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USING THE DSM-5 TO DEVELOP
THE PROFESSIONAL IDENTITY AND
CLINICAL COMPETENCE OF
MENTAL HEALTH COUNSELORS
UMHCA 2013
Annual Conference
Jason H. King, PhD, DCMHS, CCMHC, ACS
Core Faculty – Walden University MHC Program
Goals
1. Explore professional identity
2. Understand clinical competence
3. Preview the DSM 5
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2
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Professional Identity
3
DSM 5 - Jason H. King, PhD, DCMHS, ACS
What is Professional Identity?
Values
Beliefs
Assumptions
“The unique characteristics of one’s selected profession
that differentiates it from other professions” (Weinrach,

Thomas, & Chan, 2001, p. 168).
4
DSM 5 - Jason H. King, PhD, DCMHS, ACS
What is Professional Identity?
An individual’s selfdefinition as a
member of a
profession
Enactment of a
professional role
Clients
Workplace
(Chreim, Williams, & Hinings, 2007; Cohen-Scali, 2003)
5
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Colleagues
What is Professional Identity?
CACREP (2009)
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6
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PROFESSIONAL
ORIENTATION AND
ETHICAL PRACTICE
SOCIAL AND CULTURAL
DIVERSITY
HUMAN GROWTH AND
DEVELOPMENT
CAREER DEVELOPMENT
CACREP (2009)


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HELPING RELATIONSHIPS
GROUP WORK
ASSESSMENT
RESEARCH AND
PROGRAM EVALUATION
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Questions About Professional Identity
“As counselors, one of the
major questions of our
times is ‘Who are we’”
(Hendricks, 2008, p. 259)?
“What is the difference
between being a mental
health counselor and a
social worker or marriage
and family therapist?”
(Gerig, 2007, p. 6)


7
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“What type of clientele
should we serve?
What counseling
methodologies should be
employed by the
counselor?
What is the goal of the
profession of counseling”
(Palmo, 2006, p. 52)?
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Questions About Professional Identity
Myers, Sweeney, and White (2002, p. 399)
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8
How does our identity converge with and diverge from that of
other mental health professionals?
Where is our niche, and how can this niche be emphasized and
marketed to various public sectors?
How are our specialty areas defined, and how do they relate to
professional counseling in general?
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Clinical Competence
9
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Clinical Competence

What is Clinical Mental Health Counseling?

UMHCA (2011)
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10
"Clinical mental health counseling promotes
optimal wellness for individuals, couples, families,
and groups throughout the lifespan.
Those educated and trained as clinical mental
health counselors treat as well as prevent mental,
emotional, and behavioral disorders through
mental health assessments, diagnosis, prevention
and treatment plans, and psychotherapeutic
counseling interventions.“
AMHCA (2011) Standards for the Practice of
Clinical Mental Health Counseling
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Clinical Competence

Vocational Rehabilitation September 30, 2011:

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11
“USOR has determined that when we are paying for psychological
testing, evaluation, assessment, and other activities leading to a DSM
diagnosis, we will do so with the highest level of professional
credential, education, and training. Our standard is a licensed Ph.D.
level psychologist, or licensed medical doctor.
I have reviewed the most current mental health licensing laws on
DOPL. I find that the law does not allow LPC's, LCSW's, or
Substance Abuse Counselors to conduct psychological testing,
evaluation, leading to DSM diagnosis.
If the profession, as a profession, has information otherwise, I would
be happy to sit down with their professional organization and discuss
and reconsider. Until then our standard is our standard.”
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Clinical Competence

Mental Health Professional Practice Act
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Scope of practice – Limitations – PAGE 16
(1) A licensed clinical mental health counselor may engage in all
acts and practices defined as the practice of professional
counseling without supervision, in private and independent
practice, or as an employee of another person, limited only by
the licensee's education, training, and competence.
Clinical Mental Health Counselor Licensing Act Rule
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12
(H) a minimum of two semester or three quarter hours in
psychometric test and measurement theory;
(I) a minimum of four semester or six quarter hours in
assessment of mental status including the appraisal of DSM
maladaptive and psychopathological behavior
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Clinical Competence

NCE
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NCMHCE
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Psychometric statistics – types of assessment scores, measures of
central tendency, indices of variability, standard errors, and
correlations
Evaluation & Assessment
Diagnosis & Treatment Planning
AMHCA 2011 Code of Ethics
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13
Mental health counselors utilize tests (herein references educational,
psychological, and career assessment instruments), interviews, and
other assessment techniques and diagnostic tools in the counseling
process for the purpose of determining the client’s particular needs
in the context of his/her situation.
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Clinical Competence


