Download 11/4/2013 1 DSM-5 The Bigger Picture

11/4/2013
Workshop for Clinicians
Psychological Solutions
November, 2013
DSM-5
The Bigger Picture
1840
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Know this malady coined in 1840s?
Clue 1
Clue 2
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Final Clue
Drapetomania
The inexplicable, mad longing of a slave for
freedom.
DSM in 1952
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DSM-5 in 2013
There’s been a lot of progress in mental health
through the years ……..
but what will be our “drapetomania” in the next
century?
Isaac Newton said it best almost 250 years ago; 'I
can calculate the motions of the heavens, but not
the madness of men."
Figuring out how the universe works is simple stuff
compared to figuring out what causes
schizophrenia.
Allen Frances, 2013
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APA study groups worked on DSM-5 from 1999-2013
Professionals who worked on IV did not work on 5
Expanded international and female representation
Limited financial conflict (per year industry
compensation to < $10,000)
Same transparency/confidentiality requirements as
for NIH, Institutes of Medicine, WHO, and scientific
journals
Published the work in the task groups on the APA
website for review DSM5.org
Align with ICD-9 and ICD-10 to unify
psychological/medical
Changed from Roman numerals
Online component
Cultural issues more clearly delineated
Offers Cultural Formulation Interview (CFI)
Lifespan Focus
Revised Chapter Organization
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Diagnoses move away from Yes/No categories to
more dimensional/spectrum diagnosis.
Examples
Learning Disabilities
Autism Spectrum Disorder
Results in fewer NOS
Results in fewer disorders
DSM-IV TR: 172
DSM-5: 157
Single Axis rather than 5 axis
No more Axis II!
▪ Axis II disorders led to misguided belief that these were
largely untreatable (Good, 2012; Krueger & Eaton)
So how get holistic picture?
More V codes to denote stressors (pg 715)
Use subtypes, specifiers, and severity ratings
Severity ratings likely more reliable than GAF
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Example in handouts (see pg. 52 in DSM-5)
Gets at real-life functioning
For instance, ADHD now has a severity rating.
Severity may vary by context and over time.
Will Level 2 be the threshold for services?
Disclaimer in DSM-5: The severity specifiers should not be
used to determine eligibility for and provision of services;
these can only be developed at an individual level and
through discussion of personal priorities and targets.
Think dimensions.
No more 5-axis diagnosis.
Severity level and specifiers for more
description.
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Except for autism, all the DSM-5
changes loosen diagnosis and threaten
to turn our current diagnostic inflation
into diagnostic hyperinflation. Painful
experience with previous DSMs teaches
us that if anything can be turned into a
fad, it will be. Many millions of people
with
normal
grief,
gluttony,
distractibility, worries, reactions to
stress, the temper tantrums of
childhood, the forgetting of old age, and
‘behavioral addictions’ will soon be
mislabeled as psychiatrically sick and
given inappropriate treatment.
Taken from Weeks, Howard, 2013.
Director Insel’s Blog
http://www.nimh.nih.gov/about/director/2013
/transforming-diagnosis.shtml
Psychology Today responds
http://www.psychologytoday.com/blog/sideeffects/201305/the-nimh-withdraws-supportdsm-5
The ineffable complexity of brain functioning
has defeated past DSM hopes and will frustrate
even
the
best
NIMH
efforts.
Progress in understanding mental disorders will
necessarily be slow, retail, and painstakingwith no grand slam home runs, just occasional
singles, no walks, and lots of strikeouts. No
sweeping explanations- no Newtons, or
Darwins, or Einsteins.
Allen Frances, 2013
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APA website on DSM-5
http://www.psychiatry.org/practice/dsm/dsm5
PSI website
http://www.psychologicalsolutions.org/
Mike’s DSM-IV diagnosis at Admission
Use resources to find information you need to
translate into DSM-5
Share resources with those around you—
colleagues are a great resource
See pg. 59-66 in DSM-5
314.01 ADHD, Combined Type, moderate
V61.20 Parent-Child Relational Problem
V62.3 Academic or Educational Problems
What other areas would you want more information about
to consider other possibly relevant diagnoses?
Learning disabilities, oppositional behavior, possible substance
abuse, mood, anxiety?
