DSM 5 for CLINICIANS
By: Patrick L. DeChello Ph.D., MSW, LCSW, RPH
Introduction
Field of Psychiatry is not an exact science. Mankind has always tried to understand people’s actions and reactions. Explained in the past as possession and witchcraft, Psychiatry is a new science less than 100 years old. It grew out of the medical field – there are certain biological differences between men. There was a need to develop a universal language. The DSM became the means of communication and conceptualization of psychiatric illness. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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DSM – A Brief History
In 1945, Group Psychiatrists working with soldiers returning from World War 2, found a group who did not fit into the diagnostic classification that existed from 1917 to then. Previously the groups were: Lunatics, Idiots, Imbeciles, Morons, or Insane. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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History of the DSM
In 1943, the U.S. military published a list of mental disorders with the title, “War Department Technical Bulletin 203.” The American Psychiatric Association adapted this document and published it in 1952 as the “Diagnostic and Statistical Manual: Mental Disorders,” or what we now know as DSM-I. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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DSM 5 Clarifies The Definition: A syndrome characterized by clinically significant disturbance in an individuals cognition, emotion regulation or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. They are associated with underlying stress or disability in social, occupational, or other important activities. An expected cultural approved response such as death of a loved one is not a mental disorder. Social and political behaviors are not mental disorders. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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7 Main Philosophical Changes
No clear difference between a medical illness and a psychiatric one. Most normal people have personality defects. People have illnesses they aren’t illnesses. There are many different looks to each disorder. A social or political deviances are not mental disorders and are between the individual and society. Ie. Fundamentalists Childhood personality must be considered. Cultural variants in symptom definition and symptom manifestations must be considered. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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DSM 5 No more Mood Disorders as a category
Twenty classifications
*new or significantly changed classifications
1. Neurodevelopmental Disorders* 2. Schizophrenia Spectrum* and Other Psychotic Disorders 3. Bipolar and Related Disorders* 4. Depressive Disorders* 5. Anxiety Disorders
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6. Obsessive-Compulsive* and Related Disorders 7. Trauma and Stress Related Disorders* 8. Dissociative Disorders 9. Somatic Symptom Disorders* 10. Feeding and Eating Disorders* 11. Elimination Disorders* Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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12. 13. 14. 15.
Sleep-Wake Disorders* Sexual Dysfunctions Gender Dysphoria* Disruptive, Impulse Control, and Conduct Disorders* 16. Substance Use* and Addiction Disorders 17. Neurocognitive Disorders* Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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18. Personality Disorders* 19. Paraphilias* 20. Other Disorders
The multi-axial format of DSM III and DSM IV has been modified. Axis 1,2,3, and 4 have been combined & incorporated into the diagnostic categories. PTSD no longer an anxiety d/o New: Suicide and Self-Injury disorders
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Cross Cutting Dimensional Factors
Depression Anger Mania Anxiety Somatic symptoms Suicidal Ideation/attempts Psychosis
Sleep Problems Memory Repetitive Thoughts and Behaviors Dissociation Personality Functioning Substance Abuse Inattention
Primary Diagnosis
The first diagnosis listed is the primary. It should coincide with the presenting problem. When the primary reason for the visit is a mental disorder due to a medical condition, ICD rules state that the etiological medical condition be listed first and it is the primary disorder
Primary Diagnosis
When 2 diagnoses are equally possibly the main contributing factor such as a client with alcohol use and schizophrenia, the one you feel is the main focus of clinical attention should be listed first. Disorder listed first is always the primary When there is a medical dx the ICD requires it to be primary
We will just write out “no diagnosis or deferred.” If there is no diagnosis, client should be discharged: no reason to treat them. Deferrals – should be time limited for many disorders, but are mandated for Personality Disorders. Rule out is used when it is either this diagnosis or that diagnosis. One will stay one will go. Write it in! Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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No more V71.09 or 799.9
Provisional Diagnoses Use when there is a strong presumption that the full criteria will be met but not enough info is available to make a firm diagnosis. Now used in place of the old NOS disorders
No more DSM IV NOS Categories
2 conditions to use Provisional classifications 1. Guidelines for a classification are met, but the specific disorder remains unclear: Depressive Disorder CNEC, e.g., a client presents depressed; but, you don’t yet know if it is a major depression, single episode, recurrent, or dysthymia. Use this classification until you know..
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Provisional Continued 2. Uncertainty regarding nature of the disorder because client unable to provide accurate information, limited time, clinician not trained in a diagnostic category: Depressive Disorder Called in to an ER to do an Emergency Evaluation of a client with a suicide attempt. No time to tell or client not cooperative. All other diagnostic uncertainty categories are gone. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Much More Information of Cultural Relevance
Now a CFI– Cultural Formation Interview
Each diagnostic category will provide information regarding age, gender, and culture considerations. a) The CFI is a set of fourteen questions that clinicians may use to obtain information during a mental health assessment about the impact of a patient’s culture on key aspects of care. b) Culture refers primarily to the values, orientations, and assumptions that individuals derive from membership in diverse social groups (e.g., ethnic groups, the military, faith communities), which may conform or differ from medical explanations. culture also refers to aspects of a person’s background that may affect his or her perspective, such as ethnicity, race, language, or religion. Each diagnostic category will offer “developmental symptom manifestation, ”regarding the age of the client, gender specific disorders, and cultural sensitivity in regard to certain behaviors.
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V & Z codes now used instead of old axis 4
V60 Homelessness V60.2 Extreme Poverty V62.5 Conviction w/o Prison. Z62.898 or V61.29 Child affected by parent relationship distress.
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T Codes For Child Abuse/ Neglect
T74.02 Child neglect confirmed T76.12 Child neglect suspected T74.12xa Child Abuse Confirmed T76.02xa Child Abuse suspected T76.32xa Child Psychological abuse confirmed T76.32xd Child Psychological abuse suspected T74.22xa Child Sexual Abuse Confirmed T74.22xd Child Sexual Abuse suspected
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Suicide and Self Injury* New Risk Syndromes And Suicide Risk Assessment Tools- Each disorder criteria will comment on suicide risk, self-injury, and comorbidity with other disorders, e.g., depression and alcohol dependence. The DSM-5 revisions include two new scales for assessing individuals’ risk factors for committing suicide, one for adolescents and one for adults. The suicide risk tools have been designed to be applied to anyone receiving an evaluation for a mental disorder, regardless of diagnosis, to help clinicians identify those at risk for suicide.
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V 01 Non-Suicidal Self Injury*
A. In the last year, the individual has on 5 or more days, intentional self-inflicted damage to the body, likely to induce bleeding or bruising or pain not socially sanctioned (e.g., body piercing, tattooing, etc.), but expectation injury will cause minor or moderate physical harm. Behavior is not a common one, picking at a scab or nail biting.
