DSM-5

1
DSM-5

• Jim Messina, Ph.D., CCMHC, NCC
• Assistant Professor
• Troy University, Tampa Bay Site

2
Objectives DSM-5 Workshop

• Update status of new DSM-5
• Identify categories changes in DSM-5
• Review response to critique of DSM-5
• Suggest impact of DSM-5 for Clinical Mental
  Health Counselors
• Prepare steps to take to be prepared for DSM-5
  implementation

3
Websites on DSM-5

• Official APA DSM-5 site www.dsm5.org
• DSM-5 on www.coping.us

4
Timeline of DSM-5

• 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

5
Revision Guidelines for DSM-5

• 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

6
Focus of DSM-5 Changes

• 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
• Emphasis was to be on developmental adjustment
  criteria
• New disorders were considered and older disorders
  were to be deleted

7
Deconstruction Movement

• The deconstruction movement in schizophrenia
  (or any of the other categories) seeks to
  disassemble the existing categorical diagnosis
  into better-defined working parts, integrating
  data from genetics, neuroimaging, psychology and
  other disciplines, and
• then group symptoms that cluster together in
  order to rebuild them into a more valid working
  definition of schizophrenia.

8
Grouping of Diagnostic Categories

• The DSM-5 groups are
• Neurodevelopmental disorders
• Schizophrenia and primary psychotic disorders
• Bipolar and Related Disorders
• Mood Disorders
• Anxiety Disorders
• Disorders Related to Environmental Stress
• Obsessive Compulsive Spectrum

• Somatic Symptom Disorder
• Feeding and Eating Disorder
• Sleep Disorders
• Disorders of Sexual Function
• Antisocial and Disruptive Disorders
• Substance Abuse-Related Disorders
• Neurocognitive Disorders
• Personality Disorders
• Paraphilias
• Other Disorders

9
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

10
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
• They have done away with the NOS labeling and
  attempted for specificity with the dimensional
  categorization

11
No More NOS what Replaces it

• CNEC replaces NOS
• CNEC means Condition Not Elsewhere Classified

12
Use for CNEC First Rationale

• CNEC is to be used if the diagnosis of a client
  is too uncertain because of
• Behaviors associated with a classification are
  seen but there is uncertainty regarding the
  diagnostic category due to the fact that
• a) The client presents some symptoms of the
  category but a complete clinical impression is
  not clear
• b) 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

13
Use for CNEC Second Rationale

• CNEC is to be used if the diagnosis of a client
  is too uncertain because of
• 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 there is too brief a period of time in
  which the client has been seen or the clinician
  is untrained in the classification
•  

14
Rules for Use of CNEC

• Rules for use of CNEC
• CNEC designation can last only six months and
  after that a specific diagnostic category has to
  be determined for the diagnosis of the client.

15
Dimensional Specifiers to be used for each
diagnostic category

1. Syntonic vs Dystonic
2. Correlated Disorders Suicide Risk
3. Respect for age, gender culture
4. Severity Index Across Time Circumstances

16
Syntonic vs Dystonic

• The first specifier to be used for each
  diagnostic category addresses the consideration
  of the attitude of the client.
• It will specify on the clients eagerness and
  motivation for counseling/therapy based upon
  their understanding and insight toward their own
  mental health disorder.
• This is designed to enhance the distinction made
  between Axis I and Axis II formats in the DSM III
  and DSM IV.

17
Syntonic vs Dystonic

• These terms are borrowed from the terminology
  used in Motivational Interviewing
• Axis I disorder is one for which the clients
  seek help because it causes them distress and
  this is referred to as DYSTONIC
• Axis II disorder is one for which clients do not
  seek clinical help because they do not feel any
  concern about this disorder and this is referred
  to as SYNTONIC

18
Syntonic vs Dystonic

• The rating for this Dimension will be as
  follows
• 1. Good /Fair Insight Dystonic
• 2. Poor Insight Ambivalence
• 3. Absent Insight Syntonic

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Dystonic Clients

• Characteristic of Dystonic Conditions
• 1. Client is experiencing significant distress,
  disability or impairment in functioning and such
  pain helps motivate the client to seek out help
• 2. Client has no capacity to cope with the
  condition at the current time
• 3. Client is motivated for therapy to help with
  the situation and condition
• Note the more Dystonic a client is about
  disorder helps in case conceptualization
  treatment planning delineates where therapist
  will begin therapy in situation with client

