From Overview to Direct Practice: How do we use the DSM 5?

1. From Overview  to   Direct Practice:   How do we use the DSM 5?  Susan K Burns LISW New Mexico State University NASW NM conference 2/18/2014

2. Diagnosis (Greek) - to distinguish or discern Discern to perceive by sight or some other sense or by the intellect; to see or recognize

3. Removal of Multi- axial Diagnosis system • (Axis II) Remove stigma of “Untreatability” of many diagnoses • (Axis III) Conditions are no longer listed on a separate axis (Axis III in DSM-IV). Thus, they will likely take a more significant role in mental health diagnosis as they can be listed side-by-side with the mental disorder • (Axis IV)Also, psychosocial and environmental stressors, previously listed on Axis IV of DSM-IV, will be listed alongside mental disorders and physical health issues. In fact, DSM-5 has increased the number of “V codes” (Z codes in ICD-10), which are considered non-disordered conditions that sometimes are the focus of treatment and often are reflective of a host of psychosocial and environmental issues • (Axis V) GAF scale was historically unreliable tool-- highly subjective as to what clinicians used to rate their client. One assessment instrument, suggested for use in the DSM 5, is the World Health Organization Disability Assessment Schedule 2. Assesses a client’s functioning in six domains: understanding and communicating, getting around, self-care, getting along with people, life activities, and participation in society (DSM 5 2013 Pg 745)

4. ASSESSMENTS: • Cross-cutting Symptom Measures – assesses symptoms that cross over multiple diagnoses: depression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and behaviors, dissociation, personality functioning, and substance use Level 1 –assesses the 13 above domains Level 2- detailed clinical inquiry on anything significant in the level 1 assessment • World Health Organization Disability • Maladaptive Personality Inventories • Cultural Formulation Interview: The Cultural Formulation Interview (CFI) is a set of 16 questions that clinicians may use to obtain information during a mental health assessment about the impact of culture on key aspects of an individual’s clinical presentation and care. The interview systematically assesses cultural factors in the clinical encounter that may be used with any individual.

5. Cultural Formulation The CFI focuses on the individual’s experience and the social contexts of the clinical problem. The CFI follows a person-centered approach to cultural assessment by eliciting information from the individual about his or her own views and those of others in his or her social network. This approach is designed to avoid stereotyping, in that each individual’s cultural knowledge affects how he or she interprets illness experience and guides how he or she seeks help. In a cultural formulation interview we want to know these things: pg 750 DSM 5 • 1. the cultural identity of the individual • 2. the cultural conceptualization of distress • 3. the psychosocial stressors and cultural features of vulnerability and resilience. • 4. cultural features of the relationship between the individual and the clinician

6. DSM 5 V-codes and other Conditions That May be a Focus of Clinical Attention • Relational Problems • Abuse and Neglect- Child and Adult: Physical, Sexual, Psychological • Educational and Occupational Problems • Housing and Economic Problems • Other Problems Related to the Social Environment • Problems related to Crime or Interaction with the Legal System • Other Health Service Encounters for Counseling or Medical Advice • Problems Related to Other Psychosocial, Personal, and Environmental Circumstances • Other Circumstances of Personal History • Problems Related to Access to Medical and Other Health Care • Non -adherence to Medical Treatment

7. Outline of the DSM 5 disorders and related content • 1. Diagnostic Criteria Threshold of signs/ symptoms Time frame ** Ruling out medical or substance related sources of the problem **Clinically significant distress • 2. Diagnostic Features • 3. Associated features supporting Diagnosis • 4. Prevalence • 5. Development and course • 6. Risk and prognostic Factors Temperamental Environmental Genetic/physiological • 7. Cultural related Diagnostic Issues • 8. Gender related Diagnostic issues • 9. Suicide Risk • 10. Functional consequences • 11. Differential Diagnosis • 12. Co-morbidity • 13 some have Diagnostic markers section mild moderate severe, etc

8. Diagnostic Additions: Disruptive Mood Dysregulation Disorder-childrenage 6 to 10 who show persistent irritability and frequent episodes of extreme behavior outbursts three or more times a week for more than a year. Frequent temper outbursts related to frustration AND persistent angry mood Premenstrual Dysphoric Disorder- Mood lability, irritability, Dysphoria and anxiety present in the week before menses. Timing of symptom arousal and reduction is essential for a diagnosis. Must cause great disruption in work or social functioning. Must be present for most of the last 12 months. Hoarding and Excoriation – along with Trichotillomania are now in Obsessive Compulsive disorders as the symptoms hurt self, not other as are now in the Impulse control category Binge eating : at least once a week for 3 months, must show both: Eating, in a discrete period of time, an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances A sense of lack of control over eating during the episode with marked distress while eating • The binge-eating episodes are associated with three (or more) of the following: • Eating much more rapidly than normal • Eating until feeling uncomfortably full. • Eating large amounts of food when not feeling physically hungry. • Eating alone because of feeling embarrassed by how much one is eating. • Feeling disgusted with oneself, depressed, or very guilty afterward. • There is no use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