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Non-Suicidal Self-Injury
B. The intentional injury is associated with at least 2 of the following: 1. Psychological Precipitant: Interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act. 2. Urge: Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to resist. 3. Preoccupation: Thinking about self injury occurs frequently, even when it is not acted upon. 4. Contingent Response: The activity is engaged with expectations it will relieve an interpersonal difficulty, negative feeling, or cognitive state, or it will induce a positive feeling state, during the act or shortly afterwards. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Non-Suicidal Self-Injury C. The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning. D. The behavior does not occur exclusively during states of psychosis, delirium, or intoxication. In individuals with a developmental disorder, the behavior is not part of a pattern of repetitive stereotypes. The behavior cannot be accounted for by another mental or medical disorder (i.e., psychotic disorder, pervasive developmental disorder, mental retardation, Lesch-Nyhan Syndrome, stereotyped movement disorder with self-injury, or trichotillomania). E. The absence of suicidal intent has either been stated by the patient or can be inferred by repeated engagement in a behavior that the individual knows, or has learned, is not likely to result in death.
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V 02 Suicidal Behavior Disorder* A. Behaved in a way it would lead to their own death within the last 24 months. B. The behavior did not meet criteria for non-suicidal self-injury—. C. The term “suicide attempt” can, therefore, apply to individuals who initiated the behavior and survived because of the timely interruption by a third party (sometimes known as an interrupted suicide) or because the individual changed his or her intent and decided to seek help (sometimes known as an aborted suicide). Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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V 02 Suicidal Behavior Disorder, Continued
D. The act was not initiated during a confused or delirious state. However, attempts initiated during intoxication or while under the influence of a substance do not preclude this diagnosis. E. The act was not undertaken solely for a political or religious objective.
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Neurodevelopmental Disorders
F70 Intellectual Developmental Disorder* 319 F88 Intellectual or Global Developmental Delay 315.8 F80.9 Language Impairment* 315.39 INCLUDES Specific Language Impairment* F80.89 Social Communication Disorder* 315.39 F80.0 Speech Sound Disorder (Phonological Disorder)315.39 F80.81 Childhood Onset Fluency Disorder (Stuttering) 315.35
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Neurodevelopmental Disorders
F84.0 Autism Spectrum Disorder* 299.9 PG 50 F90.2 Attention Deficit/Hyperactivity Disorder F90.8 Other Specified ADHD 314.01 Learning Disorder F81.0 Dyslexia Reading 315.00 F81.2 Dyscalculia – Mathematics Disorder*315.1 F81.2 Disorder of Written Expression 315.1 Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Neurodevelopmental Disorders
F82 Developmental Coordination Disorder 315.4 F98.4 Stereotypic Movement Disorder* 307.3 F95.2 Tourette’s Disorder* 307.23 F95.1 Chronic Motor or Vocal Tic Disorder*307.22 F95.0 Provisional Tic Disorder* 307.21 Substance Induced Tic Disorder note substance F95.9 Unspecified Tic Disorder 307.20 F95.8 Tic Disorder Due to General Medical Conditions 307.2 Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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F80.89 Social Communications D/O*
Persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affects the development of social reciprocity and social relationships that cannot be explained by low abilities in the domains of word structure, grammar, or general cognitive ability. Persistent difficulties in the acquisition and use of spoken language, written language, and other modalities of language (e.g., sign language) for narrative, expository, and conversational discourse. Rule out Autism Spectrum Disorder. Autism spectrum disorder by definition encompasses pragmatic communication problems, but also includes restricted, repetitive patterns of behavior, interests, or activities as part of the autism spectrum. Symptoms must be present in early childhood. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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F84.0 Autism Spectrum Disorder
DSM IV-TR Autism Disorder and Asperger’s Disorder: 1. Deficits in social/emotional reciprocity, 2. Deficits in non-verbal communication behaviors i.e., body language or eye contact, 3. Deficits in developing and maintaining relationships to the appropriate developmental level. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Autism Spectrum Disorder 299.0
4. Repetitive speech, motor movements, or use of objects; (such as simple motor stereotypes, echolalia, repetitive use of objects, or idiosyncratic phrases), 5. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change, 6. Highly restricted, fixated interests that are abnormal preservative, preoccupation with unusual, 7. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects). 8. Symptoms must be present in early childhood. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Autism Spectrum Severity Levels
Social Communications 3. Requiring very substantial support – severe deficits in verbal & non-verbal communications rarely initiates speech or minimal response to overtures from others RESTRICTED/REPETITIVE BEHAVIORS 3.Inflexibility of behaviors, extreme difficulty coping with change, repetitive behaviors that interfere with functioning in all spheres
Autism Spectrum Severity Levels
Social Communications 2. Requiring substantial support – Marked deficits in social communication skills and social impairments even with supports in place Limited interactions or responses to overtures of others. May speak simple sentences / odd non-verbal communication. Restrictive/repetitive behaviors 2. Difficulty coping with change,, inflexibility of behavior, distress and or difficulty changing focus or action. Observable Repetitive behaviors
Autism Spectrum Severity Levels Social Communications 1. Requiring Support-Without supports in place difficulty difficulties in social communication. Difficulty initiating social interactions with others. Unsuccessful in responding to social interactions from others. Can converse with disconnection to others RESTRICTED/REPETITIVE BEHAVIORS 1.Inflexible, difficulty switching between activities. Problems of organization hamper independence.