Also need more information to consider possible V-codes:
V61.8 High Expressed Emotion Level Within Family
V61.8 Sibling Relational Problem
V62.89 Phase of Life Problem
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Pervasive
Developmental
Disorders
Autistic
Disorder/
HFA
Asperger
Disorder
Rett
Disorder
Childhood
Disintegrative
Disorder
PDD/NOS
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Autism Spectrum
Disorder
Autistic Disorder
(includes HFA)
Asperger
Disorder
PDD/NOS
Write down which ASD diagnosis, if any,
you think fit for these cases
Oxymoron
Touch
Restaurant
Sugar Motta
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Autism Spectrum
Disorder
Autistic Disorder
(includes HFA)
Asperger
Disorder
PDD/NOS
Experts in the field reliably distinguish if
someone has an ASD, but not between them.
Interestingly, this does not affect treatment.
Autism Spectrum
Disorder
According to the DSM-5, Sheldon now has “Autism
Spectrum Disorder.”
There is no more Asperger’s Disorder.
Asperger’s Disorder
1964-2013
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Social
Interaction
Restrictive/
Repetitive
Social
Communication
And Interaction
Restrictive
Repetitive
Behaviors
Communication
1.
2.
The Autism Spectrum Disorder diagnosis is the only diagnosis.
As in picture, there are now 2 main categories instead of 3.
Social Communication and Interaction
Restrictive Repetitive Behaviors
3.
4.
5.
6.
Some criteria can be by history, rather than current
presentation.
Each category receives it’s own “severity rating.”
New “specifiers” provide more robust, holistic, interconnected
information.
ADHD is diagnosed along with an ASD.
from a total of 8 criteria to 3
Persistent deficits in social communication and
social interaction across multiple contexts, as
manifested by the following, currently or by history
(not exhaustive):
Deficits in social-emotional reciprocity.
Deficits in nonverbal communicative behaviors
used for social interaction.
3. Deficits
in developing, maintaining, and
understanding relationships.
1.
2.
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1.
Deficits in social-emotional reciprocity
Failure to initiate or
respond to social interactions
Failure of normal backand-forth conversations
2. Deficits in nonverbal communicative behaviors
used for social interaction
Total lack of facial expressions
And nonverbal communication
Poorly integrated verbal
and nonverbal communication
3. Deficits in developing maintaining and
understanding relationships
Absence of interest
In peers
Difficulty adjusting behavior
to suit various social contexts
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Of behavior, interests or activities, as manifest by
at least 2 of the following, currently or by history
Stereotyped or repetitive motor movements
(lined up toys when young/stereotyped phrases
“cool”)
Insistence on sameness (rigid thinking patterns)
Perseverative interests/preoccupation with
unusual objects
Sensory issues
.
Axis I: 299.80 Asperger’s Disorder
294.9 Cognitive Disorder, NOS (includes
V61.20 Parent-Child Relational Problem
Axis II: V71.09 No Diagnosis.
Axis III: In utero cocaine/alcohol exposure
noted.
Axis IV: Problems with primary support
group; social environment; placement in a
structured therapeutic environment
Axis V: 38
broad deficits from in utero exposure to alcohol
and cocaine in areas such as impulsivity, mental
inflexibility, and dysregulation)
299.00 Autism Spectrum Disorder
Requiring support for deficits in social
communication/interaction
Requiring support for restricted, repetitive behaviors.
Without accompanying intellectual impairment.
Without accompanying language impairment. Fluent
speech with adequate receptive language and mild deficits in
expressive language.
associated with
315.8 Neurodevelopmental disorder associated with prenatal
alcohol and cocaine exposure in utero, includes broad deficits in
areas such as impulsivity, mental inflexibility, and dysregulation.
V61.20 Parent-Child Relational Problem
V62.4 Social Exclusion or Rejection
*best estimate-specifiers/format likely to evolve over time.
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Persistent difficulties in social use of verbal and
nonverbal communication. All below:
Deficits in using communication for social purposes (i.e.
sharing information)
Impairment in adapting communication style to the
context (classroom vs. recess)
Difficulties following rules for conversation and
storytelling, including nonverbals
Difficulties with nonliteral language
Not in the DSM-5