9. MODIFICATIONS/REORGANIZATIONS ---SEPARATING AND CLARIFYING CATEGORIES: • Removal of childhood disorder category entirely. Illness discussions are now found in relevant categories of symptom domains and developmental fit. e.g. Separation Anxiety Disorder and Selective Mutism are now in Anxiety Category • Trauma and Stressor related disorders- totally new category including PTSD and Acute Stress , Attachment DXs, Adjustment DXs • Anxiety disorders vs Obsessive Compulsive disorders; Bipolar vs Depressive category; • Disruptive, Impulse control and Conduct disorders: problems in self-control of emotions and behaviors that violate the rights of others and violate social norms • Major Depressive Disorder With Mixed Features. - Previously, “mixed features” applied only to bipolar I disorder but now the DSM-5 reflects observations that many unipolar depressed patients display sub-threshold signs of hypomania. • Removal of Bereavement Exclusion from Major Depressive Disorder Criteria. • Dysthymia is now Persistent Depressive Disorder • Illness Anxiety Disorder vs Somatic Symptom Disorder (Hypochondria) • Autism spectrum disorder --previously divided among autistic disorder, Aspergers, childhood disintegrative disorder, Rett’s and pervasive developmental disorder NOS. These are no longer considered to be separate clinical entities. The new criteria include 1) persistent and pervasive deficits in social communication and social interaction and 2) restricted, repetitive patterns of behavior, interests, and activities. (ASD) can now be subcategorized by the presence or absence of intellectual impairment and in addition, the identification of three severity levels helps clarify the need for additional social or occupational services.  • Substance abuse and dependence no longer separate categories, but now a part of the continuum of substance use disorders. Gambling is included as well due to a having a similar activation of the reward system as drugs. • Changes to NOS, to” improve diagnostic specificity”. Now have to choose Other Specified -when there is a specific reason why the clinical picture does not meet criteria for a specific dx within a given category - e.g... may fall short of the threshold for symptoms. or Unspecified - cannot specify the reason that a specific DX is not present. This is based on a diagnostic judgment that the clinical picture indicates a category of disorders, but the specific criteria are not clear.

10. Bereavement: Removal of Bereavement exclusion in Depression DX Grief Depression • feelings of emptiness and loss • self-esteem is generally preserved • Dysphoria in grief is likely to decrease in intensity over days to weeks ,occurs in waves, the so-called pangs of grief associated with thoughts of the deceased. The pain of grief may be accompanied or alternate with positive emotions and humor . • thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased • If self-derogatory ideation is present in grief, it typically involves perceived failings about the relationship with the deceased. (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). • If a bereaved individual thinks about dying, thoughts are generally focused on the deceased and possibly about “joining” the deceased. • persistent depressed mood and the inability to anticipate happiness or pleasure • pervasive unhappiness and misery, self-critical or pessimistic ruminations • feelings of worthlessness and self-loathing are common • thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression

11. Bereavement or Depression ??? • Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include may symptoms that are found in Major Depression. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. • This decision inevitably requires the exercise of clinical judgment based on the individual’s history, level of impairment to functioning and the cultural norms for the expression of distress in the context of loss.

12. Critical Thinking: Medical or Substance overlap • The disturbance is a direct physiologicaleffect of a substance or medical condition (e.g., neurodegeneration in Parkinson’s disease can cause depressive symptoms.) This diagnosis is not intended to describe symptoms of a psychological reaction to illness, which would instead be classified as an adjustment disorder, with depressed mood. These two pathways to diagnosing depressive symptoms (physiological versus psychological) may be difficult to differentiate and in fact, may coexist. There are, however, many cases when the evidence heavily suggests one more than the other. A previous resiliency in the face of prior stressors, an ongoing positive coping style and other signs of psychological health make the diagnosis of adjustment disorder less likely. • Guidelines for determining if symptoms are induced by substances or medication or are in fact, evidence of an separate Mental Health Diagnosis : • If disturbance is due to withdrawal or intoxication or substance intake, the symptoms/signs should abate by one month. • If history shows there is a previous non substance caused mental illness with these signs/symptoms, OR the mental health symptoms clearly began prior to use of substances, then chances are the current symptoms may indicate an accompanying co-morbid diagnosis separate from the substance use.

13. MORE CRITICAL THINKING Clinically significant distress or impairment in social , occupational, educational • academic, behavioral or other important areas of functioning. Intended to rule out individuals who meet the diagnostic criteria for a disorder but whose symptoms are not harmful enough to be considered disordered. What is a “normal “ reaction to loss or stress? Many symptoms that are part of mental health diagnoses are found in a continuum in all of human nature and diverse personalities. Idiosyncrasy vs. pathology • Who has a vested interest in the diagnosis? • Who is distressed? • Who is the historian of the “problem”? • People in crisis may appear less functional than they normally are. Essential to put coping skills and resources in play before a diagnosis can be trusted • Though your patient population may tend to certain diagnoses, be careful. Sometimes it is a zebra • Differential diagnosis- allow 3 or 4 possibilities of Dx before you give a formal one. • Is there medical or substance use problem • Mood disorders as a group are the most common DX, and often very treatable, but great potential for harm if left untreated. If signs/symptoms are present, include in the differential as a possibility