F90.2 Attention Deficit/Hyperactivity Disorder
Changes from DSM IV 314.01 1) Change the age of onset from onset of impairing symptoms by age 7 to onset of symptoms by age 12, 2) Change the three subtypes to three current presentations; 3) Add a fourth presentation for restrictive inattentive; 4) Change the examples in the items, without changing the exact wording of the DSM-IV items, to accommodate a lifespan relevance of each symptom and to improve clarity. 6) Remove PDD from the exclusion criteria. 7) Modify the pre-amble A1 and A2 to indicate that information must be obtained from two different informants (parents and teachers for children and third party/significant other for adults) whenever possible. Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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ADHD/ADD Presentations*
Combined Presentation: If both Criterion A1 (Inattention) and Criterion A2 (Hyperactivity-Impulsivity) are met for past 6 mos. Predominantly Inattentive Presentation: If Criterion A1 (Inattention) is met but Criterion A2 (Hyperactivity-Impulsivity) is not met but 3 or more symptoms from Criterion A2 present for the past 6 months. Inattentive Presentation (Restrictive)*: If Criterion A1 (Inattention) is met but no more than 2 symptoms from Criterion A2 (Hyperactivity-Impulsivity) have been present for the past 6 months. Predominantly Hyperactive/Impulsive Presentation: If Criterion A2 (HyperactivityImpulsivity) is met and Criterion A1 (Inattention) is not met for the past 6 months. Coding note: For individuals (especially adolescents and adults) who currently have symptoms with impairment that no longer meet full criteria, “In Partial Remission” should be specified. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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ADD/ADHD
A1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months: a. fails to give close attention to details or makes careless mistakes b. difficulty sustaining attention in tasks or play activities c. does not seem to listen when spoken to directly d. does not follow through on instructions and fails to finish work, chores, e. difficulty organizing tasks and activities poor time management; f. avoids, to engage in tasks that require sustained mental effort g. loses things necessary for tasks or activities (e.g., school materials, h. easily distracted by extraneous stimuli i. Is often forgetful in daily activities Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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A2. Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months
a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected c. runs about or climbs in situations where it is inappropriate. d. Often unable to play or engage in leisure activities quietly. e. Is often “on the go,” acting as if “driven by a motor f. Often talks excessively. g. Often blurts out an answer before a question has been completed h. Often has difficulty waiting his or her turn (e.g., while waiting in line). i. Often interrupts or intrudes on others (e.g., butts into conversations, or activities; may start using other people’s things without asking permission,
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Schizophrenia Spectrum & Other Psychotic Disorders
F 21 Schizotypal Personality Disorder F22 Delusional Disorder F23 Brief Psychotic Disorder F.. Substance-Induced Psychotic Disorder coding is drug specific pg110 F 04 Psychotic Disorder Associated with Another Medical Condition F06.1 Catatonic Disorder Associated with Another Medical Condition F20.89 Schizophreniform Disorder F25 Schizoaffective Disorder F20.9 Schizophrenia F29 Unspecified Schizophrenia Spectrum Disorder LISTED FROM LEAST TO MOST SEVERE
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Psychotic Dimensions
Hallucinations Delusions Disorganized speech Abnormal psychomotor behavior Negative symptoms Impaired cognition Depression Mania Suicide
F06 Attenuated Psychosis Syndrome* Section 3
Prodromal Stage of Psychosis: At least a month. A condition with recent onset of modest, psychotic-like symptoms hallucinations and delusions and clinically relevant distress and disability. These patients also are at significantly increased risk of conversion to a full-blown psychotic disorder. (35%) In DSM 4 thought to be 60% Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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• F 21 Schizotypal Personality Disorder* Merges traits of the Schizoid PD Confused identity or interpersonal functioning e.g. lack of empathy ot intimacy* Difficulty in maintaining relationships* Eccentricity oddity psychoticism Odd thoughts, beliefs and experiences Withdrawal prefers to be alone* Detachment Restricted affect-lack of response to usual situations, withdrawal* Negative Affectivity- Suspiciousness of others Ill-intent Rarely, if ever, seeks treatment for the condition* No correlation to drug use or suicidal behaviors* * schizoid criteria Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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F20.9 Schizophrenia-295.9 no types-6 mos+ F20.81 Schizophreniform 295.4– 1 mos or up to 6months A. Two (or more) of the following. At least one of these should include 1, 2, or 3. (1) delusions (2) hallucinations (3) disorganized speech (4) grossly abnormal psychomotor behavior, including catatonia (5) negative symptoms, e.g., diminished emotional expression No longer an age of onset –can occur at any age Rule out Bipolar, Depression and Schizo-Affective Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Anxiety Disorders
F93.0 Separation Anxiety Disorder* 309.21 F94.0 Selective Mutism 312.23 F41.0 Panic Disorder 300.01 F40.00 Agoraphobia 300.22 F40.2x Specific Phobia .18 animals, .29 environment .23 injection/blood, .48 situations heights, travel
F40.10 Social Anxiety Disorder F41.1 Generalized Anxiety Disorder 300.02 F 06.4 Resulting from a General Medical Conditions 293.84 F10.x depending on drug Substance-Induced Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Bipolar and Related Disorders F31.1 Bipolar I Disorder F31.81 Bipolar II Disorder 296.89 F34.0 Cyclothymic Disorder 301.13 F06.3 General Medical Conditions Substance-Induced F31.9 Unspecified Bipolar Disorder 296.80 Highest correlate with suicide, Disorders mainly unchanged
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Trauma- and Stressor-Related Disorders
F94.1 Reactive Attachment Disorder F94.2 Disinhibited Social Engagement Disorder* had been a specifier in RAD in DSM IV; it is now separate. F43.0 Acute Stress Disorder F43.10 Posttraumatic Stress Disorder F43.2x Adjustment Disorders* F43.8 Other Specified Trauma Disorders F43.9 Unspecified Trauma Disorder
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Child has experienced 1 or the following Pathogenic Realms These can create a RAD or Disinhibited Soc. Eng. D/O: 1. Deprivation child’s needs for affection or support/neglect lack of providing for the child’s basic needs/ comfort. Inept parenting 2. Failure to provide for physical or psych safety 3. Repeated changes of primary caregiver, no stable relationships, i.e. , foster care 4. Rearing in unusual settings that limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).
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Pathogenic Care Realms are the root of each of the following: * 1. F94.1 Reactive Attachment Disorder 313.89 2. F94.2 Disinhibited Social Engagement Disorder 313.89 3. PTSD in Children 4. Separation Anxiety Disorder 5. Disruptive Mood Dysregulation Disorder 6. Dissociative Disorders in Children 7. Oppositional Defiant Disorder 8. Conduct Disorder (especially the G06.1 Specifier the sociopathic child) 9. Antisocial Personality disorder
Each one of the above will require you to indicate that they are due to one or more of the Pathogenic Care Realms.