ACA 2005 Code of Ethics
Section E: Evaluation, Assessment, and Interpretation

Introduction
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E.1.a. Assessment
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14
Counselors use assessment instruments as one component of the
counseling process, taking into account the client personal and cultural
context. Counselors promote the well-being of individual clients or
groups of clients by developing and using appropriate educational,
psychological, and career assessment instruments.
The primary purpose of educational, psychological, and career assessment
is to provide measurements that are valid and reliable in either
comparative or absolute terms. These include, but are not limited to,
measurements of ability, personality, interest, intelligence, achievement,
and performance.
E. 5. Diagnosis of Mental Disorders
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Clinical Competence

ACA 2014 Code of Ethics
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CACREP (2009)
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“When possible use multiple forms of assessment, data, and/or
instruments in forming conclusions, diagnoses or recommendations”
“…Diagnostic interviews, mental status examinations, symptom
inventories, and psychoeducational and personality assessments.”
“…Psychological testing and behavioral observations.”
“…Diagnostic process, including differential diagnosis, and the use of
current diagnostic tools, such as the current edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM)”
CACREP (2016)
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15
“Use of informal assessments for diagnostic purposes”
“Use of symptom checklists, personality, and psychological testing”
“Use of assessment results to effectively diagnose developmental,
behavioral, and mental disorders”
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Clinical Competence

King (2012)

HOW ETHICAL CODES DEFINE COUNSELOR
PROFESSIONAL IDENTITY
Weighted Key Word Frequencies in Ethical Codes
16
ACA
APA
AAMFT
NASW
Assessment
1.47%
0.94%
0.00%
0.00%
Diagnose
0.04%
0.01%
0.02%
0.00%
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Clinical Competence

17
"The specific diagnostic
criteria included in the
DSM-IV are meant to
serve as guidelines to
be informed by clinical
judgment and are not
meant to be used in a
cookbook fashion" (p.
xxxii)
DSM 5 - Jason H. King, PhD, DCMHS, ACS
DSM 5
18
DSM 5 - Jason H. King, PhD, DCMHS, ACS
DSM-IV-TR
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
Why diagnose?
Most common diagnostic myth?
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19
“A common misconception is that a classification of mental
disorders classifies people, when actually what are being classified
are disorders that people have.
For this reason, the text of the DSM-IV (as did the text of DSM-III-R)
avoids the use of expressions such as “a schizophrenic” or “an
alcoholic” and instead uses the more accurate, but admittedly more
cumbersome, “an individual with Schizophrenia” or “an individual
with Alcohol Dependence.” (DSM-IV-TR, 2000, p. xxxi)
DSM 5 - Jason H. King, PhD, DCMHS, ACS
DSM 5

Backlash

The National Institute for Mental Health has launched a plan to
replace the DSM-5 with a new “Research Domain Criteria
(RDoC)” project



20
incorporating genetics, imaging, cognitive science, and other levels of
information
Stating that the DSM is little more than a dictionary, that the
DSM criteria are unreliable, and that those diagnosed with
mental disorders “deserve better,” NIMH Director Dr. Thomas
Insel made the announcement this past week
With its 1.5 billion dollar budget, NIMH is the major source of
mental health research in the United States
DSM 5 - Jason H. King, PhD, DCMHS, ACS
DSM 5
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

Dimensional assessments
Better recognizes the complexity of the interface between
psychiatry and medicine
Defines disorders on the basis of positive symptoms


distressing somatic symptoms plus abnormal thoughts, feelings, and
behaviors in response to these symptoms
Organizational Changes

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21
The proposed framework for DSM-5 re-orders the current manual’s
16 chapters based on underlying vulnerabilities as well as symptom
characteristics
The chapters are arranged by general categories such as
neurodevelopmental, emotional and somatic to reflect the potential
commonalities in etiology within larger disorder groups
Such changes are aimed at facilitating more comprehensive diagnosis
and treatment approaches and encourage research across diagnostic
criteria
DSM 5 - Jason H. King, PhD, DCMHS, ACS
DSM 5

Work Groups

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22
Clarify the boundaries between mental disorders to reduce
confusion of disorders with each other and to help guide
effective treatment
Consider “cross-cutting” symptoms (symptoms that commonly
occur across different diagnoses)
Demonstrate the strength of research for the
recommendations on as many evidence levels as possible
Clarify the boundaries between specific mental disorders and
normal psychological functioning
DSM 5 - Jason H. King, PhD, DCMHS, ACS
DSM 5

What is the most significant
change?


