Download Signs and Symptoms of Mental Illness

Jim Messina, Ph.D., CCMHC, NCC
Assistant Professor
Troy University, Tampa Bay Site
Objectives DSM-5 Workshop
Update status of new DSM-5
 Identify categories & changes in DSM-5
 Suggest impact of DSM-5 for Professional
Counselors
 Using DSM-5 for Improved Clinical
Assessment, Diagnosis and Treatment
Planning
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Websites on DSM-5
Official APA DSM-5 site: www.dsm5.org
 DSM-5 on: www.coping.us
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Timeline of DSM-5
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1999-2001 Development of Research Agenda
2002-2007 APA/WHO/NIMH DSM-5/ICD-11
Research Planning conferences
2006
Appointment of DSM-5 Taskforce
2007
Appointment of Workgroups
2007-2011 Literature Review and Data Re-analysis
2010-2011 1st phase Field Trials ended July 2011
2011-2012 2nd phase Field Trials began Fall 2011
July 2012
Final Draft of DSM-5 for APA review
May 2013
Publication Date of DSM-5
Revision Guidelines for DSM-5
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Recommendations to be grounded in empirical evidence
Any changes to the DSM-5 in the future must be made in
light of maintaining continuity with previous editions for
this reason the DSM-5 is not using Roman numeral V but
rather 5 since later editions or revision would be DSM-5.1,
DSM-5.2 etc.
There are no preset limitations on the number of changes
that may occur over time with the new DSM-5
The DSM-5 will continue to exist as a living, evolving
document that can be updated and reinterpreted over
time
Focus of DSM-5 Changes
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DSM-5 is striving to be more etiological-however disorders are
caused by a complex interaction of multiple factors and various
etiological factors can present with the same symptom pattern
The diagnostic groups have been reshuffled
There is a dimensional component to the categories to be further
researched and covered in Section III of the DSM-5
Emphasis was on developmental adjustment criteria
New disorders were considered and older disorders were to be
deleted
Special emphasis was made for Substance/Medication Induced
Disorders and specific classifications for them are listed for
Schizophrenia; Bipolar; Depressive, Anxiety, Obsessive
Compulsive; Sleep-Wake; Sexual Dysfunctions; and
Neurocognitive Disorders.
Definition of Mental Disorder
A mental disorder is a syndrome characterized by clinically significant
disturbance in an individual's cognition, emotion regulation, or behavior
that reflects a dysfunction in the psychological, biological, or
developmental processes underlying mental functioning. Mental
disorders are usually associated with significant distress or disability in
social, occupational, or other important activities. An expectable or
culturally approved response to a common stressor or loss, such as
death of a loved one, is not a mental disorder. Socially deviant behavior
(e.g., political, religious or sexual) and conflicts that are primarily
between the individual and society are not mental disorders unless the
deviance or conflict results from a dysfunction in the individual, as
described above.
(American Psychiatric Association (2013). Diagnostic and Statistical Manual of
Mental Disorders-Fifth Edition DSM-5. Arlington VA: Author, p. 20.)
Why identify a mental disorder
diagnosis?
The diagnosis of a mental disorder should have clinical utility:
 Helps to determine prognosis
 Helps in development of treatment plans
 Helps to give an indication of potential treatment outcomes
A diagnosis of a mental disorder is not equivalent to a need for treatment.
Need for treatment is a complex clinical decision that takes into
consideration:
 Symptom severity
 Symptom salience (presence of relevant symptom e.g., presence of
suicidal ideation)
 The client's distress (mental pain) associated with the symptom(s)
 Disability related to the client's symptoms, risks, and benefits of
available treatment
 Other factors such as mental symptoms complicating other illness
DSM-5 Diagnostic Categories
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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
Somatic Symptom and Related Disorders
Feeding and Eating Disorder
Elimination 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
Other Mental Disorders
Obvious Changes in DSM-5 (1)
The DSM-5 will discontinue the Multiaxial
Diagnosis, No more Axis I,II, III, IV & V-which
means that Personality Disorders will now
appear as diagnostic categories and there will
be no more GAF score or listing of psychosocial
stressor or contributing medical conditions
 The Multi-axial model will be replaced by
Dimensional component to diagnostic
categories
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Obvious Changes in DSM-5 (2)
Developmental adjustments will be added to criteria
 The goal has been to have the categories more sensitive to
gender and cultural differences
 Diagnostic codes will change from numeric to
alphanumeric e.g., Obsessive Compulsive Disorder will
change from 300.3 to F42
 Diagnostic codes will change from numeric ICD-9-CM
codes on September 30, 2014 to alphanumeric ICD-10-CM
codes on October 1, 2014 e.g., Obsessive Compulsive
Disorder will change from 300.3 to F42
 They have done away with the NOS labeling and replaced
it with Other Specified... or Unspecified
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What Replaces NOS?