Lots of research on ASD, not NLD/NVLD
No Learning Disorder, NOS diagnosis
Options (best guess based on what info we have so far)
Carefully consider Autism Spectrum Disorder and SPCD
Describe NVLD in summary but not formally diagnose
Diagnose LD and/or ADHD if warranted and note
“Associated with Nonverbal Learning Disability”
Diagnose Other Specified Neurodevelopmental Disorder
“Associated with Nonverbal Learning Disability”
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Academics
IQ
IQ
Discrepancy Model: An old-fashioned approach
Writing
Spelling
Grammar/
punctuation
Organization
Academic
PROCESSES
Mathematics
Number Sense
Accuracy/fluency
Math Reasoning
Reading
Word Reading
Fluency
Comprehension
Severity
Level
Case Study-Lexi
Remember to use resources
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Autism Spectrum Disorder 299.00
Social communication: Requiring support
Restricted, repetitive behaviors: Requiring support
Without accompanying intellectual impairment
Without accompanying language impairment
Associated with ADHD/Primarily inattentive
presentation 314.00, moderate
Note: V62.4 Social Exclusion or Rejection and V62.3 Academic or
educational problem would have applied when Lexi was
admitted at the program but no longer seems warranted.
What other possible diagnoses would you
want more information about?
Learning disabilities.
Possibly, anxiety. Missed a lot of school before,
possibly from anxiety. Is this resolved?
Had symptoms of mood problems at
admission. Have these resolved?
Other issues you thought of?
Tracine Smoot, Ph.D.
Psychological Solutions
www.psychologicalsolutions.org
Email: [email protected]
Cell: 801-824-0825
Office: 435-425-2234
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Mike (17)
From the DSM-IV to DSM-5
Mike is a 17 year old male who is seeking admission in a therapeutic boarding school following
about 8 weeks in a wilderness program. Prior to being admitted to the wilderness program, he
was acting out in school, staying out after his parent’s curfew, sneaking out of the house at night,
and arguing with his mother and father. He has always had lots of friends but lately had been
hanging out with a more negative group; his parents are very concerned about the impact of these
negative peers. His mother described him as “always on the go” when he was younger but more
recently she has noticed that he is easily bored and often restless. He “stirs things up” with his
siblings, resulting in family conflict. He also tends to act without thinking, often getting into
trouble and then feeling badly about it afterwards. He has difficulty with personal space, has
difficulty waiting for his turn when playing games, and interrupts while others are talking.
Even though he is a bright young man, he has always had difficulty following multi-step
directions and following-through with things. He frequently loses his possessions and loses track
of his homework assignments; either not completing them or forgetting to turn them in once they
were completed. Particularly in school, he has difficulty paying attention, is easily distracted,
and is fidgety. He tends to “check out” when he is not interested but is eager to participate when
he is interested, often blurting out his answers in class discussions. His grades have never been
stellar and on his last report card, he had 3 failing grades.
Mike recently had a psychological evaluation in his community and was provided with the
following DSM-IV TR diagnosis:
DSM-IV
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
314.01 ADHD Combined Type
V61.20 Parent-Child Relational Problem
V62.3
Academic Problems
V71.09 No Diagnosis
Deferred to physician
Problems with primary support group, difficulty in school, current placement.
Current GAF: 51
DSM-5
What other areas would you want more information about to consider other possibly relevant
diagnoses?
Psychological Solutions
Mastering the Nuts and Bolts of the DSM-5
11/2013
Lexi (16)
From the DSM-IV to DSM-5
Lexi is a 16-year old female currently in a residential treatment center, where she has been for
nine months. She has made excellent progress, is preparing to graduate, and will soon be
returning to her home. Her parents and treatment team have planned carefully for this transition
and have an array of services in her community in place for her return. Assume that you are
Lexi’s therapist in this program and you need to have DSM-5 diagnoses for her discharge
summary.
Lexi entered the program after experiencing significant bullying and social rejection. She had
