Download DSM-IV-TR in Action Powerpoint

Sophia F. Dziegielewski, Ph.D., LISW
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Identify the diversity, necessity, and limitations for usage of the
DSM-IV-TR in the practice environment.
List specific changes between the DSM-III-R, DSM-IV, and DSM-IVTR.
Utilize the multi-axis diagnostic system with children, adolescents,
and adults.
Acquire familiarity with the major diagnostic categories and the
criteria for proper diagnostic assessments and evaluations.
Acquire several different practice strategies currently being used to
address the diagnostic categories provided.
Identify the DSM disorders as viewed within the context of the DSMIV Text Revisions published in 2000 and expected changes for DSM5.
Identify criteria through case applications within the multi-axis
diagnostic system with children, adolescents, and adults.
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The DSM-IV-TR (2000) replaced the DSM-IV
and the DSM-III-R with coding changes
remaining the same since January 1995.
Next edition scheduled for May 2013.
Use of the DSM is recommended for trained
professionals.
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Cultural Issues and Cultural-bound
Syndromes
Research and Clinical Field Trials
Clinical Findings and Supportive
Information
DSM-5 expected publication 2013
Culture-bound Syndromes: these conditions
resemble the symptoms of a mental
disorder but are related directly to the
cultural context as relevant to clinical care
brain fag
ataque de nervios
rootwork
Research Changes:
(1)
(2)
(3)
literature reviews
data analysis and re-analysis
field trials
DSM-IV-TR clearly reflects the importance
of research to differentiate the diagnostic
categories.
Research Changes:
DSM-5
“Still Very Much a Work in Progress”
For a short-time period (till April 20, 2010) the
proposed criteria were available for public
comment: http://www.dsm5.org
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13 Work groups in process
Task force of 27 members is
overseeing the process
Overview of Suggested Changes for DSM-5
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Possibly eliminate Axis I, II, and III
Use a dimensional system where various
disorders will be coded as mild, moderate, and
severe
Introduce new suicide assessment scales, one for
adolescents and one for adults
Several new disorders proposed and some name
changes to existing disorders
Personality disorders will be completely
restructured
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Appendix for Behavioral Addictions
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Gambling (thus far is the sole disorder)
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Internet Addiction (is being considered)
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Introducing a new section on suicide scales to
help assess adults and adolescents
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New “risk syndromes” category designed
to help clinicians identify stages of some
serious mental health disorders with
scales that include research-based criteria
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Diagnosis Deferred: information is
inadequate to make a formal
diagnostic judgment.
Rule Out
Axis I
Axis II
Axis III
Axis IV
Axis V
DSM-IV-TR: Pervasive Developmental Disorders,
Learning Disorders, Motor Skills Disorders,
Communication Disorders, and Other Conditions that
may be Focus of Clinical Attention
Generally, all clinical syndromes are coded here (e.g.,
Mood Disorders, Schizophrenia, Dementia, Anxiety
Disorders, Substance Disorders, Disruptive Behavior
Disorders, etc.) and all other codes that are not
attributed to a mental disorder but are the focus of
treatment (e.g., V codes).
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Academic Problem: underachievers
Childhood or Adolescent Antisocial Behavior: isolated acts
Adult Antisocial Behavior: e.g., professional thieves, dealers
Borderline Intellectual Functioning: IQ between 71 and 84
Malingering: voluntary mental or exaggerated physical
symptoms, with an obvious recognizable goal
Bereavement
Medication-induced Movement Disorders:
 Neuroleptic Malignant Syndrome and Tardive Dyskinesia
 Acculturation Problem: exposure to living in a new culture
 Aging Associated Cognitive Decline: normal aging causes
stress or impairment
Personality Disorders
Mental Retardation
General Medical Conditions
• Hearing Impairment
• Vision Impairment
• Mixing Medical and Mental
Physical (medical) conditions relevant to the
condition being treated are listed here.
DSM-IV-TR: Psychosocial and Environmental
Problems/Stressors
The stressors can be clarified with specifics:
• problems with primary support
• problems related to social environment
• educational problems
• occupational problems
• housing problems
• economic problems
• problems with access to health care services
• problems related to interaction with the legal system and other
psychosocial problems
Global Assessment of Functioning (GAF)
GAF is a scale of 100 points
• The higher the number the higher the level of functioning
• The GAF still covers both symptomology and level of
functioning.
• The highest level of functioning is determined and rated.
• CGAF and FARS are two assessment measures used with
children to supplement the DSM
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Mental Retardation (will probably change to