NOS is replace by either:
Other specified disorder or Unspecified disorder type are to be
used if the diagnosis of a client is too uncertain because of:
1. Behaviors which are associated with a classification are seen but
there is uncertainty regarding the diagnostic category due to the fact
that
 The client presents some symptoms of the category but a complete
clinical impression is not clear
 The client responds to external stimuli with symptoms of psychosis,
schizophrenia etc. but does not present with a full range of the
symptoms need for a complete diagnosis
2. The client has been unwilling to provide information due to an
unwillingness to be with the clinician or angry about being brought in to
be seen or the there is too brief a period of time in which the client has
been seen or the clinician is untrained in the classification
Rules for use of Other Specific or Unspecified
This designation can last only six months and after that a specific
diagnostic category has to be determined for the diagnosis of the
client.
Principle Diagnosis
Principle Diagnosis is to be used when more than one diagnosis for an
individual is given in most cases as the main focus of attention or treatment:
 In an inpatient setting, the principle diagnosis is the condition established
to be chiefly responsible for the admission of the individual
 In an outpatient setting, the principle diagnosis is the condition
established as reason for visit responsible for care to be received
The principle diagnosis is often harder to identify when a
substance/medication related disorder is accompanied by a non-substancerelated diagnosis such as major depression since both may have contributed
equally to the need for admission or treatment.
 Principle diagnosis is listed first and the term "principle diagnosis" follows
the diagnosis name
 Remaining disorders are listed in order of focus of attention and
treatment
Provisional Diagnosis
Specifier "provisional" can be used when
there is strong presumption that the full
criteria will be met for a disorder but not
enough information is available for a firm
diagnosis. It must be recorded "provisional"
following the diagnosis given
Respect for Age, Gender & Culture in DSM-5
Each diagnostic definition, where appropriate
will incorporate:
1. Developmental symptom manifestation –
regarding the age of client
2. Gender specific disorders
3. Cultural sensitivity in regards to certain
behaviors
Specific Changes
Per Diagnostic Category
in DSM-5
Neurodevelopmental Disorders
1. Intellectual Disability (Intellectual Developmental Disorder) no longer
relies on IQ used as specifier because it is the adaptive functioning
that determines levels of support required.
 IQ measures are less valid in the lower end of the IQ range
 Still accepted that people with intellectual disability have scores
two standard deviations or more below the population mean,
including a margin for error which is generally +5 points. Thus on
tests with standard deviations of 15 and mean of 100 the score for
mild would involve 65-75 (70+5).
2. Asperger's Syndrome is lumped into Autism Spectrum since it is at
the milder end of the Spectrum
3. Childhood disintegrative disorder, Rett's disorder and Pervasive
developmental disorder not otherwise specified are also now
incorporated into the Autism Spectrum Disorder
4. Autism Spectrum Disorder is now characterized by deficits in two
domains:
1.
Deficits in social communication and social interaction
2.
Restricted repetitive patterns of verbal and nonverbal
communication.
Schizophrenia and Other Psychotic Disorders
1.Changes for Criteria A for Schizophrenia were made:
 1) elimination of the special attribution of bizarre delusions and
Schneiderian first-rank auditory hallucinations (two or more
voices conversing), leading to the requirement of at least two
Criterion A symptoms for any diagnosis of schizophrenia
 2) the addition of the requirement that at least one of the
Criterion A symptoms must be delusions, hallucinations, or
disorganized speech.
