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Presenters: Robert M. Gordon, Ph.D., & Alan C. Tjeltveit, Ph.D. 1.

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Presentation on theme: "Presenters: Robert M. Gordon, Ph.D., & Alan C. Tjeltveit, Ph.D. 1."— Presentation transcript:

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2 Presenters: Robert M. Gordon, Ph.D., & Alan C. Tjeltveit, Ph.D. 1

3 Educational Objectives: Learn about the ethical issues involved with making and using a diagnosis, learn about the DSM-5, ICD-10 and PDM, and learn how to integrate these systems. Goals: Understand the ethical and risk issues involved in not diagnosing accurately, identify the ethical issues associated with how we (and others) use diagnoses, and learn the difference between diagnosis as a label of disease as compared to diagnosis as a means to understand in order to better help. 2

4 Lecture you about the gross ethical violations that many of you—through ignorance, malice, or both—routinely commit and should STOP doing Provide precise, foolproof, 100% certain answers to all ethical dilemmas What we will NOT do today

5 What We Will Do Delineate general ethical principles and specific ethical standards of relevance to any diagnostic approach Contend that the best ethical clinical practice involves careful thought about diagnosis; there are many ways to practice well Discuss some ways of thinking that may help you best practice in accord with professional ethical principles and standards and your own approaches to your practice and/or research

6 Diagnostic Systems The DSM—it is claimed—is the Bible of diagnosis NIMH Director Thomas Insel declared on April 29, 2013, that “While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary” The DSM’s “weakness is its lack of validity” “NIMH will be re-orienting its research away from DSM categories”

7 Thomas Insel Director, NIMH Official picture Note what he’s leaning on Source of photo: Herper, 2013

8 NIMH’s alternative Research Domain Criteria (RDoC) research-domain-criteria-rdoc.shtml

9 Draft Research Domain Criteria Negative Valence Systems Acute threat (“fear”) Potential threat (“anxiety”) Sustained threat Loss Frustrative nonreward Positive Valence Systems Approach motivation Initial responsiveness to reward Sustained responsiveness to reward Reward learning Habit Cognitive Systems Attention Perception Working memory Cognitive (effortful) control Systems for Social Processes Affiliation and attachment Social Communication Perception & Understanding of Self Agency Self-Knowledge Perception & Understanding of Others Arousal and Regulatory Systems Arousal Circadian Rhythms Sleep and wakefulness

10 Research Domain Criteria: Is anything relevant to diagnosis left out? Agency Persons The Self Personality Relationships Community Culture Narrative Meaning Spirituality Ethics ?

11 Research Domain Criteria Some see this as praiseworthy scientific progress The chair of the Psychiatry Department at Columbia asserts that “psychiatry needs to base its decisions more on biology, and less on behavior” (Herper, 2013) Some psychologists see RDoC as either biological reductionism or slanted toward biological causation Given the current state of the research, the RDoC can be read primarily as a promissory note, which is backed up by an ideology which holds that: 1. Psychological problems are medical problems 2. Medical problems are, at root, biological problems 3. Real cures will only come at the root level

12 NIMH director & the American Psychiatric Association president-elect, May 14, 2013 Today, the … DSM [no number], along with the ICD represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5 [which was?]. As NIMH's Research Domain Criteria (RDoC) project website states, "The diagnostic categories represented in the DSM-IV [!] and the International Classification of Diseases-10 (ICD-10, containing virtually identical disorder codes) remain the contemporary consensus standard for how mental disorders are diagnosed and treated.” interests.shtml?utm_source=govdelivery&utm_medium= &utm_campaign=govdelivery, emendations by Rick Froman interests.shtml?utm_source=govdelivery&utm_medium= &utm_campaign=govdelivery

13 Why does this matter? Whatever diagnostic system we use Behavior analytic ICD: 9, 9-CM, 10, or (beginning in 2015) 11 DSM: IV-TR or 5 RDoC we face ethical issues regarding diagnosis The current controversy over the DSM-5 is an opportunity to reflect deeply on diagnosis in relationship to professional ethics

14 Case: Carlos 18-year-old high school junior (getting Cs) in the technical track of an underfunded “under-performing” school district in which 80% of the students are below the poverty line Came from the Dominican Republic at 10 & mainstreamed Tested as having an IQ of 69 at 12 (no IEP; unclear why) Parents are divorced, one older brother is in prison Has a girl friend (they’re in a band together) After his best friend was killed in a car accident, he was deeply depressed for 10 days (full range of symptoms) Had pre-18 scrapes with the law (weapon & mj possession) Wants to join the army after high school What are the ethical issues associated with diagnosing Carlos?