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F43.10 Post Traumatic Stress Disorder 309.81 (No longer under Anxiety Disorders) Criteria applies to children above 6 through adulthood
A. Exposure to actual or threatened death, serious injury, or sexual violation, in one or more of the following ways: 1.) Directly experiencing the traumatic event(s); 2.) Witnessing, in person, the traumatic event(s) as they occurred to others; 3.) Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; 4.) Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed tto details of child abuse); not due to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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PTSD, Continued
B. Presence of one or more of the following intrusion symptoms: 1.) Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) (Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.) 2.) Recurrent distressing dreams in which the content or affect of the dream is related to the event(s) (Note: In children, there may be frightening dreams without recognizable content. ) 3.) Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) are recurring (such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings. (Note: In children, trauma-specific re-enactment may occur in play.) Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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PTSD Continued 4.) Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) 5.) Marked physiological reactions to reminders of the traumatic event(s)
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PSTD Continued
C. Persistent avoidance of stimuli associated with the traumatic event(s), as evidenced by avoidance one or more of the following: 1. Distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s), 2. External reminders (i.e., people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about, or that are closely associated with, the traumatic event(s). Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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D. Negative changes in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred), as evidenced by two or more of the following:
1. inability remember an important aspect of traumatic event(s) 2. persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” "The world is completely dangerous"). 3. persistent, distorted blame of self or others about the cause or consequences of the traumatic event(s) 4. persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) 5. markedly diminished interest or participation in significant activities 6. feelings of detachment or estrangement from others 7. persistent inability to experience positive emotions (e.g., unable to have loving feelings, psychic numbing) Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following: 1. Irritable or aggressive behavior 2. Reckless or self-destructive behavior 3. Hyper vigilance 4. Exaggerated startle response 5. Problems with concentration 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep) F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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PTSD Continued
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The disturbance is not attributed to the direct physiological effects of a substance (e.g., medication, drugs, or alcohol) or another medical condition (e.g. traumatic brain injury). Specify if: With Delayed Expression: if the diagnostic threshold is not exceeded until at least 6 months after the event
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PTSD in Children Continued
B. Presence of one or more intrusion symptoms : 1. Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the trauma 2. Recurrent or distressing dreams 3. Dissociative reactions may occur on a continuum with the most extreme expression being a complete loss of awareness of present surroundings trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) 5. Marked physiological reactions to reminders of the traumatic event(s)
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One item from criterion C or D below: C. Persistent avoidance of stimuli associated with the traumatic event,, as evidenced by avoidance of: 1.) Activities, places, or physical reminders that arouse recollections of the traumatic event, 2.) People, conversations, or interpersonal situations that arouse recollections of the traumatic event. D. Negative alterations in cognitions and mood associated with the traumatic event, as evidenced by one or more of the following:
1.) Markedly diminished interest or participation in significant activities, including constriction of play, 2.) Socially withdrawn behavior, 3.) Persistent reduction in expression of positive emotions. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Depressive Disorders
F34.8 Disruptive Mood Dysregulation*Disorder F32. Major Depressive Disorder Single episode mild F32.0 moderate F32.1 Severe F32.2 Psychotic F32.3 partial remission F32.4, full remission F32.5, unspecified F32.26 Major Depressive Disorder, Recurrent mild F33.3 moderate F33.1 Severe F33.2 Psychotic F33.3 partial remission F33.41, full remission F33.42, unspecified F33.9 F34.1 Dysthymic Disorder*3004 F10. Substance Induced- depends on substance pg 176
625.4 Premenstrual Dysphoric disorder (N94.3)
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Depressive Disorders
Controversial removal of the bereavement exclusion in Major Depressive Episode. No waiting period!
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F34.8 Mood Dysregulation Disorder(296.99)
Prior to age 18. Frequency: The temper outbursts average, three or more times/ week. Mood between temper outbursts: 1. Nearly every day, most of the day, the mood between temper outbursts is persistently irritable or angry. 2. The irritable or angry mood is observable by others Duration: Criteria have been present for 12 or more months. Throughout that time, the person has not had 3 or more consecutive months when they were without the symptoms of Criteria. Criterion A or C is present in at least two settings (at home, at school, Often associated with the 5 pathogenic realms. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Disruptive Mood Dysregulation Disorder
B. Frequency: The temper outbursts average, three or more times/ week. C. Mood between temper outbursts: 1. Nearly every day, most of the day, the mood between temper outbursts is persistently irritable or angry. 2. The irritable or angry mood is observable by others D. Duration: Criteria A-C have been present for 12 or more months. Throughout that time, the person has not had 3 or more consecutive months without the symptoms of Criteria A-C. E. Criterion A or C is present in at least two settings ( home, school, Often associated with the pathogenic realms. Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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Major Depression - #1 or #2 plus 5 or more
1. depressed mood by report feels sad, empty, hopeless 2. Anhedonia by report or observation 3. Significant weight loss or gain without trying, increase appetite 4. insomnia or hypersomnia 5. Psychomotor retardation/agitation nearly every day 6. Fatique or loss of energy nearly every day 7. Sense of worthlessness or inappropriate guilt 8. Poor ability to concentrate or indecisiveness 9. Thoughts of death,suicidal ideation, suicide plan or attempt
Depressive Disorders continued
Due to a medical condition – depends on illness (primary) F06.31 With depressive features –full criteria for Maj. Depression not met F06.32 with major depressive like episode criteria met for Major Depression F06.34 with mixed features for mania/hypomania as well
Other specified Depressive disorder F32.8 3 types 1. recurrent brief dep. Depression and at least 4 other symptoms for 2-13 days/month for year not due to menses 2. Short duration depressive episode 4-13 days depressed affect and at least 4 of 8 other symptoms no past hx of depression 3. Depressive episode with insufficient symptoms – Depressed affect with at least 1 of the other 8 symptoms of depression for at least 2 weeks
625.4 Premenstrual Dysphoric disorder (N94.3)
Now included in the main depressive diagnoses section. No longer in the disorders requiring clinical consideration. For the majority of the menstrual cycles 1 week before 5 symptoms Mood Lability Irritability Anger Depressed mood Anxiety Tension Feeling keyed up. 1 of these : Decreased intest in usual activities or poor concentration, lethargy, anhedonia, feel overwhelmed, insomnia/hypersomnia breast tenderness, joint/muscle pain bloating or weight gain. Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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F43 Adjustment Disorders 309.xx
F43.22 With Anxiety 309.24 F43.21 With Depression 309.0 F43.24 With disturbance of conduct 309.3 F43.23 With mixed anxiety and depressed mood 309.4 F43.25 With disturbance of emotions and conduct 309.4 F43.8 Adjustment Disorder with Complex Bereavement F43.20 Unspecified 309.9
F43.8 Adjustment Disorder Complex Bereavement pg 289 Twelve months of symptoms are required before the diagnosis may be made. Intense yearning for the loved one Intense sorrow and emotional pain Preoccupation with the deceased or the circumstances of the death Feels life is empty Difficulty planning for the future Anger related to the loss Suicide intent Hopelessness on the value of life Detachment from support systems Found primarily in survivors of suicide, homicide, and loss of child Mourning shows substantial cultural variation; the bereavement reaction must be out of proportion or inconsistent with cultural, religious, or age-appropriate norms. Copyright 2013, D & S Associates,
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Dissociative Disorders
F48.1 Depersonalization-Derealization Disorder F44.10 Dissociative Amnesia F44.81 Dissociative Identity Disorder
Often result from the 3 pathogenic realms
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F44.10 Dissociative Amnesia
An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. (Note: there are two primary forms of Dissociative Amnesia: (1) Localized or Selective Amnesia for a specific event or events, and (2) Generalized Amnesia for identity and life history.) Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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F44.81 Dissociative Identity Disorder
Identity characterized by two or more distinct personality states or an experience of possession. Poor recall of everyday events, important personal information, and/or traumatic events The symptoms cause clinically significant distress. Not a normal part of a broadly accepted cultural or religious practice. (Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play. Often the result of repeated physical or sexual child abuse Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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F45.1 Somatic Symptom Disorders 300.82
A. Somatic symptoms: One or more somatic symptoms that are distressing and/or result in significant disruption in daily life. B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least one of the following must be present.