20
Characteristics of Syntonic Conditions

• 1. Client is heavily defended
• 2. Client rationalizes the behaviors is
  reluctant to change
• 3. Client is angry about being told what to do
• 4. Client is resigned to his or her fate
• 5. Client sees benefits to current behaviors
• 6. Client lacks insight into the condition
  typical for children
• 7. Client is resistant to therapy and often has
  to be motivated to enter therapy
• 8. Client has no motivation to change

21
Correlated Disorders Suicide Risk

• Each diagnostic definition will comment on
  research based evidence of correlation among
  disorders (associated features)
• There will be comments on each diagnosis as to
  vulnerability to suicide where appropriate

22
Respect for Age, Gender Culture

• 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

23
Severity Index Across Time Circumstances

• Time and circumstances will be essential
  specifiers in all diagnostic categories
• This will assure that individual does qualify for
  a mental disorder from definition and that it is
  a severe impairment
• This insures that the clinician will take time in
  diagnosing
• This replaces the Axis V GAF score

24
Severity Index Across Time Circumstances

• There is a need to avoid to rush to certainty
  given that Diagnostics is a process not an
  event
• Rating Scale Severity Index Across Time
  Circumstances
• 0 No impairment Equivalent to GAF 71-100
  (Normative Range)
• 1 Mild impairment Equivalent to GAF 61-70
• 2 Moderate impairment Equivalent to GAF 31-60
• 3 Severe impairment Equivalent to GAF 1-30
• Specifier must indicate level 1 or 2 or 3
  before a diagnosis is validated as a mental
  disorder

25
Pathogenic Care Realms

• 5 Pathogenic Care Realms in the Home, School
  Community
• Settings in which there is
• 1. persistent disregard for the childs emotional
  needs
• 2. persistent disregard for the childs physical
  needs
• 3. repeated changes in primary caregivers
• 4. limited opportunities for stable attachments
  for child
• 5. persistent harsh punishment or types of
  grossly inept parenting (e.g. Toxic Homes)
• It requires one or more of these five essential
  specifiers for a diagnosis which depends on a
  pathogenic realm to be fully diagnosed

26
Diagnoses needing Pathogenic Realm Specifiers

• Diagnoses in the DSM-5 requiring the 5 Pathogenic
  Care Realms Specifiers are
• G00 Reactive Attachment Disorder
• G01 Disinhibited Social Engagement Disorder
• G03 PTSD in Children
• D00 Disruptive Mood Dysregulation Disorder
• H00 Dissociative Disorders in Children
• Q00 Oppositional Defiant Disorder
• Q06.1 Conduct Disorder (Sociopathy Specifier)
• Q07 and T04 Dyssocial Personality

27
Specific Changes Per Diagnostic Category in DSM-5

• Neurodevelopmental
• IQ no longer used as criteria for Intellectual
  Developmental Disorder but the IQ still is
  understood to be below 70
• Asperger's Syndrome will be lumped into Autism
  Spectrum since it is at the milder end of the
  Spectrum

28
Specific Changes Per Diagnostic Category in DSM-5

• Schizophrenia and Other Psychotic Disorders
• Schizotypal Personality Disorder B01 moved to
  this category
• Added Attenuated Psychosis Syndrome B06

29
Specific Changes Per Diagnostic Category in DSM-5

• Bipolar and related disorders
• Bipolar is now a free standing category
• Taken out of the mood disorder category

30
Specific Changes Per Diagnostic Category in DSM-5

• Depressive Disorders
• Dysthymia now called Chronic Depressive Disorder
  D03
• Added Prementrual Dysphoric Disorder D04
• Added Mixed Anxiety/Depression D05

31
Specific Changes Per Diagnostic Category in DSM-5

• Anxiety Disorders
• No longer has PTSD in this category
• No longer has OCD in this category
• Social Phobia now called Social Anxiety Disorder
  E04