Intellectual Disability)
Pervasive Mental Disorders (will probably
change to Autism Spectrum Disorders)
Conduct and Oppositional Defiant Disorder
Elimination Disorders
ADHD
The majority of Mental Health Professionals agree:
 that diagnosing in children is a difficult and
delicate task
 that any professional other than a specialist trained
in the area should not diagnosis
 that the younger the child the more difficult the
task
 many children are taking medications and over 80%
of the WORLD’S supply of Ritalin (for ADHD) is
given in the United States
 Exercise, diet, and sleep
IQ 71-84, Code on Axis II.
If present, always diagnose it.
Must have significantly sub-average
intelligence and deficits in adaptive functioning.
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Adaptive functioning means how individuals
cope with life demands and meet expectations
of activities of daily living.
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Definition is compatible with AAMR definition
except for sub-typing.
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Onset prior to age 18—if after it is Dementia.
Must have IQ of 70 or below on an individual IQ
test (5 point error margin).
This disorder is slightly more common in males.
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MILD:
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MODERATE:
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SEVERE:
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PROFOUND:
IQ approximately (50-55) 55 to 70, considered educable,
able to perform at 6th grade level, can use minimal assistance may
need some supervision and guidance, live in community or in
supervised settings
IQ approximately (35-40) 35 to 55 (50-55),
considered trainable, able to perform at 2nd grade level, with
moderate supervision can attend to their own personal care, can
perform unskilled or semi-skilled work, can live in the community
IQ approximately (20-25) 20 to 35, (35-40) generally
institutionalized, have little or no communicative speech, possible
group home
IQ below 20, generally total care
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Involve multiple functions and behaviors that
are not considered normal at any age.
Qualitative impairment in: reciprocal
interaction, verbal and nonverbal skills,
imaginative activity, and intellectual skills.
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Severe form, onset in infancy or childhood, self-stimulating,
and self-injuring behaviors often present, (i.e., rocking,
spinning, head banging)
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2/3 of Autistic are mentally retarded/moderate range
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Facilitative communication is used
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NO PROOF THAT CONDITION IS RELATED TO PARENTING
STYLES
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Age of onset requirement in DSM-IV is age 3
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Rett’s Disorder
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Childhood Disintegrative Disorder
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Asperger's Disorder
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Only in females
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Deceleration of head growth, start out normal and 5 to 24
months problems develop
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Loss of previously acquired hand skills, loss of social
engagement, appearance of stereotyped movements,
impaired language functioning Generally associated with
severe or profound mental retardation
DSM-IV-TR highlights now that many of these cases are
related to a specific genetic mutation
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Normal development for two years then a
drastic decline
Followed by a loss of previously acquired
skills and development of autistic like
symptoms
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Autistic-like symptoms without language
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Severely impaired social interaction
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impairment
DSM-IV-TR Since this is a new category
major revisions have been made to this
section
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Asperger’s
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Autism
DSM-5
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Will suggest new categories for the learning
disorders and create a category called Autism
Spectrum Disorders, will incorporate aspects
of all the current disorders.
ASD will be categorized as mild, moderate,
and severe
Groups in opposition have already been
formed.
Learning Disabilities: These disorders have significant difficulties in
acquisition of listening, speaking, reading, writing, reasoning, and
math.
•Significant delay in skill level (2 standard deviations below
the mean)
•Generally noted between ages of 8 and 13
•More common in boys than girls
•Kids don't always catch up—continues into adulthood
•Involve specific functions—not multiple like pervasive—the
behavior is characteristic of an earlier state of development
Social Work Treatment: Generally behavioral in nature
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4.
Symptoms now in grouped in four categories:
Aggression to people and animals
Destruction of property
Deceitfulness or theft
Serious violations of rules