2. DSM-IV-TR subtypes of schizophrenia were eliminated
3. Schizoaffective disorder is reconceptualized as a longitudinal
rather than a cross sectional diagnosis and requires that a major
mood episode be present for a majority of the total disorder's
duration after Criterion A has been met
4. Schizotypal Personality Disorder is now listed in this category
Bipolar and related disorders
1. Bipolar is now a free standing category
2. Bipolar was taken out of the mood disorder
category
3. Diagnostic criteria now include both
changes in mood and changes in activity or
energy
Depressive Disorders
1. Dysthymia is now called Persistent
Depressive Disorder
2. Disruptive Mood Dysregulation
Disorder has been added for children up to
age 18 years who exhibit persistent
irritability and frequent episodes of extreme
behaviors
3. Premenstrual Dysphoric Disorder has
been added
Anxiety Disorders
1. No longer has PTSD in this category
2. No longer has OCD in this category
3. Social Phobia is now called Social Anxiety
Disorder
4. Panic Disorder and Agoraphobia are
unlinked and each now have their own separate
criteria
5. Separation anxiety disorder and selective
mutism are now classified as anxiety disorders
Obsessive-Compulsive and Related Disorders
1. OCD is now a stand alone category
2. Body Dysmorphic Disorder is now listed under
OCD
3. Hoarding has been added under the category of
OCD
3. Trichotillomania (Hair-Pulling Disorder) is listed
under OCD
4. Excoriation (Skin Picking Disorder) is listed under
OCD
Trauma and Stressor Related Disorders
1 Trauma related disorders are now a stand alone category
2. Reactive Attachment Disorder is now listed here
3. Disinhibited Social Engagement Disorder has been added
4. PTSD is listed here
5. PSTD in Preschool Children has been added
6. Acute Stress Disorder is listed here and requires qualifying
traumatic events as explicit as to whether they were
experienced directly, witnessed or experienced indirectly
7. Adjustment Disorders are now listed here and
conceptualize as a heterogeneous array of stress-response
syndromes that occur after exposure to a distressing
(traumatic or nontraumatic) event.
Dissociative Disorders
1. Dissociative Fugue has been removed from
this category and is now a specifier of
dissociative amnesia
2. Derealization is included in the name and
symptom structure of the former
depersonalization disorder to become:
Depersonalization/Derealization disorder.
Somatic Symptom Disorder
1. Replaced Somatiform Disorders category with this category
2. Somatization Disorder; Pain Disorder; Hypochondriasis and
undifferentiated somatoform disorder were eliminated
3. Complex Somatic Symptom Disorder was added
4. Simple Somatic Symptom Disorder was added
5. Illness Anxiety Disorder was added and replaces Hypochondriasis
6. Conversion Disorders (Functional Neurological Disorder) have
modified criteria to emphasize essential importance of neurological
examination, in recognition that relevant psychological factors may not
be demonstrable at time of diagnosis
7. Psychological factors affecting other medical conditions has been
added to this category and along with Factitious disorder both have
been placed among the somatic symptom and related
disorders because somatic symptoms are predominant in both
disorders
Feeding and Eating Disorders
1. Pica was moved to this category
2. Rumination Disorder was moved to this
category
3. The "feeding disorder of infancy or early
childhood” has been renamed:
Avoidant/Restrictive Food Intake Disorder
4. Binge Eating Disorder was added
Elimination Disorders
1. This category was created as
freestanding category
2. Enuresis was moved to this category
3. Encopresis was move to this category
Sleep-Wake Disorders
1. Primary Insomnia renamed Insomnia Disorder
2. Primary Hypersomnia joined with Narcolepsy
without Cataplexy
3. Cheyne-Stokes Breathing added
4. Obstructive Sleep Apnea Hypopnea added
5. Idiopathic Central Sleep Apnea added
6. Congenital Central Alveolar Hypoventilation added
7. Rapid Eye Movement Behavior Disorder added
8. Restless Leg Syndrome added
Sexual Dysfunctions
1. Male orgasmic disorder renamed Delayed Ejaculation
2. Premature (Early) Ejaculation renamed
3. Dyspareunia and Vaginismus were combined into
Genito-Pelvic Pain/Penetration Disorder
4. Sexual Aversion Disorder combined in other
categories
5. For females-sexual desire and arousal disorders have
been combined into one disorder: Female sexual
interest/arousal disorder
Gender Dysphoria
1 This is a new diagnostic class
2. It emphasizes the phenomenon of "gender
incongruence" rather than cross-gender
identification per se.