32
Specific Changes Per Diagnostic Category in DSM-5

• Obsessive-Compulsive and Related Disorders
• OCD is now a stand alone category
• Body Dysmorphic Disorder listed under OCD as F01
• Added Hoarding under category of OCD as F02
• Trichotillomania now called Hair-Pulling Disorder
  is listed under OCD as F03
• Skin Picking Disorder moved under OCD as F04

33
Specific Changes Per Diagnostic Category in DSM-5

• Trauma and Stressor Related Disorders
• Trauma related disorders are now a stand alone
  category
• Reactive Attachment Disorder is now listed here
  G00 
• Added Disinhibited Social Engagement Disorder G01
• Added PSTD in Preschool Children G03
• Acute Stress Disorder is now listed here G04
• PTSD is now listed here G05
• Adjustment Disorders are now listed here G06

34
Specific Changes Per Diagnostic Category in DSM-5

• Dissociative Disorders
• Depersonalization/Derealization Disorder renamed
  in H00
• Dissociative Fugue has been removed from this
  category

35
Specific Changes Per Diagnostic Category in DSM-5

• Somatic Symptom Disorder
• Replaced Somatiform Disorders with this category
• Eliminated the following Somatization Disorder
  Pain Disorder and Hypochondriasis
• Added Complex Somatic Symptom Disorder J00
• Added Simple Somatic Symptom Disorder J01
• Added Illness Anxiety Disorder J02
• Conversion Disorder renamed Functional
  Neurological Disorder J03

36
Specific Changes Per Diagnostic Category in DSM-5

• Feeding and Eating Disorders
• Pica K00 moved to this category
• Rumination Disorder K01 moved to this category
• Added Avoidant/Restrictive Food Intake Disorder
  K02
• Added Binge Eating Disorder K05

37
Specific Changes Per Diagnostic Category in DSM-5

• Elimination Disorders
• This category was created as freestanding
  category
• Enuresis moved to this category L00
• Encopresis moved to this category L01

38
Specific Changes Per Diagnostic Category in DSM-5

• Sleep-Wake Disorders (1)
• Primary Insomnia renamed Insomnia Disorder M00
• Primary Hypersomnia joined with Narcolepsy
  without Cataplexy M01
• Added Kleine Levin Syndrome M02 (intermittent
  excessive sleep with behavior change)
• Added Obstructive Sleep Apnea Hypopnea Syndrome
  M03
• Added Primary Central Sleep Apnea M04

39
Specific Changes Per Diagnostic Category in DSM-5

• Sleep-Wake Disorders (2)
• Added Primary Alveolar Hypoventiation M05
• Added Disorder of Arousal M08
• Added Rapid Eye Movement Behavior Disorder M09
• Added Restless Leg Syndrome M10
• Eliminated Sleep Terror Disorder  Sleepwalking
  Disorder

40
Specific Changes Per Diagnostic Category in DSM-5

• Sexual Dysfunction
• Male orgasmic disorder renamed Delay Ejaculation
  N02
• Premature Ejaculation renamed Early Ejaculation
  N03
• Dyspareunia and Vaginismus combined into
  Genito-Pelvic Pain/Penetraion Disorder N06
• Sexual Aversion Disorder combined in other
  categories

41
Specific Changes Per Diagnostic Category in DSM-5

• Disruptive Impulse Control and Conduct Disorders
• Gambling removed from this category
• Oppositional Defiant Disorder Q00 was moved
• Trichotillomania removed from this category
• Conduct Disorder Q06 was moved
• Antisocial Personality Disorder renamed Dyssocial
  Personality Disorder Q07 moved to this category

42
Specific Changes Per Diagnostic Category in DSM-5

• Substance Abuse and Addictive Disorders
• Only 3 qualifiers are used in the category Use -
  replaces both abuse and dependence while
  Intoxication and Withdrawal remain the same
• Nicotine Related renamed Tobacco Use Disorder R09
• Added Caffeine Withdrawal R24
• Added Cannabis Withdrawal R25
• Polysubstance Abuse categories discontinued
• Added Gambling R31 added to category