Two items were added to increase applicability
to females:
1.
Staying out at night
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Intimidating others
New subtypes based on age of onset
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Childhood onset and adolescent onset
Onset before age 10 has a poor prognosis
When 18 used to be diagnosed anti-social
but now can remain into early 20s because
not all conduct disorders become antisocials
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Based on research deleted from the criteria "uses
obscene language."
Also increased clarification on clearly establishing
the deviation from what could be considered
normal.
DSM-IV-TR clarifies that many children with
Oppositional Disorder do not develop conduct
disorder.
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Do not meet the full criteria for conduct or
oppositional disorder but have clinically
significant impairment
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Severe mood dysregulation
Helps to distinguish children who have
recurrent behavioral outbursts (severe and
inappropriate)
Helps adolescents from bipolar and severe
mood dysregulation, irritability, and
behavior outbursts
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Diagnosis explosion of bipolar in children
since 1994
Severe irritability and handling behavior
outbursts that could be
considered/confused with mania
Outbursts need to be severe and
developmentally inappropriate
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ADHD—TDDD is more aggressive
Bipolar—TDDD more continuous and not
cyclic
Disruptive Behavior Disorder—mood is
more labile
ALWAYS GET A PHYSICAL FIRST
NOT DUE TO A PHYSICAL or MEDICAL DISORDER
Enuresis:
 Elimination of urine during day or night
 Must be age 5 before it can be diagnosed
 Remember that a diagnosis can be made before thresholds
are met, if clinical significance can be established
Encopresis:
 Repeated elimination of feces in inappropriate places
 One time a month for 3 months (used to be 6 months)
 Must be at least four years of age to diagnose
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Must last at least six months
Predominately inattentive, hyperactivityimpulsivity
Combined symptoms required in two or
more situations: home, work, or at school
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Can occur in adulthood but must have
onset in childhood (generally before age 7)
Not intellectual deficits just attention and
concentration
Etiology: unknown, hereditary link, tends to
run in families, more common in males
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Will make it easier to diagnose ADHD in
adults
Number of symptoms will be reduced from
six to three
In adults will no longer have to have
symptoms before the age of 7 will probably
change to 12 years old
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Evaluate by a neurologist or physician
(medical check)
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Exercise, sleep habits, and diet
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Medication
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Short-acting
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Long-acting
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Non-stimulant
It is compelling to think about changing to a
new long-acting medication because of the
convenience of once-a-day dosing and their
long lasting effects, but it is important to
remember that they shouldn't be any more
effective than a short-acting medicine.
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Ritalin (Methylphenidate HCl)
Methylin Chewable Tablet and Oral Solution
Metadate ER
Methylin ER
Focalin
Dexedrine (Dextroamphetamine sulfate)
Dextrostat
Adderall
Adderall (generic)
Dexedrine Spansules
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Ritalin, Metadate (age 6 and older)
Ritalin-SR (Methylphenidate) (age 6 and older)
Concerta (Methylphenidate Extended Release) (age 6 and
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Adderall (Dextroamphetamine and Amphetamine) (age 3
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older)
and older)
Desoxyn (Methamphetamine)
Provigil (Modafanil)
Cylert* (Pemoline) (age 6 and older)
*because of potential for serious side effects to the liver,
not usually used as a first line for ADHD
Focalin (dexmethlphenidate) (age 6 and older)
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The long-acting stimulants generally have a
duration of 8-12 hours and can be used just
once a day.
They are especially useful for children who
are unable or unwilling to take a dose at
school.
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The latest medication to get approval to
treat ADHD is Vyvanse, a long-acting
stimulant.
This stimulant is similar to Adderall with a
main ingredient of lisdexamfetamine
dimesylate, a derivative of one of the
ingredients in Adderall.
Initially available in 30mg, 50mg, and 70mg
capsules, newer 20mg, 40mg, and 60mg
capsules.
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This is a methyphenidate or Ritalin patch.
The patch is available in 10mg, 15mg, 20mg,
and 30mg dosages.
Patch can be worn for about nine hours at a
time on a child's hip.
The medication works for a few more hours
once you take the patch off.
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Approved for use in children over the age of six