15 Ethical Principles & Standards Relevant to Diagnosis “Their intent is to guide and inspire psychologists toward the very highest ethical ideals of the profession” Principle A: Beneficence and Nonmaleficence “Psychologists strive to benefit those with whom they work and take care to do no harm”

16 How can optimal diagnosis benefit Better understanding/ assessment Better treatment: what to do how to be (e.g., patient) how to relate (relationship style) Better communication among professionals and with clients Better research Combats client isolation (“I’m not the only one”) Helps connect individuals with others having similar problems (those who’ve “been there”) so they can receive social support challenge

17 How can diagnosis harm? Diagnosis may Harm clients Harm family members and friends Harm society Harm may be (& probably usually is) unintentional Harm may stem from a client’s interpretation of the dx Harm may stem from how others use and interpret diagnoses

18 How may diagnosis harm? Leads to less than optimal, ineffective, or harmful treatment Leads to misunderstanding persons and their problems Labels may stick Stigma Damage a person’s self- understanding Decrease client responsibility/motivation to change Create unwarranted guilt or shame Focus attention away from key dimensions of a person’s problems Convince a person to accept as natural (& hence inevitable) what they can, in fact, change Make it more difficult or cost more to get health and/or life insurance

19 How may diagnosis harm? Result in not being hired Job loss Living down to expectations associated with a diagnosis Increased health care costs Increase expenses to Clients Employers Society ?

20 Principle B: Fidelity and Responsibility “Psychologists … are aware of their professional and scientific responsibilities to society and to the specific communities in which they work” “Psychologists … seek to manage conflicts of interest that could lead to exploitation or harm”

21 Standard 3. Human Relations 3.06 Conflict of Interest “Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence or effectiveness in performing their functions as psychologists” American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from

22 Figure 1. Comparison of financial conflicts of interest among DSM-IV and DSM-5 task force and work group members. Cosgrove L, Krimsky S (2012) A Comparison of DSM-IV and DSM-5 Panel Members' Financial Associations with Industry: A Pernicious Problem Persists. PLoS Med 9(3): e doi: /journal.pmed

23 Principle C: Integrity “Psychologists seek to promote accuracy, honesty, and truthfulness in the science, teaching and practice of psychology” Insurance fraud ?

24 Principle D: Justice “Psychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures and services being conducted by psychologists. Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases … do not lead to or condone unjust practices”

25 Principle E: Respect for People's Rights and Dignity “Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making” “Psychologists are aware of and respect cultural, individual and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language and socioeconomic status and consider these factors when working with members of such groups” “Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices”

26 Standard 9. Assessment 9.01 Bases for Assessments (a) “Psychologists base the opinions contained in their … diagnostic … statements … on information … sufficient to substantiate their findings. (See also Standard 2.04, Bases for Scientific and Professional Judgments.)” Standard 2. Competence 2.04 Bases for Scientific and Professional Judgments “Psychologists' work is based upon established scientific and professional knowledge of the discipline”

27 Exercise in Psychodiagnoses Learn about: Personality organization Personality patterns Strengths and weaknesses Emergent symptoms Cultural and Contexual issues Issues related to ethical and risk issues Countertransference and boundary issues Contribute to the science of psychological taxonomy. Participation is voluntary. 26

28 What Taxonomic Organization for Mental and Behavioral Science? Like a Biological Organization? Like a Periodic Table? 27

29 28

30 Start with a good diagnostic formulation “Once I have a good feel for the person, the work is going well, I stop thinking diagnostically and simply immerse myself in the unique relationship that unfolds between me and the client…one can throw away the book and savor individual uniqueness.” Nancy McWilliams (2011) Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, Second Edition. 29