43
Specific Changes Per Diagnostic Category in DSM-5

• Neurocognitive Disorders
• Category replaces Delirium, Dementia, and
  Amnestic and Other Cognitive Disorders Category
• Now distinguishes between Minor and Major
  Disorders
• Replace wording of Dementia due to ... with
  Neurocognitive Disorder Associated with for all
  the conditions listed
• Added Fronto-Temporal Lobar Degeneration S15/S27
  Traumatic Brain Injury S16/S28 Lewy Body Disease
  S17/S29
• Renamed Head Trauma to Traumatic Brain Injury
• Renamed Creutzfeldt-Jakob Disease to Prion
  Disease

44
Specific Changes Per Diagnostic Category in DSM-5

• Paraphilias
• They all carry over to the DSM-5 new names
• U00 Exhibitionistic Disorder U01 Fetishistic
  Disorder U02 Frotieuristic Disorder U03
  Pedophilic Disorder U04 Sexual Masochism
  Disorder U05 Sexual Sadism Disorder U06
  Tranvestic Disorder U07 Voyeuristic Disorder

45
Specific Changes Per Diagnostic Category in DSM-5

• Personality Disorders
• Only six Personality Disorders remain in this
  category Borderline T00 Obsessive-Compulsive
  T01 Avoidant T02 Schizotypal T03 Antisocial
  T04 Narcissistic T05
• Schizotypal Personality Disorder T03 also under
  Schizophrenia and Other Psychotic Disorders B02
• Antisocial Personality Disorder T04 also under
  Disruptive Impulse Control and Conduct Disorders
  as Dyssocial Personality Disorder Q07
• This category no longer stands alone as another
  AXIS II but rather as a diagnosed category with
  dimensions

46
Personality Disorders

• T00-06. Personality Disorders Classifications
• T00   Borderline Personality Disorder
• T01   Obsessive-Compulsive Personality Disorder
• T02   Avoidant Personality Disorder
• T03   Schizotypal Personality Disorder
• T04 Dyssocial   Personality Disorder (Antisocial
  Personality Disorder)
• T05   Narcissistic Personality Disorder
• T06   Personality Disorder Trait Specified

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Three Measures to Assess Personality Pathology

• 1. Core Impairments in Personality Functioning
• 2. Pathological Personality Traits
• 3. Overall Measure of Severity

48
1. Core Impairments in Personality Functioning

• 1. Self-Functioning includes
• a. Identity individual experiences oneself as
  unique, has boundaries, stable self-esteem, and
  can regulate emotions
• b. Self-direction individual has vocational,
  occupational, relational and social goals also
  has internal standards and displays a moral
  compass
• 2. Interpersonal Functioning includes
• a. Empathy listens, appreciates others
  experiences and advice, tolerance and acceptance
  and understands how ones behaviors affect others
• b. Intimacy positive connection to others, a
  desire and capacity for closeness and is
  emotionally responsive

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2. Pathological Personality Traits

• 1. Negative Affectivity labile moods emotional
  dysregulation
• 2. Detachment emotional constriction intimacy
  avoidance
• 3. Antagonism manipulative
• 4. Disinhibition or Compulsivity perfectionism
  controlling
• 5. Psychoticism unusual beliefs

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3. Overall Measure of Severity of Personality
Functioning

• 0 very little
• 1 Mild
• 2 Moderate
• 3 Extreme
• The severity level is an assessment of how the
  behavior impacts on the therapeutic relationship

51
Questions to be asked in deciding on a
Personality Disorder

• 1. Is there a significant impairment in self or
  interpersonal functioning?
• 2. What pathological personality traits are
  present?
• 3. Is the severity level so profound (2 or 3)
  that it may have an effect on treatment?
• 4. What would be the effect on treatment?

52
Possible New DSM-5 Disorders

• Not added to date
• Dissociative Trance Disorder
• Anxious Depression
• Complicated /Prolonged Grief
• Factitious disorder imposed on another
• Non-suicidal Self Injury
• Hypersexual Disorder
• Olfactory Reference Syndrome
• Paraphilic Coercive Disorder

53
Most Discussed DiagnosesB06 Attenuated Psychosis
Syndrome

• For Criteria B06 go to
• http//www.coping.us/thedsm5/dsm5specificdiagnoses
  .html

54
Critique of B06Attenuated Psychosis Syndrome

• British Psychological Society (2011) stated the
  concept of attenuated psychosis system appears
  very worrying it could be seen as an opportunity
  to stigmatize eccentric people, and to lower the
  threshold for achieving a diagnosis of psychosis.
• Society for Humanistic Psychology (2011) stated
  Attenuated Psychosis Syndrome describes
  experiences common in general population, which
  was developed from a risk concept with
  strikingly low predictive validity for conversion
  to full psychosis.

