that is offered may decrease short term distress, it increases distress in the long run. Therefore, it seems the more medical reassurance that is sought, the more distress increases. This feature makes the problem of distress a fundamental feature of the disorder. In fact, the researchers found that effective treatments all centered on decreasing the amount of distress experienced by the individual with the disorder. This decrease is accomplished through thought restructuring to refocus the individual’s attention away from somatic symptoms toward non distressing thoughts and activities, thus getting the individual to decrease the amount of behavior consumed by the distress. Ultimately, if one can lower the anxiety and distress level, a positive outcome may be more likely.
The fourth “D” of danger will be examined using a seemingly benign disorder classified in the DSM IV-TR, 305.10 Nicotine Dependence (APA, 2000). A major feature of this disorder is the danger it places on those meeting diagnostic criteria. The disorder is characterized as a substance abuse disorder but is divergent in some respects from other substance abuse disorders. Nicotine dependence features elements of tolerance and withdrawal. Nicotine dependence also features elements of distress both in the health conditions related to it and the behaviors that people exhibit when it is unavailable. Individuals may even avoid activities or situations which negatively impact their lives due to the inability to use the substance. Particular health consequences occur in those who smoke. Approximately 80 percent of smokers express the interest in quitting. Thirty five percent of smokers actually try to quit in any given year, while only five percent are successful, even though the dangers of cigarette smoking are quite well documented. In an article summarizing a center for disease report, Sibbald (2003) documented that over eight and a half million Americans are diagnosed with over 12.5 million smoking related diseases. Moreover, 10 percent of all current and former smokers have a smoking related chronic disease. These diseases include heart disease, emphysema, stroke and cancer. Further, 440,000 Americans die prematurely every year due to a smoking related illness. Clearly nicotine dependence is a dangerous diagnosis.
Even though nicotine dependence may be obvious in terms of danger, it is also clear that other mental illnesses carry substantial elements of danger. Hiroeh, Mortensen and Dunn (2001) followed over 257,000 individuals in the Danish psychiatric register and documented their causes of death. They found that individuals with mental illnesses had a 25 percent higher chance of dying from any unnatural cause, including homicide, suicide, and accidents. Further, they found that almost all psychiatric diagnoses show elevated mortality as compared to the general population. Of all types of unnatural deaths, suicide was the most prevalent.
With the clarifying aids of danger, deviance, dysfunction and distress, separating everyday problems from those that elevate to levels of disorders would be difficult. The four “D’s” are a valuable tool for the clinician to identify the points on a continuum at which human cognition, emotion and behavior change from normal into abnormal and thus can be classified as psychiatric disorders.
If everyone experienced the same level of the problem, it would not be out of the ordinary enough to warrant classification. Likewise, if the distress and dysfunction never elevated to the level of danger in some way, it would be unlikely that the disorder would be considered serious enough to obtain disorder status. In addition to assisting in the classification of a disorder, the four “Ds” also assist in the assessment of one. When kept in mind, these elements of diagnosis can be invaluable as a tool to assist the clinician in differential diagnosis.
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