31 Main Reasons for Diagnosing 1. Its usefulness for treatment planning. “Understanding character styles help the therapist be more careful with boundaries with a histrionic patient, more pursuant of the flat affect with the obsessional person, and more tolerant of silence with a schizoid client.” 2. Its implications for prognosis. “Realistic goals protect patients from the demoralization and therapist from burnout.” 30

32 Why Diagnose? 3. Its value in enabling the therapist to convey empathy. Once one knows that a depressed patient also has a borderline rather neurotic level personality structure, the therapist will not be surprised if during the second year of treatment she makes a suicide gesture. Or once a borderline client starts to have hope of real change, that the borderline client often panics and flirts with suicide in an effort to protect himself from traumatic disappointment. 31

33 Why Diagnose? 4. Its role in reducing the probability that certain easily frighten people will flee from treatment. It is helpful for the therapist to communicate to hypomanic or counter-dependent patients an understanding of how hard it may be for them to stay in therapy. 32

34 Why Diagnose? 5. Its value in risk management. Often therapists mistakenly use a presenting symptom as the only diagnosis and missed the borderline level of personality or psychopathic personality and got into trouble. 6. It’s value in process and outcome research. 33

35 Risk Factors in Litigious Patients Borderline Personality Organization Psychopathic traits History of acting out 34

36 “ I have often served as an expert witness in malpractice cases where psychologists had missed the psychopathic or borderline traits in patients. The DSM classifies antisocial and borderline personality disorders by precise and narrow symptoms. This is often misleading. Psychopathy can be a complex personality pattern that combines with or is obscured by other personality patterns, and borderline can be viewed as an entire level of personality organization that can be applied to the various personality disorders.” Gordon, R.M., (2007) PDM Valuable in Identifying High-Risk Patients. The National Psychologist, 16, 6, November/December, page 4. 35

37 Which Diagnostic Taxonomy Should We Use? DSM5? ICD-10? PDM? 36

38 DSM 5 The DSM 5 May Research started in The DSM makes the American Psychiatric Association over $5 million a year, historically adding up to over $100 million. 37

39 DSM-5 Moves from Multi-axial system to a similar ICD 10 System 38

40 Main DSM 5 Categories Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma and Stressor Related Disorders Dissociative Disorders Somatic Symptom Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse Control, and Conduct Disorders Substance Use and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Disorders 39

41 40

42 Why Will DSM-5 Cost $199 a Copy? By Allen Frances, M.D. 1/24/13 Huffington Post DSM-5 has just announced its price -- an incredible $199 First, APA has sunk more than $25 million into DSM-5 and wants to recoup as much of its investment as it can. DSM-IV cost one fifth as much -- just $5 million -- of which half came from external grants. APA is probably counting on having captive buyers who are forced to pay its price, however exorbitant it may be. DSM-5 boycotts are sprouting up all over the place The codes clinicians need for insurance purposes are available for free on the internet DSM-5 is so clunkily written, no teacher will ever want to assign it to students People are not likely to rush out to buy a ridiculously expensive DSM-5 that has already been discredited as unsafe and scientifically unsound. 41

43 DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes By Allen J. Frances, M.D. Psychology Today Dec More than fifty mental health professional associations petitioned for an outside review of DSM 5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits. Professional journals, the press, and the public also weighed in- expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense. 42

44 Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably 'psychosis risk', mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, 'hebephilia', cumbersome personality ratings, and sharply lowered thresholds for many existing disorders). 43

45 1) Disruptive Mood Dysregulation Disorder will turn temper tantrums into a mental disorder. 2) Normal grief will become Major Depressive Disorder. 3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder. 4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs. 5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony but it is a psychiatric illness called Binge Eating Disorder. 44

46 6) The changes in the DSM 5 definition of Autism will result in lowered rates- perhaps by 50% according to outside research groups. 7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause. 8) Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets. 9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. 10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings. 45