55
D00 Disruptive Mood Dysregulation Disorder

• For Criteria D00 go to
• http//www.coping.us/thedsm5/dsm5specificdiagnoses
  .html

56
Critique of D00 Disruptive Mood Dysregulation
Disorder

• Society for Humanistic Psychology (2011) stated
  Children and adolescents will be particularly
  susceptible to receiving a diagnosis of
  Disruptive Mood Dysregulation Disorder or
  Attenuated Psychosis Syndrome.
• The British Psychological Society (2011) stated
  putative diagnoses such as Disruptive Mood
  Dysregulation Disorder presented in DSM-5 are
  clearly based largely on social norms, with
  'symptoms' that all rely on subjective judgments,
  with little confirmatory physical 'signs' or
  evidence of biological causation. They stated
  that the criteria used for this diagnosis in the
  DSM-5 are not value-free, but rather reflect
  current normative social expectations.

57
S12 Mild Neurocognitive Disorder

• For Criteria of S12 go to http//www.coping.us/th
  edsm5/dsm5specificdiagnoses.html

58
Critique of S12 Mild Neurocognitive Disorder

• Society for Humanistic Psychology (2011) stated
  that We are also gravely concerned about the
  introduction of disorder categories that risk
  misuse in particularly vulnerable populations.
  For example, Mild Neurocognitive Disorder might
  be diagnosed in elderly with expected cognitive
  decline, especially in memory functions.

59
Comparison of Diagnoses

• Compare Dysthymic in DSM-IV-TR
• To
• Chronic Depressive Disorder in DSM-5
• See Comparison of DSM-IV-TR and DSM-5 at
  http//www.dsm5.org/ProposedRevision/Pages/propose
  drevision.aspx?rid46

60
Support for DSM-5 (1)

• Kupfer, Regier Kuhl (2008) reassured the mental
  health community that the creators of the DSM-5
  followed a set of revision principals to guide
  the efforts of the DSM-V Work Groups grounding
  recommendations in empirical evidence
  maintaining continuity with previous editions of
  DSM removing a priori limitations on the amount
  of changes DSM-V may incur and maintaining DSMs
  status as a living document.

61
Support for DSM-5 (2)

• Middleton (2008) stated that from a clinical
  viewpoint it is reasonable to hope that the DSM-5
  would provide a scheme of diagnostic
  classification to determine whether or not a
  particular set of symptoms reflects 'mental
  illness (case definition), provides an effective
  way of improving public health by detecting
  'hidden cases for treatment (case detection),
  and identifies indications for particular forms
  of treatment (guide treatment).

62
Support for DSM-5 (3)

• Maser, Norman, Zisook, Everall, Stein, Shettler
  Judd (2009) pointed out changes in criterion in
  DSM-5 will reduce comorbidity, allow symptom
  weighting, introduce non-criterion symptoms,
  eliminate NOS categories provide new directions
  to biological researchers. They suggested
  reevaluating threshold concept use of
  quality-of-life assessment with framework for
  such a revision. Drawbacks to changes coming from
  DSM-5 include retraining of clinicians
  administrative policy changes

63
Support for DSM-5 (4)

• Regier, Kuhl, Kupfer McNulty (2010) reassured
  the public in using the following quote In
  pursuit of increasing the accuracy and clinical
  utility of the DSM, we need people with mental
  illness to help us understand what they are
  struggling with and how best to identify it.

64
Support for DSM-5 (5)

• Sinclair (2010) pointed out in the review of the
  progress made in the revision process that new
  DSM-5 disorders are considered, based on clinical
  need, distinct manifestations, potential harm,
  and potential for treatment.

65
Support for DSM-5 (6)

• British Psychological Association (2011) did
  support the rating of the severity of different
  symptoms called the dimensional classifications,
  which are proposed in the DSM-5. They supported
  that use of dimensions because it would take away
  the focus on specific problems and recognize the
  variability among symptoms in the diagnosing
  process. But did criticize as well.