years, although regular Adderall can be used in
younger children from 3-5 years of age.
Adderall XR is a sustained release form of Adderall,
a popular stimulant which contains
dextroamphetamine and amphetamine.
Available as a 10mg, 15mg, 20mg, 25mg, and
30mg capsule.
The capsule can be opened and sprinkled onto
applesauce if your child can't swallow a pill.
When medication alone is not enough consider:
(A) Is there an accurate diagnosis?
(B) Help families deal with the child at home (e.g., parenting
styles reinforce negative behaviors).
(C) Help teachers deal with child at school (e.g., sit in least
distracting section of the class, away from the door).
(D) May need academic "catch up" help (e.g., computers are an
excellent tool for these children).
(E) Allow these children "more time" to complete tasks.
(F) Address self-esteem issues in counseling.
Impulsive type:
-Often in trouble at school
Inattentive Type:
-Poor grades in school
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PICA
Anorexia Nervosa: intense fear of gaining weight, usually
underweight, disturbance in body image, won’t eat, overexercise, often have amenorrhea, refusal to maintain
minimum normal body weight, resistance to treatment with
strong denial, onset during late adolescence (12-18) and
can go into 30s, individuals can die from starvation, 1/2
anorectics are bulimics, common co-conditions: substance
abuse and depression
Bulimia Nervosa: episodes of binge eating (recurring), selfinduced vomiting with laxatives, diuretics or fasting, sense
of lack of control during eating binges, chronic concern
with body weight and shape, two binges per week for three
months
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Substance Abuse: viewed as less severe, continued use,
knowing it is causing harm, does not apply to caffeine and
nicotine
Substance Dependence: taking larger amounts with
unsuccessful attempts to quit
Substance Intoxication: the development of a substance
specific (reversible) syndrome, condition related to recent
ingestion of psychoactive substance
Substance Withdrawal: follows termination of a psychoactive
substance (Abstinence Syndrome)
Types of Substances Include: alcohol, amphetamines, cocaine,
caffeine, hallucinogens, inhalants, nicotine, opioids,
phencyclidine (PCP), cannabis, and sedatives-hypnoticsanxiolytics
Polysubstance Dependence: the criteria for abuse or
dependence for any one substance is not met, the client abuses
more than one substance and groups them together
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Will eliminate substance abuse and dependence
and replace it with a new category “addiction and
the related disorders.”
Will include substance use disorders with each drug
identified in its own category.
Eliminate the category of dependence, will help to
differentiate between those that are drug seeking
and those that have developed tolerance (from
withdrawal).
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Each drug will have its own category
A new category of behavioral addictions will
be added (behavioral addictions, only one so
far and internet addiction is mentioned in the
appendix)
Discontinuation syndromes: related to TCA’s
and the SSRI’s
When NOT working in the area of substance
use/abuse a social worker should never counsel a
client actively using and influenced by a substance.
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The client needs to be referred for detoxification,
or rescheduled when not under the influence.
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Twelve months is required for a client to achieve
sustained remission.
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In the DSM-IV-TR all substance related
conditions are now grouped in one category
and in DSM-IV-TR much clarification was
used to outline the different areas and
substances.
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Be sure the relationship between dependence
and withdrawal is noted
Almost always when dependence is an issue
treat the substance first
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This section brings together three sections listed separately
in DSM-III-R Schizophrenia, Delusional Disorder, and
Psychotic Disorder: Not Elsewhere Classified.
Active phase has been increased from one week to one
month. Now also includes two new negative symptoms: alogia
(i.e., fluency and productivity of speech) and volition (i.e.,
goal directed behavior and drive).
DSM-IV-TR subtypes not clearly supported in research.
Added concept of SCHIZOPHRENIA SPECTRUM: represents the
range of disorders that are more likely to occur in family
members of individuals with schizophrenia (Schizoaffective
Disorder, Schizotypal Personality Disorder, etc.).
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Hallucinations
Delusions
Associative Disturbances
Affect and Mood
Alogia
Avolition
Ambivalence
Autism
Brief Reactive Psychosis: 3-day-schizophrenia, symptoms have
existed no longer than a month (at least a few hours) sudden onset
**no longer must have direct link to a severe psychosocial stressor
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Schizophreniform Disorder: less than six months
Schizoaffective Disorder: mood disorder and schizophrenia. Now it
focuses on an uninterrupted phase of illness rather than a lifetime
pattern of symptoms. In this disorder the schizophrenia is described