47 Neurodevelopmental Disorders Intellectual Disability (Intellectual Developmental Disorder) Diagnostic criteria for intellectual disability (intellectual developmental disorder) emphasize the need for an assessment of both cognitive capacity (IQ) and adaptive functioning. Severity is determined by adaptive functioning rather than IQ score. Moreover, a federal statue in the United States (Public Law , Rosa’s Law) replaces the term “mental retardation” with intellectual disability. The term intellectual developmental disorder was placed in parentheses to reflect the ICD-11 to be released in 2015). 46

48 Intellectual Disability (Intellectual Developmental Disorder) DSM-IV criteria had required an IQ score of 70 as the cutoff for diagnosis; the new criteria recommend IQ testing and describe “deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility.” The new criteria also include severity measures for mild, moderate, severe, and profound intellectual disability. 47

49 Autism Spectrum Disorder (ASD) Consolidation of DSM-IV criteria for autism, Asperger’s, childhood disintegrative disorder, and pervasive developmental disorder-not otherwise specific (PDD- NOS)—into one diagnostic category called autism spectrum disorder (ASD). The new criteria describe two principal symptoms: “deficits in social communication and social interaction” and “restrictive and repetitive behavior patterns” 48

50 Communication Disorders The DSM-5 communication disorders include: language disorder speech sound disorder childhood-onset fluency disorder (a new name for stuttering) social (pragmatic) communication disorder, a new condition for persistent difficulties in the social uses of verbal and nonverbal communication. 49

51 Attention-Deficit/Hyperactivity Disorder The same 18 symptoms are used as in DSM-IV The onset criterion has been changed from “symptoms that caused impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”; subtypes have been replaced with presentation specifiers that map directly to the prior subtypes; a comorbid diagnosis with autism spectrum disorder is now allowed; a symptom threshold change has been made for adults with the cutoff for ADHD of five symptoms, instead of six required for younger persons, 50

52 Specific Learning Disorder Specific learning disorder combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Because learning deficits in the areas of reading, written expression, and mathematics commonly occur together, coded specifiers for the deficit types in each area are included. 51

53 Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing). The second change is the addition of a requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech. At least one of these core “positive symptoms” is necessary for a reliable diagnosis of schizophrenia 52

54 Schizophrenia subtypes The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual types) are eliminated due to their limited diagnostic stability, low reliability, and poor validity. Instead, a dimensional approach to rating severity for the core symptoms of schizophrenia. 53

55 Schizoaffective Disorder The primary change to schizoaffective disorder is the requirement that a major mood episode be present for a majority of the disorder’s total duration after Criterion A has been met. It makes schizoaffective disorder a longitudinal instead of a cross-sectional diagnosis—more comparable to schizophrenia, bipolar disorder, and major depressive disorder, which are bridged by this condition. 54

56 Delusional Disorder Criterion A for delusional disorder no longer has the requirement that the delusions must be nonbizarre. A specifier for bizarre type delusions provides continuity with DSM-IV. The demarcation of delusional disorder from psychotic variants of obsessive-compulsive disorder and body dysmorphic disorder is explicitly noted with a new exclusion criterion, which states that the symptoms must not be better explained by conditions such as obsessive-compulsive or body dysmorphic disorder with absent insight/delusional beliefs. 55

57 Catatonia In DSM-5, catatonia may be diagnosed as a specifier for depressive, bipolar, and psychotic disorders 56

58 Bipolar and Related Disorders Bipolar Disorders Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood. The DSM- IV diagnosis of bipolar I disorder, mixed episode, requiring that the individual simultaneously meet full criteria for both mania and major depressive episode, has been removed. Instead, a new specifier, “with mixed features,” has been added that can be applied to episodes of mania or hypomania when depressive features are present, and to episodes of depression in the context of major depressive disorder or bipolar disorder when features of mania/hypomania are present. Other Specified Bipolar and Related Disorder categorization for individuals with a past history of a major depressive disorder who meet all criteria for hypomania except the duration criterion (i.e., at least 4 consecutive days). A second condition constituting an other specified bipolar and related disorder is that too few symptoms of hypomania are present to meet criteria for the full bipolar II syndrome, although the duration is sufficient at 4 or more days. Anxious Distress Specifier 57