66
Critique of DSM-5 (1)

• Kraemer, Shrout Rubio-Stipec (2007) Disorder
  represents something of a medical concern in
  patient, abnormality, injury, aberration, word is
  used when etiology or pathological process
  leading to disorder is unknown.
• Disease generally indicates known pathological
  process.
• Disorder may comprise two or more separate
  diseases, or one disease may actually be viewed
  as two or more separate disorders, an issue of
  concern because of well-known comorbidity of
  psychiatric disorders
• Diagnosis procedure to decide whether or not
  certain disorder or disease is present in patient
  so a disorder or disease is characteristic of
  patient
• Diagnosis is opinion that disorder or disease is
  present. Quality of diagnosis depends on how well
  opinion relates to characteristics of patient,
  issue of concern in reliability validity
  assessments

67
Critique of DSM-5 (2)

• Dalal Sivakumar (2009) warned that a
  classification is as good as its theory. They
  pointed out that the etiology of psychiatric
  disorders is still not clearly known, and that
  we still define them categorically by their
  clinical syndrome. They stated that there are
  doubts if they are valid discrete disease
  entities and if dimensional models are better to
  study them. They concluded that we have come a
  long way till ICD-10 and DSM-IV, but there are
  shortcomings and that with advances in genetics
  and neurobiology in the future, classification of
  psychiatric disorders should improve further.

68
Critique of DSM-5 (3)

• Moller (2009) stated that the dimensional
  perspective recommended to be used in the DSM-5
  needs to be pursued cautiously given that using
  such a perspective would mean that syndromes
  would have to be assessed in a standardized way
  for each person seeking help from the psychiatric
  service system. Therefore this system would need
  to be multi-dimensional assessment covering all
  syndromes existing within different psychiatric
  disorders.

69
Critique of DSM-5 (4)

• McLaren (2010) held that it does not matter if
  the language in the DSM-5 is updated. It is of no
  account if categories are reshuffled, broadened,
  blurred, or loosened the faults are conceptual,
  not operational, a case of old wine in new
  bottles. The DSM-5 Task Force has spent some 3
  million hours so far (600 people at 10 hours per
  week for 10 years), and the biggest jobs are
  still to come. It has been 3 million wasted
  hours, just as all those psychoanalytic textbooks
  and conferences, plus the therapeutic hours on
  the analysts couch, were wasted. It is the wrong
  model.

70
Critique of DSM-5 (5)

• Ben-Zeev, Young Corrigan (2010) explored the
  relationship between diagnostic labels and stigma
  in the context of the DSM-5. They looked at three
  types of negative outcomes public stigma,
  self-stigma, and label avoidance. They concluded
  that a clinical diagnosis under the DSM-5 may
  exacerbate these forms of stigma through
  socio-cognitive processes of groupness,
  homogeneity, and stability.

71
Critique of DSM-5 (6)

• Andrews, Sunderland Kemp (2010) concluded that
  the diagnostic thresholds for social phobia and
  for obsessivecompulsive disorder are less
  stringent than that for the other disorders and
  require revision in DSM-V. The concern is for
  Bracket Creep.

72
Critique of DSM-5 (7)

• Wittchen (2010) in her criticism of the process
  pointed out that the barriers to having womens
  issues addressed in the DSM-5 is the
  fragmentation of the field of women's mental
  health research, lack of emphasis on diagnostic
  classificatory issues beyond a few selected
  clinical conditions, and finally, the current
  rules of game used by the current DSM-V Task
  Forces in the revision process of DSM-5.

73
Critique of DSM-5 (8a)

• The British Psychological Society (2011) put out
  a major critique of the DSM-5.
• Their concern clients and general public are
  negatively affected by medicalization of their
  natural and normal responses to their
  experiences responses which undoubtedly have
  distressing consequences which demand helping
  responses, but which do not reflect illnesses so
  much as normal individual variation.