(1) Disproportionate and persistent thoughts about the seriousness of one's symptoms. (2) Persistently high level of anxiety about health or symptoms (3) Excessive time and energy devoted to these symptoms or health concerns C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically >6 months). Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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F45.21 Illness Anxiety Disorder 300.7
A. Somatic symptoms are not present or, if present, are only minimal. B. Preoccupation with having or acquiring a serious illness. C. High level of anxiety about health and a low threshold for becoming alarmed about their health. D. The individual performs excessive health-related behaviors (e.g., repeatedly checking one's body for signs of illness), or exhibits maladaptive avoidance (e.g., avoiding doctors' appointments and hospitals). E. Chronic (at least 6 months). Subtypes Care-seeking subtype: Elevated rates of medical utilization. Care-avoidant subtype: Rarely seek medical care because seeing a physician and undergoing laboratory tests and diagnostic procedures heightens anxiety to intolerable levels. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Feeding and Eating Disorders
307.52 Pica F50.8 adult F98.3 children F98.91 Rumination Disorder* F50.8 Avoidant/Restrictive Food Intake D/O* F50.01 Anorexia Nervosa F50.2 Bulimia Nervosa F50.08 Binge Eating Disorder* Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Feeding and Eating Disorders
F50.08 New Binge Eating Disorder* Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1.) Eating, in a discrete period of time (e.g., within any 2hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances, 2.) A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating). Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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F 64 Gender Dysphoric Disorder* F64.1 Gender Dysphoria in Children F64.2 Gender Dysphoria in Adolescents and Adults F64.3 Unspecified Gender Dysphoria Removed from DSM 4 Sexual and Gender Identity Disorders
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Gender Dysphoria (in Children)** A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6* of the following indicators: 1.) Strong desire to be of the other gender or an insistence that he or she is the other gender, 2.) In boys, a strong preference for cross-dressing or simulating female attire; in girls, a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing. 3.) Strong preference for cross-gender roles in make-believe or fantasy play.
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Gender Dysphoria (in Children) Continued
4. Strong preference for the toys, games, or activities typical of the other gender, 5. Strong preference for playmates of the other gender, 6. In boys, a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; in girls, a strong rejection of typically feminine toys, games, and activities, 7. Strong dislike of one’s sexual anatomy, 8. Strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender, B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability.** Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Gender Dysphoria (in Adolescents or Adults)** A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by two* or more of the following indicators: 1.) Marked incongruence between one’s experienced expressed gender and primary and/or secondary sex characteristics, 2.) Strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics), 3.) Strong desire for the primary and/or secondary sex characteristics of the other gender, 4.) Strong desire to be of the other gender (or some alternative gender different from one’s assigned gender), Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender) 6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender) B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability** Specifier** Post-transition, i.e., the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is undergoing) at least one cross-sex medical procedure or treatment regimen, namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male, mastectomy, phalloplasty in a natal female). Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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Conduct Disorder F91.1 children .2 adolescent
Now incorporates Pyromania & Kleptomania Repetitive, persistent patterned behaviors where the rights of others or societal norms or rules are violated, as in 3 of the following 15, including Aggression to people and animals
1. Often bullies, threatens, or intimidates others, 2. Often initiates physical fights, 3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun), 4. Has been physically cruel to people, 5. Has been physically cruel to animals, 6. Has stolen while confronting a victim (e.g., mugging, extortion, robbery), 7. Has forced someone into sexual activity. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Conduct Disorder/Antisocial Destruction of Property 8. Deliberately engaged in fire setting with the intention of causing serious damage 9. Deliberately destroyed others’ property (not by fire) Deceitfulness or theft 10. Has broken into someone else’s house, building, or car 11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others) 12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery) Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Children or (adults if antisocial criteria not met)
Conduct Disorder
Serious violations of rules 13. Often stays out at night despite parental prohibitions, beginning before age 13 years . (In adults, often violates rules of family life, e.g., neglects basic needs of a child.) 14. Has run away from home overnight at least twice while living in parental or parental surrogate home, or once without returning for a lengthy period. (In adults, often violates major societal norms, e.g., rulings of the court or conditions of parole/probation or rules of a public agency or residential setting.) 15. Often truant from school, beginning before age 13 years. (In adults or adolescents not in school, often violates rules of the workplace, e.g., chronic work absenteeism without acceptable reason.) Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Antisocial Personality Classic F63.1 A. Disregard for the rights of others 3 of the following 7: 1. Repeatedly performing acts that are grounds for arrest. 2. Deceitfulness lying, using aliases, conning for profit or pleasure 3. Impulsivity or failure to plan ahead. 4. Irritability/ aggressiveness – physical fights or assaults. 5. Reckless disregard for the safety of self or others 6. Consistent irresponsibility failure to sustain work or pay obligations 7. Lack of remorse –indifferent as to hurting, mistreating or stealing B. Must be at least 18 C. Evidence of onset before 15 D . Not during the course of bipolar or schizophrenia disorders.
Antisocial New Version 1.Identity –Egocentric – Self esteem from power/pleasure seeking 2. Self-direction-Illegal acts Personal Gratification no internal standards 3.Empathy- lacks concern for others 4. Intimacy-exploits others – unable to form mutual intimate relations. Must be 18+ years old All of the above plus ---->
6+ of the following” 1.Manipulates 2.Callousness-no concern for others 3.Deceitful – dishonest, fraudulent 4.Hostility often angry/aggression 5. Risk Taking w/o regard for consequences disregards danger 6. Impulsivity-acts w/o planning or concern for consequences 7. Irresponsibility-failure to honor obligations or commitments
Substance Use and Addictive Disorders
Newly reorganized by drug type not diagnosis like DSM 4 4 Groups: Substance use, intoxication, withdrawal, induced Ten classes of drugs: Alcohol; caffeine; cannabis; hallucinogens/PCP(separate); inhalants; tobacco; opioids; sedatives-hypnotics-anxiolytics; stimulants/amphetamines type/cocaine or other stimulants. Gambling Addiction is included. Hypersexuality disorder (Sex Addiction) in Paraphillias section Poly-Substance Dependent Disorder is eliminated. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Substance Use
A. A pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period: 1. Use more than intended or for a longer time than intended 2. Persistent desire or unsuccessful efforts to cut down or control 3. A great deal of time is spent in activities necessary to obtain subs. 4. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home, 5. Continued substance use, despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse).
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Substance Use, Continued 6. Important social, occupational, or recreational activities are given up or reduced because of substance use, 7. Recurrent use in physically hazardous situations (driving), 8. Continued using despite having physical & psychological effects, 9. Tolerance – need for more to get same effect or diminished effect with same amount, 10. Withdrawal or use of drugs to prevent withdrawal 11. Craving or a strong desire to have the drug. #s 1,2,8,9,10 Indicate Severe Subs Use with Physiological Dependence. #s 4,5,6.7 Indicate Substance Use Moderate w/o physiological dependence. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Gambling Disorder 4 of following
1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement 2. Restless or irritable when attempting to cut down or stop gambling 3. Repeated unsuccessful efforts to control, cut back, or stop gambling 4. Often preoccupied with gambling 5. Gambles often when feeling dysphoric. 6. After losing money gambling, often returns another day to get even (“chasing” one’s losses) Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Gambling Disorder 4 of following con’t 7. Lies to conceal the extent of gambling 8. Jeopardized or lost a significant relationship, job, or educational or career opportunity because of it 9. Relies on others to provide money to relieve desperate financial situations caused by gambling B. The gambling behavior is not better accounted for by a Manic Episode.