also been having serious academic problems. Moreover, she had been missing a great deal of
school. It did not help that she often stayed up very late playing video games and was tired in the
morning. Her parents had significant difficulty managing her behavior at home. She resisted
following rules and when she didn’t get her way, Lexi had angry outbursts that were more
intense than the situation seemed to call for. In school, Lexi’s grades had dropped dramatically in
the year before entering the program. She had always had difficulty in school and had
previously been in special education with an “Other Health Impaired” classification due to
having severe ADHD, Inattentive Type.
Lexi has made very good progress in residential treatment. She formed a strong therapeutic
alliance with her therapist, in spite of a slow start. She has learned to better regulate her
emotions and behavior. She is also better able to understand the impact of her behavior on others
and her ability to adapt her behavior to the context has improved, even though she continues to
have mild social problems in the milieu (such as with conversational give-and-take). Even
though she still tends to be a rigid thinker and has difficulty switching between activities, she has
learned to accept other’s feedback, follow the rules, and has gotten better at being able to “go
with the flow.” She has also learned how having Asperger’s Disorder impacts her and how to
better advocate for her needs. In school, she still has problems with attention, concentration and
organization but has learned to use a planner system and is doing much better at tracking her
assignments and getting her work completed. She still struggles in some classes, but with support
(especially in organization) earns As, Bs, and some Cs. Her family relationships have always
been supportive, and now that her parents understand better how to support Lexi, they each have
close and healthy relationships with her.
Lexi had a psychological evaluation shortly after she entered the program. Even though Lexi has
made good progress, the primary diagnoses still seem to fit and match the diagnoses on her
treatment plan so you plan to use these in your discharge summary; however, they need to be
updated to the new DSM-5 formulation. Here are highlights from the evaluation, including the
IQ scores:
WECHSLER INTELLIGENCE SCALES FOR CHILDREN-IV
Index/Subtest
Verbal Comprehension
Similarities
Psychological Solutions
Mastering the Nuts and Bolts of the DSM-5
11/2013
Scaled Score
Standard Score
(mean=10, SD=3)
(mean=100, SD=15)
108
11
Percentile
Rank
70
Vocabulary
Comprehension
Perceptual Reasoning
Block Design
Picture Concepts
Matrix Reasoning
Working Memory
Digit Span
Letter-Number Sequencing
Processing Speed
Coding
Symbol Search
Full Scale IQ Score
12
12
96
39
99
47
85
16
99
47
11
9
8
10
10
7
8
Lexi was noted to have strong verbal comprehension abilities that were consistent with her
therapist’s report of having adequate language skills. Lexi’s overall reading scores were on grade
level but her math scores and writing scores were below grade level; however, because her
scores were not significantly different than her Full Scale IQ score, she was not diagnosed with
any learning disabilities. The psychological evaluation noted that Lexi had moderate symptoms
of inattention and disorganization but did not diagnose ADHD/Inattentive Type because of a new
Asperger’s Disorder diagnosis. Lexi also had specialty social/developmental testing, as well as
personality testing. It was noted that Lexi had experienced a great deal of stress related to social
problems.
DSM-IV
299.80 Asperger’s Disorder
V62.3
Academic Problems
Axis II: V71.09 No Diagnosis
Axis III: Deferred to physician
Axis IV: Problems with primary support group, social problems, difficulty in school, current
placement.
Axis V: Current GAF: 59
Axis I:
DSM-5
What other areas would you want more information about to consider other possibly relevant
diagnoses/clinical issues?
Psychological Solutions
Mastering the Nuts and Bolts of the DSM-5
11/2013
11/4/2013
Kevin Fenstermacher, Ph.D.
Disorders related to trauma or distress reactions shares many symptoms in common with other Anxiety Disorders including:
 Hyperarousal, irritably, insomnia, poor
concentration,
 Startle response and avoidance behavior
 Derealization and depersonalization and,
 Persistent and intrusive thoughts.
Trauma and Stress
DSM‐IV
Anxiety and Fear‐Based Response
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Trauma and Stress
Anxiety and Fear‐Based Responses