74
Critique of DSM-5 (8b)

• The BPS (2011)also stated that putative diagnoses
  presented in DSM-5 are clearly based largely on
  social norms, with 'symptoms' that all rely on
  subjective judgments, with little confirmatory
  physical 'signs' or evidence of biological
  causation. They stated that criteria used in
  DSM-5 are not value-free, but rather reflect
  current normative social expectations. The BPA
  pointed out that researchers have pointed out
  that psychiatric diagnoses are plagued by
  problems of reliability, validity, prognostic
  value, and co-morbidity.

75
Critique of DSM-5 (9a)

• The Society for Humanistic Psychology (2011)
  questioned the proposed changes to the
  definition(s) of mental disorder that deemphasize
  sociocultural variation while placing more
  emphasis on biological theory. They stated that
  in light of the growing empirical evidence that
  neurobiology does not fully account for the
  emergence of mental distress, as well as new
  longitudinal studies revealing long-term hazards
  of standard neurobiological (psychotropic)
  treatment, we believe that these changes pose
  substantial risks to patients/clients,
  practitioners, and the mental health professions
  in general.

76
Critique of DSM-5 (9b)

• The Society for Humanistic Psychology (2011)
  pointed out
• The proposed removal of Major Depressive
  Disorders bereavement exclusion, which currently
  prevents the pathologization of grief, a normal
  life process.
• The reduction in the number of criteria necessary
  for the diagnosis of Attention Deficit Disorder,
  a diagnosis that is already subject to
  epidemiological inflation.
• The reduction in symptomatic duration and the
  number of necessary criteria for the diagnosis of
  Generalized Anxiety Disorder.

77
Critique of DSM-5 (10)

• ACA Blog (2012) K. Dayle Jones points out very
  few substantive changes have been made in
  response to public comments since first drafts
  were posted-despite fact so many proposals have
  been so heavily criticized. Final public comment
  period originally scheduled for September-
  October 2011, has been twice postponed because
  everything is so far behindfirst to
  January-February 2012 and now to May 2012. Given
  the late date, new public feedback will almost
  certainly have no impact whatever on DSM-5
  appears to be no more than a public relations
  gimmick.

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Impact of DSM-5 on Mental Health Counselors

• Nov 8, 2011 in letter from ACA President Dr. Don
  W. Locke to APA President Dr. John Oldham, Locke
  indicated that there are 120,000 licensed
  professional counselors in U.S. -- second largest
  group that routinely uses DSM -- and that these
  professionals have expressed uncertainty about
  quality credibility of DSM-5

79
ACAs Concerns about DSM-5 (1)

• ACA is concerned that many of proposed revisions
  will promote
• Inaccurate diagnoses
• Diagnostic inflation
• Prescribing of unnecessary potentially harmful
  medication.

80
ACAs Concerns about DSM-5 (2)

• A major concern for professional counselors is
  proposed definition of mental disorders. The
  language suggested implies that all mental
  disorders have a biological component.
• An example of mental disorders that do not
  necessarily have a biological basis is the severe
  anxiety an individual may face upon losing a job.
  This is an environmental issue, according to ACA,
  not necessarily a problem rooted in biology. The
  trauma faced by an earthquake victim or the grief
  following the death of a loved one are other
  examples of mental conditions that might lead an
  individual to seek therapy, yet would not qualify
  under the proposed definition emphasizing a
  biological basis.

81
ACAs Concerns about DSM-5 (3)

• "Although advances in neuroscience have greatly
  enhanced our understanding of psychopathology,
  the current science does not fully support a
  biological connection for all mental disorders,"
  Locke stated in the letter.

82
ACAs Concerns about DSM-5 (4)

• The ACA Task force on the DSM-5 took the position
  that "in general, counselors are against
  pathologizing or 'medicalizing' clients with
  diagnoses as we prefer to view clients from a
  strength-based approach and avoid the stigma that
  is often associated with mental health
  diagnoses."

83
ACAs Concerns about DSM-5 (5)

• ACA had appointed a task force to work on DSM-5
  revision in 2010 this task force called for an
  independent scientific review to ensure that
  counselors can have faith that the DSM-5 will be
  a safe scientifically sound guide to
  psychiatric diagnosis

84
ACAs Concerns about DSM-5 (6)

• In a reply dated Nov. 21, 2011 APA addressed
  ACA's concerns expressed their strong desire to
  ensure that the DSM-5 is a tool that is useful to
  the counseling profession and all mental health
  providers. The letter also stated that the
  definition of mental disorder is still a work in
  progress and, in fact, a revised definition will
  be posted in the spring and will be open to
  another round of public comment.