23
Roman numerals have been
attached to DSM since the
second edition of the manual was
published more than four
decades ago
But in the 21st century, when
technology allows immediate
electronic dissemination of
information worldwide, Roman
numerals are especially limiting
DSM 5 - Jason H. King, PhD, DCMHS, ACS
DSM 5

New definition of mental disorder

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24
A behavioral or psychological syndrome
or pattern that occurs in an individual
That reflects an underlying
psychobiological dysfunction
The consequences of which are
clinically significant distress (e.g., a
painful symptom) or disability (i.e.,
impairment in one or more important
areas of functioning
Must not be merely an expectable
response to common stressors and
losses (for example, the loss of a loved
one) or a culturally sanctioned
response to a particular event (for
example, trance states in religious
rituals)
That is not primarily a result of social
deviance or conflicts with society

DSM IV-TR definition of mental
disorder



Mental Disorder unfortunately implies a
distinction between 'mental' disorders
and 'physical disorders' that is a
reductionistic anachronism of
mind/body dualism.
A compelling literature documents that
there is much 'physical' in 'mental
disorders' and much 'mental' in
'physical' disorders
Mental Disorders can generally be
categorized as a clinically significant
behavior or psychological syndrome or
pattern that occurs in an individual and
that is associated with present distress
or disability or with a significantly
increased risk of suffering death, pain,
disability, or an important loss of
freedom
DSM 5 - Jason H. King, PhD, DCMHS, ACS
DSM 5

Chapter Layout


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
Neurodevelopmental
Disorders
Schizophrenia Spectrum and
Other Psychotic Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and
Related Disorders
Trauma and Stressor-Related
Disorders
Dissociative Disorders
Chapter Layout

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25
Somatic Symptom and Related
Disorders
Feeding and Eating Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse-Control,
and Conduct Disorders
Substance-Related and
Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Neurodevelopmental Disorders
26
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Neurodevelopmental Disorders


Intellectual Developmental Disorder
 Assessment of both cognitive capacity (IQ) and adaptive
functioning – severity
Communication Disorders
 Language disorder (which combines DSM-IV expressive and
mixed receptive-expressive language disorders)
 Speech sound disorder (a new name for phonological disorder)
 Childhood-onset fluency disorder (a new name for stuttering)
 Social (pragmatic) communication disorder

27
a new condition for persistent difficulties in the social uses of verbal
and nonverbal communication
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Neurodevelopmental Disorders

Autism Spectrum Disorders
 Merger of the following from DSM-IV:


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Autistic Disorder
Asperger’s Disorder
Childhood Disintegrative Disorder,
Pervasive Developmental Disorder Not Otherwise Specified

Because both components are required for diagnosis of ASD, Social
Communication Disorder is diagnosed if no RRBs are present
DSM-IV was skewing Autism diagnoses towards children with social
and communication difficulties
As the APA puts it "delays in language are not unique nor universal in
ASD"
ASD is characterized by 1) deficits in social communication and
social interaction and 2) restricted repetitive behaviors,
interests, and activities (RRBs)
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


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28
Lifting age requirement of 3 years
Including sensory processing issues
1-3 Severity Rating (support, substantial, very substantial)
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Neurodevelopmental Disorders

ADHD
 Still 18 symptoms, cross-situational requirement strengthened
to “several” symptoms in each setting
 Examples added to the criterion to facilitate application across
the life span
 Age of onset: “Several noticeable inattentive or hyperactiveimpulsive symptoms were present by age 12”
 “Presentations” instead of “Subtypes”
 Comorbid diagnosis with ASD is now allowed
 Symptom threshold change for adults


29
reflects their substantial evidence of clinically significant ADHD
impairment
with the cutoff for ADHD of five symptoms, instead of six
required for younger persons, both for inattention and for
hyperactivity and impulsivity
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Neurodevelopmental Disorders
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
30
Specific Learning Disorder
 Combines the DSM-IV
diagnoses of reading disorder,
mathematics disorder,
disorder of written
expression, and learning
disorder not otherwise
specified
 Coded specifiers
Motor Disorders
 Developmental coordination
disorder, stereotypic
movement disorder, Tourette’s
disorder, persistent (chronic)
motor or vocal tic disorder,
provisional tic disorder, other
specified tic disorder, and
unspecified tic disorder
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Schizophrenia Spectrum and
Other Psychotic Disorders
31
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Schizophrenia Spectrum and Other
Psychotic Disorders

New Chapter Organization

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Changes

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Schizotypal Personality Disorder
Psychotic Disorder Associated with Medical Condition, Substance or
Catatonia
Dropped subtypes
Elimination of the special attribution of bizarre delusions and
“Schneiderian” first-rank auditory hallucinations (e.g., two or more
voices conversing)
Addition of a requirement in Criterion A that the individual must have at
least one of these three symptoms: delusions, hallucinations, and
disorganized speech
Clarification of negative symptoms


32
Avolition
Expressive deficits
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Bipolar and Related Disorders
33
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Bipolar and Related Disorders