Externalizing Angry and Aggressive Symptoms
Dissociative Symptoms
Disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion








Anhedonic
and Dysphoric
Symptoms
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder (NEW)
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
Other Specified Trauma‐and Stressor‐Related Disorder
Unspecified Trauma‐and Stressor‐Related Disorder
DSM‐IV: Two Types
 Inhibited
 Disinhibited

DSM‐5: Two Diagnoses
 Reactive Attachment Disorder
 Disinhibited Social Engagement Disorder
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
Although both disorders have a common etiology of “Social Neglect”, they are expressed quite differently
Internalizing Symptoms
Reactive Attachment Disorder

Externalizing Symptoms
Disinhibited Social Engagement Disorder
Internalizing Symptoms of RAD
 Consistent pattern of emotionally withdrawn behavior toward adult caregiver(s)
 Persistent social and emotional disturbance

Extremes of Insufficient Caregiving  Social Neglect or Deprivation
 Repeated Changes in primary caregiver
 Rearing in unusual settings


No Autism Spectrum Disorder
Evident prior to the age of 5; Developmental age of 9 months


Specify if: Persistent (12 months)
Specify Severity: Severe (all symptoms at high levels)
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
Externalizing Symptoms of DSED
 Reduced/absent reticence in approaching or interacting with unfamiliar adults
 Overly familiar verbal/physical boundaries
 Diminished or absent “check‐ins”
 Willingness to go off with unfamiliar adult

Extremes of Insufficient Caregiving  Social Neglect or Deprivation
 Repeated Changes in primary caregiver
 Rearing in unusual settings


Developmental age of 9 months
Specify if: Persistent, Specify Severity : Severe

DSED presents even after signs of neglect are gone
DSED can present in children across the attachment spectrum.


Significant changes
 More explicit as to how trauma was experienced
▪ Directly, Witnessed, or Indirectly
 Removal of subjective emotional reaction to traumatic event (broadening beyond fear‐based and dissociative symptoms)
 3 major symptoms clusters become 4
▪ Avoidance/numbing cluster becomes avoidance and persistent negative emotional states
 Developmentally sensitive
▪ Thresholds lowered for children and adolescents
▪ Separate criteria added for children age 6 and younger
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Avoidance
Intrusion Symptoms
PTSD
Marked alterations in arousal and reactivity


Negative alterations in cognitions and mood
Specify whether:
With Dissociative symptoms
1. Depersonalization
2. Derealization
Specify if:
With delayed expression
Criteria reflect adjustments made to PTSD for clarity as to how trauma was experienced as well as removal of subjective reaction to the traumatic event
Five Symptom Categories (9 of 14)
 Intrusion, negative mood, dissociation, avoidance, and arousal


This category was reconceptualized as a heterogeneous array of stress‐response syndromes that occur after exposure to a distressing event.
Subtypes are the same (depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of emotions and conduct) 5
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
Defined as conditions involving problems with self‐control of emotions and behaviors that impact others
▪ aggression, destruction of property, conflict with society and authority figures, etc.
Kleptomania
Pyromania
Conduct Disorder

Oppositional Defiant Disorder
Intermittent Explosive Disorder
Three groups of symptoms
 Angry/Irritable Mood
 Argumentative/Defiant Behavior
 Vindictiveness