59 Depressive Disorders DSM-5 contains several new depressive disorders, including disruptive mood dysregulation disorder and premenstrual dysphoric disorder. To address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is included for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol. Finally, DSM-5 conceptualizes chronic forms of depression in a somewhat modified way. What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive disorder, which includes both chronic major depressive disorder and the previous dysthymic disorder. 58

60 Bereavement In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5. 1, to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. 2, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, and an increased risk for persistent complex bereavement disorder, which is now in Conditions for Further Study in DSM-5 Section III. 3, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes 59

61 Anxiety Disorders The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (which is included with the obsessive-compulsive and related disorders) or posttraumatic stress disorder and acute stress disorder (which is included with the trauma- and stressor-related disorders). However, the sequential order of these chapters in DSM-5 reflects the close relationships among them. 60

62 PTSD The 3 clusters of DSM-IV symptoms will be divided into 4 clusters in DSM-5: intrusion symptoms, avoidance symptoms, arousal/reactivity symptoms and negative mood and cognitions. Criterion A2 (requiring fear, helplessness or horror happen right after the trauma) will be removed. The diagnosis is proposed to move from the class of anxiety disorders into a new class of "trauma and stressor-related disorders." PTSD assessment measures, such as the CAPS and the PCL, are being revised by the National Center for PTSD to be made available upon the release of DSM-5. 61

63 Somatic Symptom and Related Disorders The DSM-5 classification reduces the number of these disorders and subcategories. Diagnoses of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed. 62

64 The International Classification of Diseases ICD The ICD is currently the most widely used statistical classification system for diseases in the world. This is in fact the official diagnostic system for mental disorders in the US. The ICD-10, was developed in ICD-11 is currently being researched and should be ready in

65 ICD History The first international conference to revise the International Classification of Causes of Death convened in 1900; with revisions occurring every ten-years thereafter. In 1948, the World Health Organization (WHO) assumed responsibility for preparing and publishing the revisions to the ICD every ten-years. WHO sponsored the seventh and eighth revisions in 1957 and 1968, respectively. It later become clear that the established ten-year interval between revisions was too short. The America Psychiatric Association has long lobbied against the use of the ICD (but due to federal law is forced to work with the ICD). 64

66 ICD is Required by HIPPA The deadline for the United States to begin using Clinical Modification ICD-10-Clinical Modification (CM) is currently October 1, The deadline was previously October 1, The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA), Medicare and Medicaid. 65

67 ICD-10 MENTAL AND BEHAVIOURAL DISORDERS consists of 10 main groups: F0: Due to known physiological conditions F1: Due to use of psychoactive substances F2: Schizophrenia, schizotypal and delusional disorders F3: Mood [affective] disorders F4: Anxiety, dissociative, stress-related and somatoform disorders F5: Behavioural syndromes associated with physiological disturbances and physical factors F6: Disorders of personality and behaviour in adult persons F7: Intellectual disabilities F8: Pervasive and specific developmental disorders F9: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence In addition, a group of "unspecified mental disorders". 66

68 ICD 10 Disorders of adult personality and behavior F60 Specific personality disorders F60.0 Paranoid personality disorder F60.1 Schizoid personality disorder F60.2 Antisocial personality disorder F60.3 Borderline personality disorder F60.4 Histrionic personality disorder F60.5 Obsessive-Compulsive personality disorder F60.6 Avoidant personality disorder F60.7 Dependent personality disorder F60.8 Other specific personality disorders F60.81 Narcissistic personality disorder F60.89 Other specific personality disorder F60.9 Personality disorder, unspecified 67

69 ICD-11 Survey Overview 2155 global psychologists participated in the WHO and International Union of Psychological Sciences (IUPsyS) Recruited through 23 IUPsyS member national psychological associations in 23 countries 10 low and middle-income countries Administered in 5 languages (English, Spanish, French, German, Turkish) Parallel to survey conducted by WHO and World Psychiatric Association (WPA) of 4887 psychiatrists in 44 countries 68