Course Specifiers. - Episodic- Chronic- In Remission Episodic ie. only gambles during baseball season Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Severity Scale:
The Severity of each Substance Use Disorder is based on: - 0 or 1 criterion: No diagnosis - 2-3 criteria: Mild Substance Use Disorder - 4-5 criteria: Moderate Substance Use Disorder - 6 or more criteria: Severe Substance Use Disorder
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Recommended for Further Study in Section III of the DSM 5 Caffeine Use Disorder Internet Use Disorder Neuro-behavioral Disorder Associated with Prenatal Alcohol Exposure
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Paraphilic Disorders
F65.2 Exhibitionistic Disorder 302.4 F65.0 Fetishistic Disorder 302.81 F65.81 Frotteuristic Disorder 302.89 F65.4 Pedophilic Disorder 302.2 F65.51 Sexual Masochism Disorder 302.83 F65.52 Sexual Sadism Disorder 302.84 F65.1 Transvestic Disorder 302.3 F65.3 Voyeuristic Disorder 302.82 Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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F65.4 Pedophilic Disorder
A. 6+ months, an equal or greater sexual arousal from prepubescent or early pubescent children (generally 13 and younger) than from physically mature persons, as manifested by fantasies, urges, or behaviors. B. The individual has acted on these sexual urges, or the sexual urges or fantasies. C. The individual must be at least 16 years of age and at least 5 years older than the children in Criterion A. Do not include a late adolescent involved in an ongoing sexual relationship with a 12 or 13 year old. Specify type: Exclusive – only children or non-exclusive - or incest type only Classic Type—Sexually Attracted to Prepubescent Children Hebephilic Type—Sexually Attracted to Early Pubescent Children Pedohebephilic Type—Sexually Attracted to Both Specify type: Sexually Attracted to Males, Females or Both Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Hypersexual Disorder A. Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria: 1.) Excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior 2.) Repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability) 3.) Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events (4) Repetitive but unsuccessful efforts to control or reduce (5) Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Specifiers
Specify if: Masturbation Pornography Sexual Behavior with Consenting Adults Cybersex Telephone Sex Adult Entertainment Venues/Clubs Other:
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Obsessive-Compulsive and Related Disorder
F 00 Obsessive-Compulsive Disorder F 01 Body Dysmorphic Disorder* F 02 Hoarding Disorder *F 03 Hair-Pulling Disorder* F 04 Skin Picking Disorder* F 05 Substance Induced OCD F 07 OCD Due to General Medical Conditions F 08 OCD NEC
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F 00 Obsessive-Compulsive Disorder
A. Presence of obsessions, compulsions, or both B. Are time consuming 1 hour+/day and cause distress
*Indicate if OCD beliefs are currently characterized by: Good or fair insight: The individual recognizes that OCD beliefs are definitely or probably not true, or that they may or may not be true, Poor insight: The individual thinks OCD beliefs are probably true, Absent insight: The individual is completely convinced OCD beliefs are true. Specify if: Tic-related OCD: The individual has a lifetime history of a chronic tic disorder Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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F02 Hoarding Disorder*
A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. B. Anxiety due to a perceived need to save the items and distress associated with discarding them. C. Clinically significant distress or impairment maintaining a safe environment for self and others. D. Not due to another mental illness/medical condition/drug
Specify if: With Excessive Acquisition: excessive collecting, buying, or stealing items not needed or there is no available space. Copyright 2013, D & S Associates, 800-950-5559 All rights reserved
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Personality Disorder Points
2 separate sections on Personality – old is kept currently for continuity and the new suggested method is in keeping with the latest science. Section 2 keeps the traditional diagnoses and clusters. Section 3 does away with many personalities and keeps 5 which are considered the most pathological. You may use either the old or the new version. New approach addresses many of the short comings of the old method where the typical client in the old method meets the requirements for one disorder, also meets the requirement for 2 or more personality disorders.
DSM 5
ALTERNATIVE DIANOSTIC APPROACH
Six specific Personality Disorder types Antisocial, Avoidant, Borderline, Narcissistic, Obsessive-compulsive, Schizotypal Personality Disorder Due to a Medical Condition F07.0
These are the the recommended personlities. Impairments in Personality functioning and pathological traits.
Where did they go in the new method?
Paranoid was eliminated Schizoid was merged with Schizotypal Schizotypal was merged with Schizophrenia Spectrum Histrionic was eliminated Antisocial(Dysocial) & Conduct DO merged and put in the Disruptive, Impulse Control, and Conduct Disorders Borderline, Narcissistic, Avoidant Personality still there Dependent was eliminated
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LEVELS OF PERSONALITY FUNCTIONING DSM 5 Self and Interpersonal Functioning Dimensional Definition The levels of personality functioning are based on the severity of disturbances in self and interpersonal functioning. Self: Identity: Experience of oneself as unique, clear boundaries between self and others; stability of self-esteem accuracy of selfappraisal; capacity for, and ability to regulate, a range of emotional experience Self-direction: Pursuit of coherent & meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively Interpersonal: Empathy: Comprehension and appreciation of others’ experiences and motivations; tolerance of differing perspectives; understanding of the effects of own behavior on others Intimacy: Depth and duration of positive connections with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior D & S 2012
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Standard Approach to the Assessment of Personality Pathology 1.Pathological Personality Traits a. Negative Affectivity: labile moods, anxiousness, separation insecurity, perseveration, hostile, submissive, suspicious, dysphoric, emotional dysregulation b. Detachment: emotional constriction, anhedonia, social withdrawal, intimacy avoidance Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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2. Pathological Personality Traits c. Antagonism: manipulative, deceitful, attention seeking, grandiose, callous d. Disinhibition or Compulsivity: perfectionism, controlling, impulsive, risk taking, distancing, emotionally inaccesible e. Psychoticism: unusual beliefs, eccentric, cognitive dysregulation Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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3. Overall Measure of Severity a. Very little - 0 b. Mild - 1 c. Moderate - 2 d. Extreme - 3
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SELF Level
Identity -Ongoing awareness of a unique self; maintains roleappropriate boundaries. -Consistent and self-regulated positive selfesteem, with accurate selfappraisal. -Capable of experiencing, tolerating and regulating a full range of emotions.