Guidance on duration, frequency, and intensity of behavior with regard to age, developmental level, gender, and culture
Severity Rating based on number of settings
▪ Mild=1, Moderate=2, Severe=3 or more
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
Primary Change:  Added verbal aggression or physical aggression that is nondestructive/noninjurious in nature

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Specific criteria defining frequency
Aggressive outbursts are impulsive or anger‐
based and not an effort to achieve a tangible objective, cause marked distress to the individual, relationships, or occupational functioning, etc.
Minimum age of 6 and (for ages 6‐18) not part of an adjustment disorder
Criteria are similar to DSM‐IV
 Aggression to People/Animals; Destruction of Property; Deceitfulness or Theft, Serious Violation of Rules 


Specify Whether: Childhood‐onset, Adolescent‐onset; Unspecified onset
Specify If: Limited Prosocial Emotion
Specify Severity: Mild, Moderate, Severe
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
Formerly known and loved as Disruptive Behavior Disorder NOS
 “Other specified disruptive, impulse‐control, and conduct disorder; recurrent behavioral outbursts of insufficient frequency”
Changes for the DSM‐5

Dependence and Abuse diagnostic categories have been collapsed (criteria are nearly identical)
 Substance Use Disorders
 Substance Induced Disorder
▪ Substance Intoxication and Withdrawal
 Substance/Medication‐Induced Mental Disorders
 Unspecified Substance‐Induced Disorders

DSM‐IV recurrent legal problems is replaced by craving/urge/strong desire to use a substance.
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
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Polysubstance Dependence is no more
Cannabis Withdrawal ,Caffeine Withdrawal, and Tobacco Use Disorder are new to DSM‐5
Gambling Disorder is also new
Specify Severity (for substance use disorder) based on number of symptom criteria endorsed
: Mild (2‐3) Moderate (4‐5), Severe (6+)
▪ Coding is based on severity

Specify : “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.”


Alcohol
Caffeine *
Cannabis
Hallucinogens ***

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


Stimulants
Tobacco**
Other(Unknown)
 Phencyclidine
 Other



Inhalants***
Opioids
Sedatives, Hypnotics or anxiolytics
* No Substance Use Disorder
** No Substance Intoxication
*** No Substance Withdrawal
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
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No more Axis‐II
The Debate: Categorical versus Dimensional
An Alternative model was developed for the DSM‐5, considered for inclusion, and then included in Section III for further study.
 Wanting to destigmatize personality disorders and view them as treatable

The criteria for personality disorders has not changed from DSM‐IV

Criteria A: Level of Personality Functioning
 Disturbances in self and interpersonal functioning constitute the core of personality pathology. Self (Identity and Self‐Directions) and Interpersonal (Empathy and Intimacy)

Criterion B: Pathological Personality Traits
 Pathological personality traits are organized into broad domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism

Negative Affectivity (vs. Emotional stability)
 Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/shame, worry, anger) and their behavioral (e.g., self‐harm) and interpersonal (e.g., dependency) manifestations.

Detachment (vs. Extraversion)
 Avoidance of socio‐emotional experiences, including both withdrawal from interpersonal interactions, ranging from casual, daily interactions to friendships to intimate relationships, as well as restricted affective experience and expression, particularly limited hedonic capacity.
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
Antagonism (vs. Agreeableness)
 Behaviors that put the individual at odds with other people, including an exaggerated sense of self‐importance and a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both unawareness of others’ needs and feelings, and a readiness to use others in the service of self‐enhancement

Disinhibition (vs. Conscientiousness)
 Orientation toward immediate gratification, leading to impulsive behavior drive by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences.

Psychoticism (vs. Lucidity)
 Exhibiting a wide range of culturally incongruent odd, eccentric, or unusual behaviors and cognitions, including both process (e.g., perception, dissociation) and content (e.g., beliefs)

Criterion C and D: Pervasiveness and Stability
 Impairments in personality function and personality traits are relatively pervasive across a range of personal and social contexts.