with periods of major depressive, manic, or mixed episodes
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Shared Psychotic Disorder/Induced Psychotic Disorder: Folie a Deux,
a delusion develops in one related to the delusional belief of another
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Substance Induced Psychotic Disorder: includes both organic
delusional disorder and organic hallucinosis
Possibly add new diagnosis
Psychosis Risk Syndrome
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Delusions, hallucinations, and disorganized
speech-but not an intense as in a psychotic
episode
Occur once per week and appear to worsen
Symptoms cause distress or disability
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Subtype categories will be eliminated
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Chlorpromazine (Thorazine) (introduced in the
1950s)
Thioridazine (Mellaril) (age 2 and older)
Trifluoperazine (Stelazine)
Phenazine (Prolixin)
Haloperidol (Haldol) (age 3 and older)
Loxapine (Loxitane)
Thiothixene (Navane)
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Clozaril (Clozapine) (Introduced again in 1990)
(age 18 and older)
Risperdal (Risperidone) (age 18 and older)
Zyprexa (Olanzapine) (age 18 and older)
Seroquel (Quetiapine) (age 18 and older)
Geodon (Ziprasidone)
Abilify (Aripiprazole)—Schizophrenia,
Alzheimer's, psychosis
Orap (Pimozide) (age 12 and older for
Tourette’s) (side effects: weight gain and
diabetes)
*Brand names listed first.
Parkinsonian or Extra-Pyramidal (EPS) Side Effects
include:
 Dystonia—Acute contractions of the tongue (stiff or
thick tongue)
 Akathisia—Most common form of EPS (e.g., inner
restlessness)
 Tardive Dyskinesia—This is a permanent neurological
condition that can result from using the older
antipsychotic medications and not taking anything to
help control the EPS side effects
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Combines active ingredients of two well-known brand
medications—Prozac and Zyprexa.
As of 2006, approved for treatment resistant
depression.
Prior to this, used for symptoms of schizophrenia and
the down-phase of bipolar disorder.
Since NEW use, monitor/report resultant side effects.
Combines both drugs and has same types of warning
and concerns for both drugs. For example, Symbyak is
not approved for use with elderly individuals that suffer
from dementia similar to Zyprexa (NIMH, 2009).
Major Depressive Episode:
 loss of interest and pleasure for at least 2 weeks
Manic Episode:
 elevated an expansive mood for at least 1 week
Mixed Episode:
 alternating moods that last at least 1 week, must
meet criteria for both manic and depressive almost
daily
Hypomanic Episode:
 expansive, irritable, and elevated mood that lasts
at least 4 days
Bipolar
I
Bipolar II
Cyclothymia
(We expect major changes in this criteria with
regard to children in DSM-5)
Major
Depressive Disorder
Dysthymia (different criteria for children)
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Bipolar I Disorder: one or more manic episodes,
usually with a history of depressive episodes (can
have psychotic aspects)
Bipolar II Disorder: one or more depressive with at
least one hypomanic episode, no psychosis
Cyclothymic Disorder: persistent mood
disturbance lasting at least two years, must not be
without for two months, less severity than bipolar
Bipolar Disorder NOS
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Major Depressive Disorder: one or more
major depressive episodes, episodes must
last at least two weeks
Dysthymia: two-year history of depressed
mood, must not be without for two months,
less severity than major depression,
constant for a period of two years (children
one year agitated depression)
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More information on co-morbidity of alcohol and
substance abuse (Bipolar Disorders)
Major Depressive Disorder: now the symptoms
must last two months after loss of a loved one
(used to be two weeks) tried to separate from
condition called Bereavement.
Dysthymia—in DSM-IV-TR—outcome is better with
active treatment
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New diagnosis proposed: mixed anxiety
depression.
Each mood disorder diagnosis is
accompanied by some type of anxiety
dimension.
A rating of anxiety should be included from 0
(no anxiety) to 4 (severely anxious with 5
symptoms and motor agitation).
Tricyclics (TCA): Examples of TCAs include:
• Tofranil (generic name Imipramine)
• Elavil/Amitriptyline
MAO Inhibitors: Many dietary restrictions, no foods with the chemical
tyramine (e.g., cheese, beef or chicken liver, pickled herring, red wine,
chocolate, coffee, raisins, pineapple, bananas)
• Eldepryl (Selegiline)
Other Anti-Depressants: Selective Serotonin Re-uptake Inhibitors (SSRIs).
• Prozac/Fluoxetine
• Paxil/Paroxetine hydrochloride
• Zoloft
Side effect of the SSRIs: sexual disinterest and ORGASMIC DELAY
In 2004, the FDA ordered the strongest safety
warning possible:
Antidepressants increase the risk of suicidal
thinking and behavior (suicidality) in children and
adolescents with major depressive disorder (MDD)
and other psychiatric disorders. Anyone
considering the use of [Drug Name] or any other
antidepressant in a child or adolescent must
balance this risk with the clinical need. (Prozac is
the exception.)
In 2006 added “young adults.”
Anafranil (clomipramine)
Asendin (amoxapine)
Aventyl (nortriptyline)
Celexa (citalopram hydrobromide)