Overview
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

Criterion A for manic and hypomanic episodes now includes an
emphasis on changes in activity and energy as well as mood
“With mixed features”
Categorization for individuals with a past history of a major
depressive disorder who meet all criteria for hypomania except the
duration criterion (i.e., at least 4 consecutive days)


Anxious Distress Specifier

34
Too few symptoms of hypomania are present to meet criteria for the full
Bipolar II syndrome, although the duration is sufficient at 4 or more days
Intended to identify patients with anxiety symptoms that are not part of
the bipolar diagnostic criteria
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Depressive Disorders
35
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Depressive Disorders

Disruptive Mood Dysregulation Disorder

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
Underserved children who are often misdiagnosed as having
Pediatric Bipolar NOS
They do not show the same characteristics of individuals with classic
bipolar disorder (ex: episodic grandiosity/elevated mood/manic
episodes)
Have developmentally inappropriate and significant difficulties
Ages 6-18
3+ times per week for 12 months of verbal rages or physical
aggression
Premenstrual Dysphoric Disorder
Major Depressive Disorder
Chronic Depressive Disorder – the new Dysthymic Disorder
Bereavement Exclusion

36
2 months versus 1-2 years
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Anxiety Disorders
37
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Anxiety Disorders

Agoraphobia, Specific Phobia, and Social Anxiety Disorder
(Social Phobia)

Deletion of the requirement that individuals over age 18 years
recognize that their anxiety is excessive or unreasonable



6-month duration, which was limited to individuals under age 18 in
DSM-IV, is now extended to all ages


This change is based on evidence that individuals with such disorders often
overestimate the danger in “phobic” situations and that older individuals often
misattribute “phobic” fears to aging
Instead, the anxiety must be out of proportion to the actual danger or threat
in the situation, after taking cultural contextual factors into account
Intended to minimize overdiagnosis of transient fears
Panic Disorder

38
Situationally bound/cued, situationally predisposed, and
unexpected/uncued is replaced with unexpected and expected panic
attacks
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Anxiety Disorders

Agoraphobia
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This change recognizes that a substantial number of individuals with
agoraphobia do not experience panic symptoms
Endorsement of fears from two or more agoraphobia situations is
now required, because this is a robust means for distinguishing
agoraphobia from specific phobias
Criteria for agoraphobia are extended to be consistent with criteria
sets for other anxiety disorders (e.g., clinician judgment of the fears
as being out of proportion to the actual danger in the situation, with
a typical duration of 6 months or more)
Social Anxiety Disorder (Social Phobia)

“Generalized” specifier replaced with a “performance only” specifier


39
problematic in that “fears include most social situations” was difficult to
operationalize
distinct subset of social anxiety disorder in terms of etiology, age at onset,
physiological response, and treatment response
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Anxiety Disorders

Separation Anxiety Disorder


Core features remain mostly unchanged
Wording of the criteria has been modified to more adequately
represent the expression of separation anxiety symptoms in
adulthood



For example, attachment figures may include the children of adults
with separation anxiety disorder, and avoidance behaviors may occur
in the workplace as well as at school
Diagnostic criteria no longer specify that age at onset must be
before 18 years, because a substantial number of adults report
onset of separation anxiety after age 18
Selective Mutism
40
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Obsessive Compulsive and
Related Disorders
41
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Obsessive Compulsive and Related Disorders

Clinical utility of grouping these disorders in the same chapter


“With poor insight” specifier refined to allow a distinction
between individuals with good or fair insight, poor insight, and
“absent insight/delusional” obsessive-compulsive disorder
beliefs


Reflects the increasing evidence that these disorders are related to
one another in terms of a range of diagnostic validators
“Tic-related” specifier
New disorders
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


42
Hoarding disorder
Excoriation (skin-picking) disorder
Substance-/medication-induced obsessive-compulsive and related
disorder
Obsessive-compulsive and related disorder due to another medical
condition
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Obsessive Compulsive and Related Disorders

Body Dysmorphic Disorder

Diagnostic criterion describing repetitive behaviors or mental
acts in response to preoccupations with perceived defects or
flaws in physical appearance added


A “with muscle dysmorphia” specifier added


43
consistent with data indicating the prevalence and importance of this
symptom
reflects growing literature on the diagnostic validity and clinical utility
of making this distinction in individuals with body dysmorphic
disorder
The delusional variant of body dysmorphic disorder no longer
coded as both delusional disorder, somatic type, and body
dysmorphic disorder
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Obsessive Compulsive and Related Disorders

Hoarding Disorder

Available data do not indicate that hoarding is a variant of obsessivecompulsive disorder or another mental disorder

evidence for the diagnostic validity and clinical utility of a separate
diagnosis of hoarding disorder