Criterion E, F, and G: Alternative Explanations for Personality Pathology (Differential Diagnosis)
 On some occasions, what appears to be a personality disorder maybe better explained by another mental disorder, the effects of substance or medical condition, a normal developmental state, or sociocultural environment.
Relational Problems, Abuse, and Neglect
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Parent‐Child Relational Problem
Sibling Relational Problem
Upbringing Away From Parents
Child Affected by Parental Relationship Distress
Impaired functioning across domains
 Behavioral: Inadequate parental control, supervision, and involve with child, parental overprotection, excessive parental pressure, arguments that escalate to threats of physical violence, and avoidance without resolution of problems.
 Cognitive: Negative attributions of other’s intentions, hostility toward or scapegoating other, and unwarranted feelings of estrangement
 Affective: Feelings of sadness, apathy or anger about the other individual in the relationship
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Maltreatment by a family member or nonrelative
Suspected versus Confirmed
Initial or subsequent therapeutic visit
Personal History of Abuse (past history) in childhood
Perpetrator or Victim


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Child Physical Abuse
Child Sexual Abuse
Child Psychological Abuse
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 Examples include berating, disparaging, or humiliating the child; threatening the child; harming/abandoning (or indicating the alleged offender will harm/abandon) people or things that the child cares about; confining the child (tying to chair, binding, small enclosed area like a closet); egregious scapegoating of the child; coercing the child to inflict pain on himself/herself, and disciplining the child excessively through physical or nonphysical means

Educational Problems
 Problems with academic performance or underachievement (below what is expected given intellectual capacity), discord with teachers, school staff, other students, etc.

Phase of Life Problem
 Problems adjusting to life‐cycle transition (particular developmental phase)

Social Exclusion or Rejection
 Bullying, teasing, intimidation, being targeted for verbal abuse or humiliation, and purposefully excluded