Cymbalta (duloxetine)
Desyrel (trazodone HCl)
Effexor (venlafaxine HCl)
Elavil (amitriptyline)
Etrafon (perphenazine/amitriptyline)
Fluvoxamine maleate
Lexapro (escitalopram hydrobromide)
Limbitrol (chlordiazepoxide/amitriptyline)
Ludiomil (maprotiline)
Marplan (isocarboxazid)
Nardil (phenelzine sulfate)
Norpramin (desipramine HCl)
Pamelor (nortriptyline)
Parnate (tranylcypromine sulfate)
Paxil (paroxetine HCl)
Pexeva (paroxetine mesylate)
Prozac (fluoxetine HCl)
Remeron (mirtazapine)
Sarafem (fluoxetine HCl)
Serzone (nefazodone HCl)
Sinequan (doxepin)
Surmontil (trimipramine)
Symbyax (olanzapine/fluoxetine)
Tofranil (imipramine)
Tofranil-PM (imipramine pamoate)
Triavil (perphenazine/amitriptyline)
Vivactil (protriptyline)
Wellbutrin (bupropion HCl)
Zoloft (sertraline HCl)
Zyban (bupropion HCl)
No Harm No Risk Agreements
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Complete a comprehensive safety plan with
clear documentation.
No Harm-No Risk Agreements as Standard of
Practice
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I will not harm myself or someone else, if I
feel as though I could harm myself or
someone else I will immediately go to the
nearest emergency room at _________.
Have family member acknowledge and
document acknowledgement.
If children at risk call CPS.
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Suicide risk scale takes into account 7 risk factor groups, add
them together for risk level (1-no concern to 4; 5-7 items
with high concern)
Risk Factors: history of suicide attempt, tendency to lose
temper with little provocation, living alone, chronic severe
pain, recent significant loss, recent psychiatric hospital
admission/discharge, 1st dx of major depression, bipolar or
schizophrenia, recent alcohol abuse or worsening of
depression, current preoccupation of plans for suicide,
current psychomotor agitation, feelings of anxiety and
hopelessness
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DSM-IV-TR information on relative co-morbidity &
associated features added
DSM-5: Major changes to this section.
 A grouping of these disorders will be termed
Obsessive-Compulsive Spectrum Disorders
 Delete Agoraphobia without history of panic
disorder
 Numerous clarifications and changes to almost all
diagnoses in this category
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Social Phobia: now includes avoidant disorder
of childhood.
Specific Phobia was called Simple Phobia:
must now have marked excessive or
unreasonable fear. Based on research, now
added sub-types.
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Obsessive-Compulsive Disorder: the
definition between the obsession and
compulsion has been clarified, the obsession
causes distress and the compulsion is a way
to try to handle it.
New Name:
Anxiety and Obsessive-Compulsive Spectrum
Disorders
 Will also include trichotillomania and possible other
conditions
 Obsessions to be described as urges rather than
impulses
 Term “impulses” is problematic as how do you
distinguish them from impulse control disorders,
so will change term
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Panic Disorder With or Without
Agoraphobia: recent attacks involving at
least one month of consistent concern, the
thresholds have been changed for both.
Agoraphobia with History of Panic Disorder:
fear of being in places where escape may be
difficult.
Generalized Anxiety Disorder: now includes
over-anxious disorder.
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Post-Traumatic Stress Disorder: symptoms must last at
least one month, if more that 6 months after event
should specify delayed onset (no longer must be must
be outside of range of usual experience, often relive
situation, now has acute and chronic specified, must
cause distress).
Acute Stress Disorder: This new category was added
into the DSM-IV to address acute reactions to extreme
stress (occurring within four weeks of the stressor and
lasting from 2 days to 4 weeks). This may help predict
the development of PTSD.
The trauma experienced in acute stress disorder will
not include:
Witnessing events on television
Witnessing events through electronic media
 Will also drop the criteria that the person must
experience intense fear
 Symptoms may no longer need to involve feelings of
dissociation
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Developmental manifestations of PTSD are still being
developed.
The term 'developmental manifestation' in DSM-5 refers
to age-specific expressions of one or another criteria
that is used to make a diagnosis across age groups.
For children, inclusion of loss of a parent or other
attachment figure is being considered.
The optimal number of required symptoms for both
adults and children will be further examined with
empirical data.
 New
disorder proposed:
Hoarding Disorder
GENERIC/BRAND
DURATION OF ACTION DOSE (MG)
Librium/Temezepam
Long Acting, 15-75 mg day
Valium/Diazepam
Long Acting, 4-30 mg day
Dalmane/Flurazepam
Long Acting, 15-30 mg day
Xanax/Alprazolam
Short Acting, 0.5-1.5 mg day
Restoril/Temazepam
Short Acting, 15 - 30 mg day
Halcion/Triazolam
Short Acting, 0.125 - 0.5 mg
Serax/Clorazepate), Tranxene/Diazepam,
Klonopin/Clonazepam
The benzodiazepine is a central nervous system
depressant so do not mix it with alcohol or
significant depression can result.
Consider Buspar (Buspirone HCL) if history of
drug seeking or abuse behavior is suspected.