Hoarding disorder may have unique neurobiological correlates


which reflects persistent difficulty discarding or parting with possessions due to
a perceived need to save the items and distress associated with discarding
them
associated with significant impairment
Excoriation (Skin-Picking) Disorder


44
AKA: Dermatillomania, neurotic excoriation, pathologic skin picking
compulsive skin picking, or psychogenic excoriation
“Repetitive and compulsive picking of skin which results in tissue
damage”
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Obsessive Compulsive and Related Disorders


Trichotillomania is now termed Trichotillomania (hairpulling disorder)
Other Specified and Unspecified Obsessive-Compulsive
and Related Disorders

Body-focused repetitive behavior disorder


Obsessional jealousy


45
Characterized by recurrent behaviors other than hair pulling and skin
picking (e.g., nail biting, lip biting, cheek chewing) and repeated
attempts to decrease or stop the behaviors
Characterized by nondelusional preoccupation with a partner’s
perceived infidelity
Unspecified obsessive-compulsive and related disorder
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Trauma and Stressor-Related
Disorders
46
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Trauma and Stressor-Related Disorders

AMHCA (2011) Standards for the Practice of CMHC


Trauma training standards
CACREP (2009) and (2016)

PROFESSIONAL ORIENTATION AND ETHICAL PRACTICE


HUMAN GROWTH AND DEVELOPMENT


Nothing
COAMFTE (2005)


c. effects of crises, disasters, and other trauma-causing events on persons of all
ages
APA-CoA (2007)


c. counselors’ roles and responsibilities as members of an interdisciplinary
emergency management response team during a local, regional, or national crisis,
disaster or other trauma-causing event
Nothing
CSWE (2008)

47
Nothing
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Trauma and Stressor-Related Disorders

Acute Stress Disorder

Stressor criterion (Criterion A) changed


Criterion A2 regarding the subjective reaction to the traumatic event
(e.g., “the person’s response involved intense fear, helplessness, or
horror”) eliminated



evidence that acute posttraumatic reactions are very heterogeneous
DSM-IV’s emphasis on dissociative symptoms is overly restrictive
Exhibit any 9 of 14 listed symptoms in these categories:


requires being explicit as to whether qualifying traumatic events were
experienced directly, witnessed, or experienced indirectly
intrusion, negative mood, dissociation, avoidance, and arousal
Adjustment Disorders


48
Reconceptualized as a heterogeneous array of stress-response
syndromes that occur after exposure to a distressing event
Subtypes unchanged
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Trauma and Stressor-Related Disorders

Posttraumatic Stress Disorder



Stressor criterion (Criterion A) is more explicit
Criterion A2 (subjective reaction) eliminated
Diagnostic thresholds lowered for children and adolescents


separate criteria for children age 6 years or younger
Now four symptom clusters in DSM-5


1. Reexperiencing
2. Avoidance


3. Numbing


includes new or reconceptualized symptoms & persistent negative
emotional states
4. Arousal and reactivity

49
Now with persistent negative alterations in cognitions and mood
includes irritable or aggressive behavior and reckless or self-destructive
behavior
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Trauma and Stressor-Related Disorders

Reactive Attachment Disorder

DSM-IV subtypes emotionally withdrawn/inhibited and
indiscriminately social/disinhibited is now two DSM-5 distinct
disorders


1. Reactive Attachment Disorder




dampened positive affect
more closely resembles internalizing disorders
essentially equivalent to a lack of or incompletely formed preferred
attachments to caregiving adults
2. Disinhibited Social Engagement disorder


50
result of social neglect or other situations that limit a young child’s
opportunity to form selective attachments
more closely resembles ADHD
may occur in children who do not necessarily lack attachments and
may have established or even secure attachments
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Dissociative Disorders
51
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Dissociative Disorders

Derealization


Dissociative Fugue


Now included in the name and symptom structure of what previously
was called Depersonalization Disorder and is now called
Depersonalization/Derealization Disorder
Now a specifier of dissociative amnesia rather than a separate diagnosis
Dissociative Identity Disorder

Criterion A expanded






52
includes certain possession-form phenomena
functional neurological symptoms to account for more diverse presentations of
the disorder
Symptoms of disruption of identity may be reported as well as observed
Gaps in the recall of events may occur for everyday
Experiences of pathological possession in some cultures included
Other text modifications clarify the nature and course of disruptions
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Somatic Symptom and Related
Disorders
53
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Somatic Symptom and Related Disorders

In DSM-IV, there is significant overlap across the
somatoform disorders and a lack of clarity about their
boundaries



These disorders are primarily seen in medical settings, and
nonpsychiatric physicians found the DSM-IV somatoform
diagnoses problematic to use
The DSM-5 classification reduces the number of these
disorders and subcategories to avoid problematic overlap
Removed