Child or Adolescent Antisocial Behavior
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American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
American Psychiatric Association. DSM‐5. (2012) http://www.psychiatry.org/dsm5 American Psychiatric Association. Task Force Fact Sheet. (2012) http://www.psychiatry.org/dsm5 Duncan, G. (2013). Differential Diagnosis and the DSM‐5. Annual GCAD Summit Presentation
Zeanah, C. & Gleason, M. (2010). Reactive Attachment Disorder: A Review for DSM‐V. American Psychiatric Association.
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Kevin Fenstermacher, Ph.D.
Psychological Solutions
www.psychologicalsolutions.org
Email: [email protected]
Cell: 801‐201‐3139
Office: 435‐425‐2234
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Laura Brockbank, Ph.D.
Anxiety Disorders DSM‐IV
Anxiety Disorders
Trauma & Stressor Related Disorders
Obsessive‐Compulsive and Related Disorders
Separation Disorder
Selective Mutism
Acute Stress Disorder
Obsessive‐Compulsive Disorder Specific Phobia
Body Dysmorphia Disorder
Posttraumatic Stress Disorder
Social Anxiety Disorder (Social Phobia)
Trichotillomania (Hair‐Pulling Disorder)
Reactive Attachment Disorder
Panic Disorder
Hoarding Disorder
Panic Attack Specific
Excoriation (Skin‐Picking) Disorder
Disinhibited Social Engagement Disorder
Agoraphobia
Adjustment Disorders
Generalized Anxiety Disorder
Other Specified Trauma or Stressor Related Disorder
Substance/Medication‐Induced Anxiety Disorder
Unspecified Trauma or Stressor Related Disorder
Anxiety Disorder Due to Another Medical Condition
Separation Anxiety Disorder
Generalized Anxiety Disorder
Selective Mutism
Anxiety Disorders
Agoraphobia
Specific Phobia
Panic Disorder
Social Anxiety Disorder
Substance/Medication Induced Other Medical Condition
Other Specified Unspecified 1
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2
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3
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OCD
Body Dysmorphic Disorder
Obsessive Compulsive & Related Disorders
Hoarding Disorder
Trichotillomania
(Hair‐Pulling)
Excoriation Disorder
Substance/Medication‐Induced
Other Medical Condition
Other Specified
Unspecified
(Skin‐Picking)
4
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5
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Specify if:
With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.
Specify if:
“With good or fair insight”
“With fair insight”
“With absent insight or delusional beliefs” 6
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First episode, currently in acute episode
First episode, currently in partial remission
First episode, currently in full remission
Multiple episodes, currently in acute episode
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous or Unspecified
With Catatonia
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Full Manic +MDD
Now a Specifier
nearly every day /1 week
“with mixed features”
Manic +3/6 MDD Symptoms
MDD + 3/7 Manic Symptoms
Depressive Disorders
Major Depressive Disorder
Disruptive Mood Dysregulation
Disorder
Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric
Disorder
Substance/Medication Induced Other Medical Condition
Other Specified Unspecified 10
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11
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ODD
Anger‐guided disobedience and noncompliance to authority figures
Hostilely defiant behavior and vindictiveness
Often loses temper
Deliberately annoys others
Easily annoyed
Argumentative behavior
Rare mood symptoms
Duration 6 months
Can be diagnosed under age 5
One setting
Lower severity, chronicity and frequency of temper outbursts
Episodic irritability and mood issues
Changes in mood
Elevated and expansive
mood or grandiosity
Mania
Clear change from typical behavior
Low rates of occurrence prior to adolescence steady increase into early adulthood
(Mean age onset Bipolar I is 18)
Equal gender prevalence
DMDD
Chronic, persistent irritability without changes in mood
Extreme behavior problems with no mania
Recurrent temper outbursts
More common prior to adolescence
Predominately male
More likely to develop depression and anxiety disorders later in adulthood
Present for 12 or more months w/o 3 months w/o symptoms
Age of onset before age 10 (6‐18)
Two settings
DMDD can not be diagnosed if a child has experienced a full‐duration manic or hypomanic episode (irritability or euphoric), or lasting more than 1 day. Symptom threshold is higher for DMDD
If children meet criteria for both ODD and DMDD, only DMDD is given
Chronic, persistent irritability
Recurrent temper outbursts
Irritability without changes in mood
Extreme behavior dyscontrol with no mania
More common prior to adolescence
Predominately male
More likely to develop depression and anxiety disorders later in adulthood
Present for 12 or more months w/o 3 months w/0 symptoms
Age of onset before age 10 (6‐18)
DMDD can not be diagnosed if a child has experienced a full‐duration manic or hypomanic episode (irritability or euphoric) or lasting more than 1 day. 13
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Axis I: 296.90 Mood Disorder NOS
305.20 Alcohol Abuse
313.81 Oppositional Defiant Disorder
314.01 Attention Deficit Hyperactivity Disorder – Combined Type
995.5 Neglect of a Child, Victim V61.20 Parent‐Child Relational Problem V62.3 Academic Problems
Axis II: None
Axis III: Deferred to MD
Axis IV: Problems with primary support group, social environment,
difficulty in school, history of substance abuse, current placement in residential program. Axis V: Current GAF: 37
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Axis I: 296.33 Major Depressive Disorder, recurrent, moderate, without psychotic features
300.00 Anxiety Disorder NOS
305.20 Cannabis Abuse
312.9 Disruptive Behavior Disorder NOS
V61.20 Parent‐Child Relational Problem Axis II: Avoidant Personality Traits
Axis III: Mild Acne, Headaches, Asthma
Axis IV: Problems with primary support group, poor coping skills, difficulty in school, history of substance abuse, multiple hospitalizations, current placement in residential program Axis V: Current GAF: 39
Laura Brockbank, Ph.D.
Psychological Solutions, Inc.
7105 Highland Drive #304 Salt Lake City, UT 84121
Phone: 435‐425‐2234
Fax: 435‐425‐3635
Office 801‐483‐3068
[email protected]
http://www.psychiatry.org/dsm5
http://www.psychiatry.org/dsm5
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