85
Exercise in Diagnosising with DSM-5 System

1. Read each of the 5 cases thoroughly
2. Then address each of the 5 steps outlined
3. Be ready to present your findings to the group

86
So what should a Clinical Mental Health Counselor
do?

1. Keep up with the developments of the new DSM-5
2. Refresh ones skills in doing an effective
   Initial Assessment Process
3. Keep up with what are the best techniques to get
   to the Why Now Issues facing clients

87
Steps to formulate an initial tentative diagnosis

1. Do a thorough Psychosocial History
2. Do a Mental Status Examination
3. Develop a Diagnosis using the
4. Multiaxial diagnosis with DSM-TR-IV
5. Dimensional diagnosis with DSM-5

88
In HistoryFirst 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

89
Second Review clients mental health history

• Previous treatment for mental health problems?
• Hospitalization for psychiatric conditions?
• As child involved in family therapy?
• Treatment for substance abuse problems-outpatient
  or inpatient?

90
Third Determine if client is on any psychotropic
medications

• What medications?
• Level of prescription?
• Who prescribed medications?
• For what are the medications prescribed?

91
Fourth Review clients 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?

92
Fifth Review clients 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

93
Sixth Review clients 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?

94
Seventh Review clients 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?

95
Eighth List clients 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?

96
Ninth Finally in History 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

97
After Psychosocial History do a Mental Health
Status Exam

• Mental Health Status Exam Rates Clients
• Appearance
• Consciousness
• Orientation to person, place time
• Speech
• Affect

• Mood
• Concentration
• Activity level
• Thoughts
• Memory
• Judgment

98
Once Psychosocial History Mental Health Status
Exam Done!

• Once the Mental Health Status Exam is completed
  now you are ready to make a tentative
• Multiaxial Diagnosis using DSM-TR-IV
• Dimensional Diagnosis using DSM-5

99
Axis I Diagnosis or DSM-5 Singular Diagnosis

• You are to use the DSM-TR-IV Number Description
  in Axis I or DSM-5 for letter number
• You first must rule out other diagnoses
• You compare clients symptoms lists with those
  contained in DSM-TR-IV or DSM-5 to get to most
  appropriate tentative primary diagnosis

100
Axis I Diagnosis (continued)

• You might also list a secondary diagnosis if the
  clients symptoms match up for this labeling
• You could also list additional diagnoses if the
  clients presentation allows for these additional
  diagnoses
• Each must be listed with number description
  just like the primary diagnosis

101
Axis II Personality Disorder-Mental Retardation

• Use Axis II if clients symptoms match up with a
  Personality Disorder or Mental Retardation in
  DSM-IV-TR and list its number description if
  primary put (primary) behind its listing
• Can also list maladaptive behaviors which do not
  meet DSM-TR-IV criteria here
• Axis II can have Deferred, or N.A. (not
  applicable), or left blank

102
Axis III Current medical condition affecting
mental health

• Lists general medical condition(s) which is (are)
  relevant to the mental health condition
• The medical condition could affect the treatment
  of the individual
• Axis III could also be None or deferred if no
  current medical condition seems appropriate

103
Axis IV Psychosocial Environmental Problems

• These problems may affect diagnosis, treatment
  prognosis
• These problems can initiate or exacerbate mental
  health problems
• These problems can develop as a result of
  persons mental health condition

104
Axis IV Psychosocial Environmental - Categories

• Problems with primary support group
• Problems related to social environment
• Educational problems
• Occupational problems

• Housing problems
• Problems with access to health care services
• Problems related to interaction with legal
  system/crime
• Other psychosocial environmental problems

105
Axis V Global Assessment of Functioning (GAF
score)

• GAF score considers psychological, social
  occupational functioning on hypothetical
  continuum of mental health-illness
• Criteria for these scores available p. 34 in
  DSM-TR-IV
• Methodology of getting to score is given on p. 33
  in DSM-TR-IV

106
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 individuals presentation
  functioning