0
INTERPERSONAL Self-Direction
Empathy
Intimacy
-Sets and aspires -Capable of -Maintains multiple to reasonable goals accurately satisfying and based on a realistic understanding others’ enduring assessment of experiences and relationships in personal capacities. motivations in most personal and -Utilizes appropriate situations. community life. standards of -Comprehends and -Desires and behavior, attaining appreciates others’ engages in a fulfillment in perspectives, even if number of caring, multiple realms. disagreeing. close and -Can reflect on, and -Is aware of the effect reciprocal make constructive of own actions on relationships. meaning of, internal others. -Strives for experience. cooperation and mutual benefit and flexibly responds to a range of others’ ideas, emotions and behaviors. Copyright 2008D & S Associates
SELF Identity
Level
Self-Direction
-Relatively intact sense of -Excessively goalself, with some decrease directed, somewhat goalin clarity of boundaries inhibited, or conflicted when strong emotions and about goals. mental distress are experienced. -May have an unrealistic
1
-Self-esteem diminished at times, with overly critical or somewhat distorted self-appraisal. Strong emotions may be distressing, associated with a restriction in range of emotional experience.
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INTERPERSONAL Empathy
Intimacy
-Somewhat compromised -Able to establish in ability to appreciate and enduring relationships in understand others’ personal and community life, with some limitations experiences; may tend to on degree of depth and see others as having satisfaction. unreasonable
or socially inappropriate expectations or a wish for set of personal standards, control. -Capacity and desire to limiting some aspects of form intimate and fulfillment. reciprocal relationships, -Although capable of but may be inhibited in considering and -Able to reflect upon meaningful expression internal experiences, but understanding different and sometimes perspectives, resists doing constrained if intense may overemphasize a single (e.g., intellectual, so.-Inconsistent in emotions or conflicts awareness of effect of emotional) type of selfarise. own behavior on others. knowledge. -Cooperation may be inhibited by unrealistic standards; somewhat limited in ability to respect or respond to others’ ideas, emotions and behaviors.
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SELF Identity
Level
Self-Direction
2
INTERPERSONAL Empathy
-
-
Excessive dependence on Goals are more often a means of gaining external others for identity approval than selfdefinition, with compromised boundary generated, and thus may lack coherence and/or delineation. -Vulnerable self-esteem stability. controlled by exaggerated concern about external evaluation, with a wish for approval. Sense of incompleteness or inferiority, with compensatory inflated, or deflated, self-appraisal. -Emotional regulation depends on positive external appraisal. Threats to self-esteem may engender strong emotions such as rage or shame.
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-Personal standards may be unreasonably high (e.g., a need to be special or please others) or low (e.g., not consonant with prevailing social values).
Intimacy -
-Hyper-attuned to the experience of others, but only with respect to perceived relevance to self.
Capacity and desire to form relationships in personal and community life, but connections may be largely superficial.
-Excessively selfreferential; significantly compromised ability to appreciate and understand others’ experiences and to consider alternative perspectives.
-Intimate relationships are largely based on meeting self-regulatory and selfesteem needs, with an unrealistic expectation of being perfectly understood by others.
Fulfillment is -Generally unaware of or compromised by a sense unconcerned about effect of lack of authenticity. of own behavior on others, or unrealistic -Impaired capacity to appraisal of own effect. reflect upon internal experience.
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-Tends not to view relationships in reciprocal terms, and cooperates predominantly for personal gain.
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SELF Identity
Level
-A weak sense of autonomy/agency; experience of a lack of identity, or emptiness. Boundary definition is poor or rigid: may be over identification with others, overemphasis on independence from others, or vacillation between these.
3
INTERPERSONAL Empathy
Self-Direction
-Difficulty establishing and/or achieving personal goals. -Internal standards for behavior are unclear or contradictory. Life is experienced as meaningless or dangerous. -Significantly compromised ability to reflect upon and understand own mental processes.
-Fragile self-esteem is easily influenced by events, and self-image lacks coherence. Self-appraisal is un-nuanced: self-loathing, self-aggrandizing, or an illogical, unrealistic combination.
-Ability to consider and understand the thoughts, feelings and behavior of other people is significantly limited; may discern very specific aspects of others’ experience, particularly vulnerabilities and suffering. -Generally unable to consider alternative perspectives; highly threatened by differences of opinion or alternative viewpoints. -Confusion or unawareness of impact of own actions on others; often bewildered about peoples’ thoughts and actions, with destructive motivations frequently misattributed to others.
-Emotions may be rapidly shifting or a chronic, unwavering feeling of despair.
-Some desire to form relationships in community and personal life is present, but capacity for positive and enduring connection is significantly impaired. -Relationships are based on a strong belief in the absolute need for the intimate other(s), and/or expectations of abandonment or abuse. Feelings about intimate involvement with others alternate between fear/rejection and desperate desire for connection. -Little mutuality: others are conceptualized primarily in terms of how they affect the self (negatively or positively); cooperative efforts are often disrupted due to the perception of slights from others.
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SELF Level
4
Identity
Self-Direction
-Experience of a unique self and sense of agency/autonomy are virtually absent, or are organized around perceived external persecution. Boundaries with others are confused or lacking.
-Poor differentiation of thoughts from actions, so goal-setting ability is severely compromised, with unrealistic or incoherent goals. -Internal standards for behavior are virtually lacking. Genuine fulfillment is virtually inconceivable.
Intimacy
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INTERPERSON AL Empathy
-Pronounced inability to consider and understand others’ experience and motivation.
Intimacy
-Desire for affiliation is limited because of profound disinterest or expectation of harm. Engagement with others is detached, disorganized or consistently negative.
-Attention to others' perspectives virtually absent (attention is hypervigilant, focused on need-fulfillment and harm -Relationships are conceptualized almost avoidance). -Weak or distorted selfexclusively in terms of image easily threatened -Profound inability to -Social interactions can their ability to provide by interactions with constructively reflect upon be confusing and comfort or inflict pain and others; significant suffering. distortions and confusion own experience. Personal disorienting. motivations may be around self-appraisal. unrecognized and/or -Social/interpersonal experienced as external behavior is not reciprocal; -Emotions not congruent to self. rather, it seeks fulfillment with context or internal of basic needs or escape experience. Hatred and from pain. aggression may be dominant affects, although they may be disavowed and attributed to others.
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Borderline Personality Disorder
1 a. Self-functioning: Identity – poorly developed and unstable, self-critical, feelings of emptiness, dissociates under stress Self-direction – instability in goals, aspirations, values, career goals 1 b. Interpersonal functioning: Empathy: limited ability to recognize the feelings or needs of others, hypersensitivity to perceived rejection or criticism from others Intimacy: intense, unstable, conflicted in relationships, views relationships with extreme idealization or devaluation, mistrusting, needy, suspicious of abandonment
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Borderline
2. Pathological Personality Traits: Negative affectivity – emotional lability, anxiousness, separation insecurity, dysphoria Disinhibition – impulsivity, risk taking Antagonism – hostility 3. Severity Levels of 2 or 3 consistent across time and circumstances Copyright 2012, D & S Associates, 800-950-5559 All rights reserved
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[email protected] 800-950-5559 D & S Associates, P.O. Box 178, Middlefield, CT 06455 www.dandsassociates.net
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Cultural Formulation Interview GUIDE TO INTERVIEWER:
INSTRUCTIONS TO THE INTERVIEWER ARE IN ITALICS, BOLD, AND CAPITALIZED.