54
Somatization Disorder
Hypochondriasis
Pain Disorder
Undifferentiated Somatoform Disorder
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Somatic Symptom and Related Disorders

Somatic Symptom Disorder (Somatization Disorder and
Undifferentiated Somatoform Disorder)


Individuals with somatic symptoms plus abnormal thoughts,
feelings, and behaviors may or may not have a diagnosed
medical condition
The relationship between somatic symptoms and
psychopathology exists along a spectrum



55
the arbitrarily high symptom count required for DSM-IV somatization
disorder did not accommodate this spectrum
The diagnosis of somatization disorder was essentially based
on a long and complex symptom count of medically
unexplained symptoms
Maladaptive thoughts, feelings, and behaviors that define the
disorder, in addition to somatic symptoms
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Somatic Symptom and Related Disorders

Hypochondriasis


Eliminated as a disorder, in part because the name was
perceived as pejorative and not conducive to an effective
therapeutic relationship
Most individuals who would previously have been diagnosed
with hypochondriasis have significant somatic symptoms in
addition to their high health anxiety


now receive a DSM-5 diagnosis of somatic symptom disorder
Illness Anxiety Disorder

In DSM-5, individuals with high health anxiety without somatic
symptoms receive this diagnosis

56
unless their health anxiety was better explained by a primary anxiety
disorder, such as generalized anxiety disorder
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Somatic Symptom and Related Disorders

Pain Disorder




57
In DSM-IV, this diagnoses assumes that some pains are
associated solely with psychological factors, some with medical
diseases or injuries, and some with both
There is a lack of evidence that such distinctions can be made
with reliability and validity, and a large body of research has
demonstrated that psychological factors influence all forms of
pain
Most individuals with chronic pain attribute their pain to a
combination of factors, including somatic, psychological, and
environmental influences
In DSM-5, some individuals with chronic pain would be
appropriately diagnosed as having somatic symptom disorder,
with predominant pain
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Somatic Symptom and Related Disorders

Psychological Factors Affecting Other Medical Conditions
and Factitious Disorder


Formerly included in the DSM-IV chapter “Other Conditions
That May Be a Focus of Clinical Attention”
Conversion Disorder (Functional Neurological Symptom
Disorder)

58
Criteria modified to emphasize the essential importance of the
neurological examination, and in recognition that relevant
psychological factors may not be demonstrable at the time of
diagnosis
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Feeding and Eating Disorders
59
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Feeding and Eating Disorders

Pica and Rumination Disorder


Avoidant/Restrictive Food Intake Disorder (DSM-IV Feeding
Disorder of Infancy or Early Childhood)



The DSM-IV criteria for pica and for rumination disorder have been
revised for clarity and to indicate that the diagnoses can be made for
individuals of any age
Was rarely used, and limited information is available on the
characteristics, course, and outcome of children with this disorder
A large number of individuals substantially restrict their food intake
and experience significant associated physiological or psychosocial
problems but do not meet criteria for any DSM-IV eating disorder
Anorexia Nervosa



60
Requirement for amenorrhea eliminated
The wording of the criterion is changed for clarity, and guidance
Criterion B is expanded to include overtly expressed fear of weight
gain and persistent behavior that interferes with weight gain
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Feeding and Eating Disorders

Bulimia Nervosa


Binge-Eating Disorder



Reduction in the required minimum average frequency of binge
eating and inappropriate compensatory behavior frequency
from twice to once weekly over 3 months, from 6 months
Extensive research followed the promulgation of preliminary
criteria for binge eating disorder in Appendix B of DSM-IV, and
findings supported the clinical utility and validity of binge-eating
disorder
Same time duration as Bulimia Nervosa
Elimination Disorders

61
No significant changes
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Sleep-Wake Disorders
62
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Sleep-Wake Disorders

Overview




Primary Insomnia renamed Insomnia Disorder
Distinguishes narcolepsy


Pediatric and developmental criteria and text are integrated where
existing neurobiological and genetic evidence support such
integration
Greater specification of coexisting conditions is provided
Which is now known to be associated with hypocretin deficiency,
from other forms of hypersomnolence
Removed


Sleep disorders related to another mental disorder
Sleep disorder related to a general medical condition

63
this change underscores that the individual has a sleep disorder
warranting independent clinical attention
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Sleep-Wake Disorders

Breathing-Related Sleep Disorders



Obstructive Sleep Apnea Hypopnea
Central Sleep Apnea
Sleep-Related Hypoventilation


Circadian Rhythm Sleep-Wake Disorders

Expanded to include…





this change reflects the growing understanding of their pathophysiology
advanced sleep phase syndrome
irregular sleep-wake type
non-24-hour sleep-wake type,
jet lag type removed
Rapid Eye Movement Sleep Behavior Disorder and Restless
Legs Syndrome


64
In DSM-IV both are included under Dyssomnia Not Otherwise
Specified
Their full diagnostic status is supported by research evidence
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Sexual Dysfunctions
65
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Sexual Dysfunctions

Overview

In DSM-IV, sexual dysfunctions referred to sexual pain or to a
disturbance in one or more phases of the sexual response
cycle.