70 ICD ICD-11 will draw on research about how clinicians conceptualize mental disorders in hopes of creating a more intuitive and psychological classification system. ICD-11 will be available for free on the Internet (ICD-9 and 10 apps are free). 69

71 Purpose of Classification % Participants 70

72 Number of Categories Desired % Participants 71

73 ICD-10 and DSM-IV Categories Used Most Often ICD-10 and DSM-IV Categories Used Most Often ICD-10%DSM-IV% Depressive Episode 71% Major Depressive Disorder60% Generalized Anxiety Disorder 48% Generalized Anxiety Disorder59% Social Phobia 46% Post-Traumatic Stress Disorder42% Mixed Anxiety and Depressive Disorder 44% Adjustment Disorders41% Recurrent Depressive Disorder 44% Attention-Deficit/Hyperactivity Disorder38% Post-Traumatic Stress Disorder 42% Obsessive-Compulsive Disorder37% Borderline Personality Disorder 42% Social Phobia37% Adjustment Disorder 42% Borderline Personality Disorder34% Specific (Isolated) Phobias 41% Single Major Depressive Episode34% Hyperkinetic (Attention Deficit) Disorder 34% Panic Disorder without Agoraphobia32% Obsessive-Compulsive Disorder 34% Bipolar I Disorder27% Bipolar Affective Disorder 28% Alcohol-Related Disorders26% 72

74 Categories With the Lowest Ease of Use ICD-10EOUDSM-IVEOU Asperger's Syndrome 0.50 Dissociative Disorders0.48 Dissociative [Conversion] Disorders 0.50 Impulse Control Disorders0.50 Schizoaffective Disorder 0.51 Schizotypal Personality Disorder0.54 Schizotypal Disorder 0.51 Schizoaffective Disorder0.54 Somatoform Disorders 0.52 Asperger's Disorder0.56 Borderline Personality Disorder 0.56 Somatoform Disorders0.56 Hyperkinetic (Attention Deficit) Disorder 0.56 Primary Sleep Disorders0.58 Delirium 0.58 Bipolar II Disorder0.58 MBDs due to Use of Volatile Solvents 0.58 Tic disorders0.59 Habit and Impulse Disorders 0.59 Brief Psychotic Disorder0.60 MBDs due to Use of Hallucinogens 0.60 Vascular Dementia0.60 Bipolar Affective Disorder 0.60 Sexual Dysfunctions0.60 Mixed Anxiety and Depressive Disorder 0.60 Autistic Disorder0.61 Adjustment Disorder 0.60 Delusional Disorder

75 Categories With the Lowest Goodness of Fit ICD-10GOFDSM-IVGOF Dissociative [Conversion] Disorders 0.45 Schizotypal Personality Disorder0.44 Asperger's Syndrome 0.45 Dissociative Disorders0.45 Hyperkinetic (Attention Deficit) Disorder 0.50 Somatoform Disorders0.47 Schizoaffective Disorder 0.51 Asperger's Disorder0.48 Somatoform Disorders 0.51 Impulse Control Disorders0.48 Borderline Personality Disorder 0.51 Schizoaffective Disorder0.49 MBDs Due to Use of Hallucinogens 0.52 Primary Sleep Disorders0.51 Schizotypal Disorder 0.53 Tic disorders0.53 Vascular Dementia 0.53 Bipolar II Disorder0.53 Dissocial (Antisocial) Personality Disorder 0.55 Borderline Personality Disorder0.54 Adjustment Disorder 0.55 Autistic Disorder0.54 Habit and Impulse Disorders 0.55 Brief Psychotic Disorder0.55 Mixed Anxiety and Depressive Disorder 0.56 Sexual Dysfunctions

76 An enduring pattern of unusual speech, perceptions, beliefs and behaviors that are not of sufficient intensity to meet the requirements of schizophrenia. 3 or 4 of the following:  Constricted affect, the individual appearing cold and aloof.  Behaviour or appearance which is odd, eccentric, or peculiar.  Poor rapport with others, tendency towards social withdrawal.  Unusual beliefs, magical thinking or paranoid ideation  Unusual perceptual distortions  Suspiciousness or paranoid ideas  Occasional transient psychotic episodes  Vague, circumstantial, stereotyped thinking  Obsessive ruminations  Not met diagnostic criteria for schizophrenia ICD 10 / ICD 11 Schizotypal Disorder 75

