Counselors & The DSM- IV-TR

1. Counselors & The DSM- IV-TR Charles Pemberton, Ed.D.,LPCC Robin Adams

2. Why do we need this book? • Communication • Classification • Research • Payment

3. Conceptualization of DSM • Syndromes • Criteria • Normal vs. Abnormal • Dimensional vs. Categorical • Problems • Labeling • Meeting some criteria • Impairment??

4. Major Groupings Childhood* Dementia Substance Schizophrenia Mood Anxiety Somatoform Factitious Dissociative Sexual and Gender Eating Sleep Adjustment Personality Organization of DSM

5. Organization of each D/O • Diagnostic Features • Episode • Associated • Culture, Age and Gender • Prevalence • Familial Pattern • Differential Diagnosis • Criteria

6. General Criteria of DSM (these apply to all disorders) • Disorder not due to direct effects of a substance. • Disorder not due to direct effects of a general medical condition. • Disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

7. Precedence of Dx • “not due to the direct effects of a substance…” • “has never met the criteria for…”bipolar vs. MDD • “does not meet the criteria for…”ODD vs. CD • “does not occur exclusively during the course of ….”ADHD vs. PDD • “not better accounted for by…”ADHD vs. Mood/Anxiety

8. AXIS • Axis I : Clinical Disorders • Axis II: Personality Disorder and Mental Retardation • Axis III: General Medical Condition • Axis IV: Psychosocial and Environmental Problems • Axis V: Global Assessment of Functioning

9. Numbering System and Specifiers • Numbers • Follows ICD 10 format • First three numbers • Last two numbers • Text Specifiers • Severity (Mild, Moderate, Severe) • Timing (Seasonal, Rapid Cycling, Partial/Full Remission)

10. Attention Deficit Hyperactivity Disorder • Within the “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” grouping, then subgrouped by the category of “disruptive or self injurious behavior”

11. ADHD, Major Diagnostic Features • Often will not complete tasks • Easily distracted by minor stimuli • Work often messy and completed w/o thought • Forgetful in day-to-day activities • Impulsive (interrupting others, cannot wait turn, etc.) • Fidgetiness • Excessive talking

12. Prevalence of ADHD • Estimated at 3-7% of school age children • More common in males than females • Often diagnosed during elementary school years.

13. Differential Diagnosis of ADHD • Must distinguish from age-appropriate behaviors • Mental Retardation or Learning Disability • Oppositional behavior (ODD, Conduct D/O) • Stereotypic Movement D/O • Behavior due to medications • Mood or Anxiety D/O

14. Subtypes of ADHD • 314.01 ADHD, Combined Type • Criteria A1 & A2 both met for past 6 months • 314.00 ADHD, Inattentive Type • Criteria A1 met, but not A2 • 314.01 ADHD, Hyperactive-Impulsive Type • Criteria A2 met, but not A1 • 314.9 ADHD NOS • Prominent symptoms but do not meet diagnostic criteria

15. Diagnostic Criteria for ADHD • A 1. Must exhibit 6 or more symptoms of inattention, persisting for minimum of 6 months: from list of 9 items, a through i. • A 2. Must exhibit 6 or more symptoms of hyperactivity-impulsivity, persisting for minimum of 6 months, from list of 9 items, a through i.

16. Diagnostic Criteria, cont’d: • B. symptom onset PRIOR to age 7 years • C. impairment present in two or more environments • D. clear clinically significant impairment in functioning • E. cannot be accounted for by other mental disorder

17. Diagnostic Presentation of ADHD • Symptoms will vary based on age. • More common in males than females. • Hyperactivity may manifest as internal feeling of restlessness for older individuals, versus fidgeting. • No test exists to “diagnose” ADHD. Several instruments measure symptomatology that is associated with ADHD, but only way to diagnose is through clinical impression and observation.

18. Mood Disorders • “disorders that have a disturbance in mood as the predominant feature” • Divided into Depressive Disorders and Bipolar Disorders

19. Other Mood Disorders • Major depressive Disorder • Dysthymic Disorder • Bipolar I Disorder • Bipolar II Disorder • Cyclothymic Disorder

20. MDD, Major Diagnostic Features • One or more Major Depressive Episodes • No Hx of Manic, Mixed or Hypomanic • Single Episode or Recurrent • Severity: • Mild – 5 or 6 symptoms, • Moderate • Severe – most of symptoms are met • Severe can be with or without psychotic features

21. Prevalence of MDD • Lifetime estimates of 10% – 25% for women and 5% - 12% for men • Appear unrelated to ethnicity, education, income or martial status

22. Differential Diagnosis of MDD • Mood D/O due to General Medical Condition • Substance-Induced Mood D/O • MDD and Dysthymic D/O differentiated by severity, chronicity and persistence • Schizoaffective D/O has delusions or hallucinations

23. Major Depressive Episode • Five or more in same 2 week period and change from previous functioning: • Depressed mood most of the day, nearly every day • Diminished interest or pleasure in almost all activities • Significant weight loss or gain • Insomnia or hypersomnia • Psychomotor agitation or retardation • Loss of energy • Feelings of worthlessness or guilt • Diminished ability to think or concentrate • Recurrent thoughts of death

24. Major Depressive Episode cont’ • Don’t meet criteria for mixed episode • Cause significant distress or impairment • Not due to effects of substance or GMC • Not better accounted for by bereavement

25. Diagnostic Criteria for MDD • A. Presence of Major Depressive Episode • B. Not better accounted fore by Schizoaffective D/O, not superimposed on Schizophrenia, Schizophreniform Delusional or psychotic D/O NOS • C. Never been a Mixed, Manic or Hypomanic Episode

26. Diagnostic Criteria Recurrent: • Same with two or more Major Depressive Episodes

27. Specifiers • Mild • Moderate • Severe without Psychotic Features • Severe with Psychotic Features • Mood Congruent • Mood Incongruent • In partial Remission • In Full Remission

28. Specifiers – cont’ • Chronic • Catatonic • Melancholic • Atypical • Longitudinal • Seasonal Pattern • Rapid Cycling

29. References • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. • Fauman, M. A. (2002). Study Guide to DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.