Gender-specific sexual dysfunctions added


66
Research suggests that sexual response is not always a linear, uniform
process and that the distinction between certain phases (e.g., desire
and arousal) may be artificial
For females, sexual desire and arousal disorders have been combined
into one disorder: female sexual interest/arousal disorder
To improve precision regarding duration and severity criteria
and to reduce the likelihood of overdiagnosis, all of the DSM-5
sexual dysfunctions (except substance-/medication-induced
sexual dysfunction) now require a minimum duration of
approximately 6 months and more precise severity criteria
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Sexual Dysfunctions

Genito-Pelvic Pain/Penetration Disorder


Sexual Aversion Disorder removed


Represents a merging of the DSM-IV categories of Vaginismus
and Dyspareunia, which were highly comorbid and difficult to
distinguish
due to rare use and lack of supporting research
Subtypes


Includes only lifelong versus acquired and generalized versus
situational subtypes
To indicate the presence and degree of medical and other
nonmedical correlates:

67
partner factors, relationship factors, individual vulnerability factors,
cultural or religious factors, and medical factors
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Gender Dysphoria
68
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Gender Dysphoria




Reflects a change in conceptualization of the disorder’s defining
features by emphasizing the phenomenon of “gender incongruence”
rather than cross-gender identification per se, as was the case in
DSM-IV gender identity disorder
Considered to be a multicategory concept rather than a dichotomy
Acknowledges the wide variation of gender-incongruent conditions
In the wording of the criteria, “the other sex” is replaced by “some
alternative gender”


Gender instead of sex is used systematically because the concept “sex”
is inadequate when referring to individuals with a disorder of sex
development
Criterion A (cross-gender identification) and Criterion B (aversion
toward one’s gender) merged

69
no supporting evidence from factor analytic studies supported keeping
the two separate
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Gender Dysphoria


Separate criteria sets are provided for Gender Dysphoria in
children and in adolescents and adults
Child criteria



“strong desire to be of the other gender” replaces the previous
“repeatedly stated desire” to capture the situation of some children
who, in a coercive environment, may not verbalize the desire to be of
another gender
Criterion A1 (“a strong desire to be of the other gender or an
insistence that he or she is the other gender . . .)” is now necessary
(but not sufficient), which makes the diagnosis more restrictive and
conservative
Subtypes and Specifiers


The subtyping on the basis of sexual orientation removed
A posttransition specifier added

70
many individuals, after transition, no longer meet criteria for gender
dysphoria; however, they continue to undergo various treatments to
facilitate life in the desired gender
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Disruptive, Impulse-Control, and
Conduct Disorders
71
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Disruptive, Impulse-Control, and Conduct
Disorders

Overview




These disorders are all characterized by problems in emotional and
behavioral self-control
Antisocial Personality Disorder has dual listing in this chapter and in
the chapter on personality disorders
ADHD is frequently comorbid with the disorders in this chapter but
is listed with the neurodevelopmental disorder
Intermittent Explosive Disorder


Minimum age of 6 years (or equivalent developmental level) now
required
Physical aggression, verbal aggression, and nondestructive/
noninjurious physical aggression


72
specific criteria defining frequency needed to meet criteria and specifies
that the aggressive outbursts are impulsive and/or anger based in nature
must cause marked distress, impairment in occupational or interpersonal
functioning, or be associated with negative financial or legal consequences
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Disruptive, Impulse-Control, and Conduct
Disorders

Oppositional Defiant Disorder

Four refinements






1. symptoms are now grouped into three types: angry/irritable mood,
argumentative/defiant behavior, and vindictiveness
This change highlights that the disorder reflects both emotional and
behavioral symptomatology
2. exclusion criterion for conduct disorder removed
3. a note added to the criteria to provide guidance on the frequency
typically needed for a behavior to be considered symptomatic of the
disorder
4. a severity rating added to reflect research showing that the degree of
pervasiveness of symptoms across settings is an important indicator of
severity
Conduct Disorder

A descriptive features specifier with limited prosocial emotions

73
callous and unemotional interpersonal style across multiple settings and
relationships
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Substance-Related and Addictive
Disorders
74
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Substance-Related and Addictive Disorders