77 A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior… 5 or more of the following: (1) ideas of reference (2) odd beliefs or magical thinking (3) unusual perceptual experiences (4) odd thinking and speech (e.g., vague, circumstantial) (5) suspiciousness or paranoid ideation (6) inappropriate or constricted affect (7) behavior or appearance that is odd, eccentric, or peculiar (8) lack of close friends or confidants other than first-degree relatives (9) excessive social anxiety DSM-IV Schizotypal Personality Disorder 76

78 DSM-5 Schizotypal Personality Disorder A. Significant impairments in personality functioning: 1. Impairments in self functioning (a or b): a. Identity: Confused boundaries between self and others; b. Self-direction: Unrealistic or incoherent goals; AND 2. Impairments in interpersonal functioning (a or b): a. Empathy: Difficulty understanding impact of behaviors on others; b. Intimacy: Marked impairments in developing close relationships. B. Pathological personality traits in the following domains : 1. Psychoticism, characterized by: a. Eccentricity b. Cognitive and perceptual dysregulation: c. Unusual beliefs and experiences 2. Detachment, characterized by: a. Restricted affectivity b. Withdrawal 3. Negative Affectivity, characterized by: a. Suspiciousness 77

79 DSM-5 Schizotypal Personality Disorder The only two non-US members of the DSM-5 Personality Disorders Work group (Roel Verheul and John Livesley) resigned in April 2012: “First, the proposed classification is unnecessarily complex, incoherent, and inconsistent. … Second, the proposal displays a truly stunning disregard for evidence. The current proposal represents the worst possible outcome: it displays almost total discontinuity with DSM-IV while failing to improve validity and clinical utility of the classification.” 78

80 A diagnostic framework that attempts to characterize the whole person--the depth as well as the surface of emotional, cognitive, and social functioning; from healthy to disturbed in a mixed categorical -dimensional system 79

81 Psychodynamic Theory as a Complex Adaptive System- interaction, interdependence and diversity of constructs (temperament, affects, cognitions, development, traumas, defenses, fantasies, attachments), emergences (symptoms), tails (one event can move the entire central tendency) and tipping points (break downs). 80

82 PDM’s Current Taxonomy Manifest Symptoms and Concerns Mental Functioning Personality Patterns and Disorders 81

83 Types of Personality Disorders or Patterns P101. Schizoid Personality Disorders P102. Paranoid Personality Disorders P103. Psychopathic (Antisocial) Personality Disorders P103.1 Passive/Parasitic P103.2 Aggressive P104. Narcissistic Personality Disorders P104.1 Arrogant/Entitled P104.2 Depressed/Depleted P105. Sadistic and Sadomasochistic Personality Disorders P105.1 Intermediate Manifestation: Sadomasochistic Personality Disorders P106. Masochistic (Self-Defeating) Personality Disorders P106.1 Moral Masochistic P106.2 Relational Masochistic 82

84 P107. Depressive Personality Disorders P107.1 Introjective P107.2 Anaclitic P107.3 Converse Manifestation: Hypomanic Personality Disorder P108. Somatizing Personality Disorders P109. Dependent Personality Disorders P109.1 Passive-Aggressive Versions of Dependent Personality Disorders P109.2 Converse Manifestation: Counterdependent Personality Disorders P110. Phobic (Avoidant) Personality Disorders P110.1 Converse Manifestation: Counterphobic Personality Disorders P111. Anxious Personality Disorders 83

85 P112. Obsessive-Compulsive Personality Disorders P112.1 Obsessive P112.2 Compulsive P113. Hysterical (Histrionic) Personality Disorders P113.1 Inhibited P113.2 Demonstrative or Flamboyant P114. Dissociative Personality Disorders (Dissociative Identity Disorder/Multiple Personality Disorder) P115. Mixed/Other 84