3. Posttransition specifier has been added to
identify individuals who have undergone at
least one medical procedure or treatment to
support new gender assignment
Disruptive, Impulse Control, and
Conduct Disorders
1. This is a new diagnostic class and combines
"Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence" and the "Impulsecontrol Disorders Not Elsewhere Classified"
2. Oppositional Defiant Disorder was added here
3. Trichotillomania removed from this category
4. Conduct Disorder now in this freestanding
category
5. Antisocial Personality Disorder added to this
category as well as in Personality Disorders
Category
Substance Abuse and Addictive Disorders
Only 3 qualifiers are used in the category:
1. Use - replaces both abuse and dependence
2. Intoxication and Withdrawal remain the same
2. Nicotine Related renamed Tobacco Use Disorder
3. Caffeine Withdrawal added
4. Cannabis Withdrawal added
5. Polysubstance Abuse categories discontinued
6. Gambling added to this category
Neurocognitive Disorders
1. Category replaces “Delirium, Dementia, and Amnestic and
Other Cognitive Disorders” Category
2. Now distinguishes between Minor and Major Disorders
3. Replace wording of Dementia "due to" with Neurocognitive
Disorder "Associated with" for all the conditions listed
4. Added new Neurocognitive Disorders:
1. Fronto-Temporal Lobar Degeneration
2. Traumatic Brain Injury
3. Lewy Body Disease
5. Renamed Head Trauma to Traumatic Brain Injury
6. Renamed Creutzfeldt-Jakob Disease to Prion Disease
Personality Disorders
Cluster A Personality Disorders
 301.0 (F60.0) Paranoid Personality Disorder
 301.20 (F60.1) Schizoid Personality Disorder
 301.22 (F21) Schizotypal Personality Disorder
Cluster B Personality Disorders
 301.7 (F60.2) Antisocial Personality Disorder
 301.83 (F60.3) Borderline Personality Disorder
 301.50 (F60.4) Histrionic Personality Disorder
 301.81 (F60.81) Narcissistic Personality Disorder
Cluster C Personality Disorders
 301.82 (F60.6) Avoidant Personality Disorder
 301.6 (F60.7) Dependent Personality Disorder
 301.4 (F60.5) Obsessive-Compulsive Personality Disorder
Other Personality Disorders
 310.1 (F07.0) Personality Change Due to Another Medical Condition Specify
whether Labile type; Disinhibited Type; Aggressive Type; Apathetic Type;
Paranoid Type; Other Type; Combined Type; Unspecified Type
 301.89 (F60.89) Other Specified Personality Disorder
 301.9 (F60.9) Unspecified Personality Disorder
Paraphilic Disorders
1. They all carried over to DSM-5
2. New names for them all but the category remains the
same
3. Overarching change is the addition of course specifiers
 in a controlled environment
 in remission
4. Distinction between paraphilias and paraphilic disorder
was made:
 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.
 Paraphilia is a necessary but not a sufficient condition for
having a paraphilic disorder, and a paraphilia by itself does not
automatically justify or require clinical intervention
Conditions Designated for Further
Study in DSM-5 in Section III
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Attenuated Psychosis Syndrome
Depressive Episodes with Short-Duration
Hypomania
Persistent Complex Bereavement Disorder
Caffeine Use Disorder
Internet Gaming Disorder
Neurobehavioral Disorder Associated with
Prenatal Alcohol Exposure
Suicidal Behavior Disorder
Nonsuicidal Self-Injury
Possible Disorders Discussed But Not
Included in Section III of DSM-5
Dissociative Trance Disorder
 Anxious Depression
 Factitious disorder imposed on another
 Hypersexual Disorder
 Olfactory Reference Syndrome
 Paraphilic Coercive Disorder
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Other Conditions That May Be a Focus of
Clinical Attention (V Codes and TZ Codes)
Relational Problems
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Problems Related to Family Upbringing
Other Problems Related to Primary Support Group
Abuse and Neglect
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Child Maltreatment and Neglect Problems
 Child Physical Abuse; Child Sexual Abuse Child Neglect Child
Psychological Abuse
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Adult Maltreatment and Neglect Problems
 Spouse or Partner Violence, Physical; Spouse or Partner Violence,
Sexual; Spouse or Partner Neglect; Spouse or Partner Abuse,
Psychological; Adult Abuse by Nonspouse or Nonpartner; Adult Sexual
abuse by nonspouse or nonpartner; Adult Psychological abuse by
nonspouse or nonpartner
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Other Conditions That May Be a Focus of Clinical
Attention Continued:
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Educational and Occupational Problems
Housing and Economic Problems
Other Problems Related to Social Environment
Problems Related to Crime or Interaction with Legal
System
Other Health Services Encounters for Counseling and
Medical Advice
Problems Related to Other Psychosocial, Persons and
Environmental Circumstances
Other Circumstance of Personal History
Problems Related to Access to Medical and Other Health
Care
Nonadherence to Medical Treatment
Steps to formulate an initial tentative
diagnosis
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Do a thorough Psychosocial History
Do a Mental Status Examination
Develop a Diagnosis using DSM-5
STEP 1:
Complete Psychosocial
History
First: Establish - WHY NOW?