Personality Traits: inflexible and maladaptive that
cause significant impairment and distress

Stable pattern of long duration must be able to
trace back to adolescence or early adulthood

May be applied to children in RARE instances when
patterns are pervasive, persistent, and not related
to developmental state (excluding Antisocial PD)
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Enduring pattern of behavior that deviates
markedly from expectations of individuals
culture.
Manifested in two of the following: cognition,
affect, interpersonal functioning, impulse
control
Pattern is inflexible and pervasive
Pattern leads to distress or impairment
Stable pattern over a long duration
The following often have odd/eccentric
behavior:

Paranoid Personality Disorder

Schizoid Personality Disorder

Schizotypal Personality Disorder
The following often have dramatic, emotional and/or
erratic behavior:
 Antisocial Personality Disorder: some criterion
changes on parenting style and failure to maintain
a monogamous relationship
 Borderline Personality Disorder: some new criterion
DSM-IV-TR, prognosis with treatment is GOOD
 Narcissistic Personality Disorder
 Histrionic Personality Disorder
The following have anxious or fearful behavior:

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Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive Compulsive Personality Disorder:
want to maintain a sense of control in all areas of
their life, hoarding is not extreme or dangerous;
DSM-IV-TR further clarifies relationship between
OCD and OCPD
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A differentiation is made between personality traits and
having a disorder, as severe traits can exist without a
disorder
Each category must have SIGNIFICANT problems with selfidentity and interpersonal functioning
Impaired functioning is linked directly to an extreme
personality trait
Adaptive failure is manifested in one or both of the following:
Failure to develop a sense of self-identity
Failure to develop effective interpersonal functioning
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Antisocial
Obsessive compulsive
Avoidant
Borderline
Schizotypal
Specify the traits that stand out (six traits that can be
made more specific)
Does the client meet the threshold for having a PD?
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Assess level of functioning (0-no impairment
to 4-extreme impairment)
Match five personality types from the
narrative description (antisocial, obsessive
compulsive, avoidant, borderline, schizotypal)
Assess for trait profiles for any type of PD
and list all moderate or extreme traits
Cumulate totals and decide if the client meets
the criteria for a diagnosis of PD
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Academic Problem: underachievers
Childhood or Adolescent Antisocial Behavior: isolated
acts
Borderline Intellectual Functioning: IQ between 71 and
84 *(this is only V Code that goes on Axis II)
Malingering: voluntary produce symptoms in presence
of exaggerated voluntary physical symptoms, there is
an obvious recognizable goal
Bereavement
Problems Related to Abuse and Neglect: child physical
abuse, child sexual abuse, neglect of child, adult
physical abuse, and adult sexual abuse

Related to the death of a loved one

May present similar to Major Depressive Disorder

Sadness, insomnia, poor appetite, and weight loss

Timeframe can vary based on culture

If symptoms persist two months after the loss may
consider Major Depressive Disorder
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Non-compliance with treatment for either a mental
disorder or a medical condition
Should only use this when severe enough to
warrant independent clinical attention
Reasons include: medications side-effects, expense
of treatment, cultural beliefs, value judgments, etc.
Problems Related to Abuse and Neglect:
Can be coded for perpetrator of the abuse or
the relational unit (person affected) in which it
occurs.
 Physical Abuse of a Child
 Sexual Abuse of a Child
 Neglect of a Child
 Physical Abuse of an Adult
 Sexual Abuse of an Adult

Acting Out

Denial

Projection and Projective Identification

Sublimation

Displacement
When using medications, “Anything
Strong Enough to Create an Action, is
CLEARLY Strong Enough to Create a
Reaction”
 There are no “quick fixes”
 Start where the client is
 Be careful as a label can last a lifetime
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