Substance Use Disorder

No more Substance Abuse and Substance Dependence


Utah DOPL





75
"Substance Use Disorder Counselor”
Criteria


“Eliminating the category of dependence will better differentiate between the
compulsive drug-seeking behavior of addiction and normal responses of
tolerance and withdrawal that some patients experience when using prescribed
medications that affect the central nervous system”
nearly identical to the DSM-IV substance abuse and dependence criteria
combined into a single list
threshold = 2
removed: recurrent legal problems criterion
added: craving or a strong desire or urge to use a substance
Criteria for intoxication, withdrawal, substance/medication-induced
disorders, and unspecified substance-induced disorders
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Substance-Related and Addictive Disorders

Substance Use Disorder

Remission specifiers






76
Substance Use Disorder

No more partial and full
Early remission = at least 3 but
less than 12 months without
substance use disorder criteria
(except craving)
Sustained remission = at least
12 months without criteria
(except craving)
Severity ratings


2–3 criteria indicate = a mild
disorder
4–5 criteria = moderate
disorder
6 or more = a severe disorder
Removed






Polysubstance
Abuse/Dependence
Amphetamine
Cocaine
Specifier for a physiological
subtype
On agonist therapy
Added





Caffeine Withdrawal
Cannabis Withdrawal
Tobacco-Related Disorder
Stimulant –Related Disorder
On maintenance therapy
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Substance-Related and Addictive Disorders

Gambling Disorder



77

“This change reflects the
increasing and consistent
evidence that some behaviors,
such as gambling, activate the
brain reward system with
effects similar to those of
drugs of abuse and that
gambling disorder symptoms
resemble substance use
disorders to a certain extent”
Lowering of the pathological
gambling threshold to 4
symptoms
Removal of the ‘‘illegal acts’’
criterion for the disorder
Why not other Addictive
Disorders such as Process
Addictions proposed by Dr.
Kevin McCauley?








Sex
Relationships
Codependency
Cults
Performance
Compulsive spending
Rage/violence
Media/entertainment
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Neurocognitive Disorders
78
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Neurocognitive Disorders

Delirium


The criteria for delirium have been updated and clarified on the basis
of currently available evidence
Major and Mild Neurocognitive Disorder (NCD)



Diagnostic criteria are provided for both major NCD and mild NCD,
followed by diagnostic criteria for the different etiological subtypes



79
Dementia and Amnestic Disorder are subsumed
The term dementia is not precluded from use in the etiological subtypes
where that term is standard
Threshold between mild NCD and major NCD is inherently arbitrary
Individuals with Alzheimer’s disease, cerebrovascular disorders, HIV,
traumatic brain injury, Parkinson’s disease, Huntington’s disease, Pick’s
disease, Creutzfeldt-Jakob disease, and other medical conditions specified
Updated listing of neurocognitive domains is also provided
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Personality Disorders
80
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Personality Disorders

Overview


The criteria has not changed from those in DSM-IV
Revised personality functioning criterion (Criterion A) developed
based on a literature review of reliable clinical measures of core
impairments central to personality pathology



Diagnostic thresholds for both Criterion A and Criterion B set
empirically to minimize change in disorder prevalence and overlap
with other personality disorders and to maximize relations with
psychosocial impairment
2012 proposed criteria:

81
With a single assessment of level of personality functioning, a clinician can
determine whether a full assessment for personality disorder is necessary
http://www.dsm5.org/Documents/Personality%20Disorders/DSMIV%20and%20DSM5%20Criteria%20for%20the%20Personality%20Disorders%205-1-12.pdf
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Paraphilic Disorders
82
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Paraphilic Disorders

Specifiers


“in a controlled environment” and “in remission”
Change to Diagnostic Names


In DSM-5, paraphilias are not ipso facto mental disorders
There is a distinction between paraphilias and paraphilic
disorders




83
A paraphilic disorder is a paraphilia that is currently causing distress
or impairment to the individual or a paraphilia whose satisfaction has
entailed personal harm, or risk of harm, to others
A paraphilia is a necessary but not a sufficient condition for having a
paraphilic disorder,
A paraphilia by itself does not automatically justify or require clinical
intervention
Thus, for example, DSM-IV Pedophilia has become DSM-5
Pedophilic Disorder
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Cultural Formulation Interview
84
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Cultural Formulation Interview (CFI)


Set of fourteen questions
that clinicians may use to
obtain information during a
mental health assessment
about the impact of culture
on key aspects of care
The CFI emphasizes four
main domains:




85
1. Cultural Definition of the
Problem
2. Cultural Perceptions of
Cause, Context, and Support
3. Cultural Factors Affecting
Self Coping & Past Help
Seeking
4. Current Help Seeking
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Conclusion
86
DSM 5 - Jason H. King, PhD, DCMHS, ACS
Conclusion
87
DSM 5 - Jason H. King, PhD, DCMHS, ACS
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