THE FOLLOWING QUESTIONS AIM TO CLARIFY KEY ASPECTS OF THE PRESENTING CLINICAL PROBLEM FROM THE PATIENT’S POINT OF VIEW, INCLUDING ITS MEANING, POTENTIAL SOURCES OF HELP, AND EXPECTATIONS FOR SERVICES.
INTRODUCTION FOR THE PATIENT: I would like to understand the problems that bring you here so that I can help you more effectively. I want to know about your experience and ideas. I will ask some questions about what is going on and how you are dealing with it. There are no right or wrong answers. I just want to know your views and those of other important people in your life. CULTURAL DEFINITION OF THE PROBLEM
ELICIT THE PATIENT’S VIEW OF CORE PROBLEMS AND KEY CONCERNS.
1. What problems or concerns bring you to the clinic? (IF PATIENT ONLY MENTIONS SYMPTOMS, PROBE: Anything else?)
FOCUS ON THE ASPECTS OF THE PROBLEM THAT MATTER MOST TO THE PATIENT.
2. What troubles you most about your problem?
ASK FOR THE PATIENT’S OWN WAY OF UNDERSTANDING THE PROBLEM.
3. People often understand their problems in their own way, which may be similar or different from how doctors explain the problem. How would you describe your problem to someone else?
THIS CAN BE A CULTURAL LABEL, A TERM IN A DIFFERENT LANGUAGE OR AN INFORMAL EXPRESSION.
USE THE TERM, EXPRESSION, OR BRIEF DESCRIPTION TO IDENTIFY THE PROBLEM IN SUBSEQUENT QUESTIONS.
3a. Sometimes people use particular words or phrases to talk about their problems. Is there a specific term or expression that describes your problem? Yes No 3b. IF YES: What is it? CULTURAL PERCEPTIONS OF CAUSE, CONTEXT AND SUPPORT CAUSES
THIS QUESTION INDICATES THE MEANING OF THE CONDITION FOR THE PATIENT, WHICH MAY BE RELEVANT FOR CLINICAL CARE.
4. Why do you think this is happening to you? What do you think are the particular causes of your [PROBLEM]? PROMPT FURTHER IF REQUIRED: Some people may explain their problem as the result of bad things that happen in their life, problems with others, a physical illness, a spiritual reason, or by some other cause. STRESSORS AND SUPPORTS
IDENTIFY STRESSORS THAT COULD BE ADDRESSED DURING TREATMENT. CLARIFY IDEAS ABOUT NEGATIVE EFFECTS OF THE SOCIAL NETWORK ON THE PATIENT’S PROBLEM.
LISTEN FOR COPING STRATEGIES, RESOURCES, SOCIAL SUPPORTS AND RESILIENCE. CLARIFY HOW THE PATIENT’S FAMILY AND SOCIAL NETWORKS HELP TO COPE WITH THE PROBLEM.
5. What, if anything, makes your [PROBLEM] worse, or makes it harder to cope with? 5a. IF DOES NOT MENTION FAMILY/SOCIAL NETWORK: What have your family, friends, and other people in your life done that may have made your [PROBLEM] worse? 6. What, if anything, makes your [PROBLEM] better, or helps you cope with it more easily? 6a. IF DOES NOT MENTION FAMILY/SOCIAL NETWORK: What have your family, friends, and other people in your life done that may have made your [PROBLEM] better? ROLE OF CULTURAL IDENTITY
ASK THE PATIENT TO REFLECT ON ELEMENTS OF HIS/HER CULTURAL IDENTITY THAT ARE IMPORTANT LIFE PROBLEMS.
7. Is there anything about your background, for example your culture, race, ethnicity, religion or geographical origin that is causing problems for you in your current life situation? Yes
No
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7a. IF YES: In what way? ASK THE PATIENT TO REFLECT ON ELEMENTS OF HIS/HER CULTURAL IDENTITY THAT CONSTITUTE IMPORTANT SUPPORTS.
8. On the other hand, is there anything about your background that helps you to cope with your current life situation? Yes No 8a. IF YES: In what way? CULTURAL FACTORS AFFECTING SELF COPING AND PAST HELP SEEKING
CLARIFY SELF-COPING FOR THE PROBLEM.
9. Sometimes people consider various ways of making themselves feel better. What have you done on your own to cope with your [PROBLEM]?
LISTEN FOR MENTAL HEALTH TREATMENT, MEDICAL CARE, SUPPORT GROUPS, WORK-BASED COUNSELING, FOLK HEALING, RELIGIOUS OR SPIRITUAL COUNSELING, OR OTHER ALTERNATIVE HEALING.
10. Often, people also look for help from other individuals, groups, or institutions to help them feel better. In the past, what kind of treatment or help from other sources have you sought for your [PROBLEM]?
CLARIFY THE PATIENT’S EXPERIENCE AND REGARD FOR PREVIOUS TREATMENT.
IF SOUGHT OUTSIDE HELP 10a. What type of help or treatment was most useful? Why?/How? 10b. What type of help or treatment was not useful? Why?/How?
CLARIFY THE ROLE OF SOCIAL BARRIERS TO HELP-SEEKING, ACCESS TO CARE, AND PROBLEMS ENGAGING IN PREVIOUS TREATMENT.
11. Has anything prevented you from getting the help you need-- for example, cost or lack of insurance coverage, getting time off work or family responsibilities, concern about stigma or discrimination, or lack of services that understand your language or culture? 11a. IF YES: What got in the way?
Yes
No
CURRENT HELP-SEEKING ELICIT POSSIBLE CONCERNS ABOUT THE CLINICIAN-PATIENT RELATIONSHIP, INCLUDING PERCEIVED RACISM OR CULTURAL DIFFERENCES THAT MAY UNDERMINE COMMUNICATION, GOODWILL, OR CARE DELIVERY.
CLINICIAN-PATIENT RELATIONSHIP 12. Now let’s talk about the help you would be getting here. Is there anything about my own background that might make it difficult for me to understand or help you with your [PROBLEM]? Yes No 12a. In what way?/Why not?
ADDRESS POSSIBLE BARRIERS TO CARE OR CONCERNS ABOUT THE CLINICIAN-PATIENT RELATIONSHIP RAISED PREVIOUSLY.
13. How can I and others at our clinic be most helpful for you?
CLARIFY PATIENT’S CURRENT PERCEIVED NEEDS AND EXPECTATIONS OF MENTAL HEALTH SERVICES (E.G., PSYCHOTHERAPY, SPECIFIC ADVICE, MEDICATION, REFERRAL, OR ASSISTANCE WITH DISABILITY BENEFITS).
PREFERENCES 14. What kind of help would you like from us now, as specialists in mental health?
HERE THE CLINICIAN SUMMARIZES THE MAIN POINTS AND MAKES A TRANSITION TO THE REST OF THE INTERVIEW.
© 2012 American Psychiatric Association. All Rights Reserved. See Terms & Conditions of Use for more information.