You must be able to describe the presenting
problem
 Listing specific symptoms and complaints
which would justify diagnosis
 You must be able to list the duration of the
symptoms or at least estimate the duration
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Second: Review client’s mental
health history
Previous treatment for mental health
problems?
 Hospitalization for psychiatric conditions?
 As child involved in family therapy?
 Treatment for substance abuse problemsoutpatient or inpatient?
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Third: Determine if client is on
any psychotropic medications
What medications?
 Level of prescription?
 Who prescribed medications?
 For what are the medications
prescribed?
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Fourth: Review client’s relevant
medical history
What is current overall physical health of client?
 When was last physical?
 Is there anything currently or in the past
medically accounting for this current mental
health complaint?
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Fifth: Review client’s family history
Do a genogram of the family
 Identify psychosocial stressors within the
family structure
 Mental health and/or substance abuse
history with in the family and if
successfully treated
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Sixth: Review client’s social history
School history: Failed grades? Academic
success? Social interaction with peers?
Highest academic level attained?
 Community history: Peer group? Current
network of social support? Activities and
interests: sports, hobbies, social functioning?
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Seventh: Review client’s
vocational history
Level of current employment and commitment
to current job?
 Relevant past employment history: length of
tenure on past jobs, job hopping, relationships
with work peers?
 Level of satisfaction with current employment?
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Eighth: List client’s strengths
Identify those strengths which make the client
a good candidate for successful therapy to
address the “here and now” mental health
problem
 How motivated for therapy is client?
 How insightful to symptoms?
 How psychologically minded is client?
 How verbal and intelligent?
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Ninth: List liabilities client brings
to therapy
Level of present social support system?
 Mandated for freely coming to therapy?
 Perceptual problems which could interfere
e.g. hearing, vision, etc.
 Risk of decompensating (relapsing) if not
treated
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Tenth: Rate Client on ACE Scale
Identify Relevant ACE (Adverse Childhood Experiences)
Abuse
1. Emotional Abuse
2. Physical Abuse
3. Sexual Abuse
Neglect
4. Emotional Neglect
5. Physical Neglect
Household Dysfunction
6. Mother was treated violently
7. Household substance abuse
8. Household mental illness
9. Parental separation or divorce
10. Incarcerated household member
Step 2:
Mental Status Examination
Mental Health Status Exam
Mental Health Status Exam Rates Client’s:
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Appearance
Consciousness
Orientation to person,
place & time
Speech
Affect
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Mood
Concentration
Activity level
Thoughts
Memory
Judgment
Step 3:
Formulate Tentative Diagnosis
Formulate Tentative Diagnosis
You are ready to make a tentative
Diagnosis using DSM-5 Including:
1. Principle Diagnoses
2. Any Provisional Diagnosis
3. Any relevant Other Conditions That May Be a
Focus of Clinical Attention
DSM-5 Single Diagnosis
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Use DSM-5 Most Appropriate Classification
Include relevant rule-out diagnoses
Compare client’s symptoms lists with those
contained in DSM-5 to get to most appropriate
tentative Principle diagnosis
Then list any and all secondary diagnosis if the
client’s symptoms match up for such classifications
Also list Provisional diagnoses if the client’s
presentation allows for these additional diagnoses
List all relevant V (T,Z) Code Conditions
Each must be listed with number & description just
like the principal diagnosis
It is important to remember
The Diagnosis given a client is tentative
dependent on gathering more data in future
anticipated treatment
 Diagnoses can ALWAYS be changed to
address changes with the individual’s
presentation & functioning
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