86 Profile of Mental Functioning - M Axis Capacity for Regulation, Attention, and Learning Capacity for Relationships (Including Depth, Range, and Consistency) Quality of Internal Experience (Level of Confidence and Self- Regard) Affective Experience, Expression, and Communication Defensive Patterns and Capacities Capacity to Form Internal Representations Capacity for Differentiation and Integration Self-Observing Capacities (Psychological-Mindedness) Capacity for Internal Standards and Ideals: A Sense of Morality 85

87 Symptom Patterns: The Subjective Experience - S Axis S301. Adjustment Disorders S302. Anxiety Disorders S302.1 Psychic Trauma and Posttraumatic Stress Disorder S302.2 Phobias S302.3 Obsessive-Compulsive Disorders S303. Dissociative Disorders S304. Mood Disorders S304.1 Depressive Disorders S304.2 Bipolar Disorders S305. Somatoform (Somatization) Disorders S306. Eating Disorders S307. Psychogenic Sleep Disorders S308. Sexual and Gender Identity Disorders S308.1 Sexual Disorders S308.2 Paraphilias S308.3 Gender Identity Disorders S309. Factitious Disorders S310. Impulse Control Disorders S311. Addictive/Substance Abuse Disorders S312. Psychotic Disorders S313. Mental Disorders Based on a General Medical Condition 86

88 Classification of Child and Adolescent Mental Health Disorders Profile of Mental Functioning for Children and Adolescents - MCA Axis Capacity for Regulation, Attention, and Learning Capacity for Relationships (Including Depth, Range, and Consistency) Quality of Internal Experience (Level of Confidence and Self-Regard) Affective Experience, Expression, and Communication Defensive Patterns and Capacities Capacity to Form Internal Representations Capacity for Differentiation and Integration Self-Observing Capacities (Psychological-Mindedness) Capacity for Internal Standards and Ideals: Sense of Morality Summary of Child and Adolescent Mental Functioning 87

89 Child and Adolescent Personality Patterns and Disorders - PCA Axis Developmental Aspects of Emerging Personality Patterns PCA101. Fearful of Closeness/Intimacy (Schizoid) Personality Disorders PCA102. Suspicious/Distrustful Personality Disorders PCA103. Sociopathic (Antisocial) Personality Disorders PCA104. Narcissistic Personality Disorders PCA105. Impulsive/Explosive Personality Disorders PCA106. Self-Defeating Personality Disorders PCA107. Depressive Personality Disorders PCA108. Somatizing Personality Disorders PCA109. Dependent Personality Disorders PCA110. Avoidant/Constricted Personality Disorders PCA110.1 Counterphobic Personality Disorders PCA111. Anxious Personality Disorders PCA112. Obsessive-Compulsive Personality Disorders PCA113. Histrionic Personality Disorders PCA114. Dysregulated Personality Disorders PCA115. Mixed/Other 88

90 Child and Adolescent Symptom Patterns: The Subjective Experience Anxiety Disorders SCA301. Anxiety Disorders SCA302. Phobias SCA303. Obsessive-Compulsive Disorders SCA304. Somatization (Somatoform) Disorders Affect/Mood Disorders SCA305. Prolonged Mourning/Grief Reaction SCA306. Depressive Disorders SCA307. Bipolar Disorders SCA308. Suicidality Disruptive Behavior Disorders SCA309. Conduct Disorders SCA310. Oppositional-Defiant Disorders SCA311. Substance Abuse Related Disorders Reactive Disorders SCA312. Psychic Trauma and Posttraumatic Stress Disorder SCA313. Adjustment Disorders (other than developmental) Disorders of Mental Functioning SCA314. Motor Skills Disorders SCA315. Tic Disorders SCA316. Psychotic Disorders SCA317. Neuropsychological Disorders SCA317.1 Visual-Spatial Processing Disorders SCA317.2 Language and Auditory Processing Disorders SCA317.3 Memory Impairments SCA317.4 Attention Deficit/Hyperactivity Disorder (AD/HD) SCA317.5 Executive Function Disorders SCA317.6 Severe Cognitive Deficits 89

91 Child and Adolescent Symptom Patterns: The Subjective Experience SCA318. Learning Disorders SCA318.1 Reading Disorders SCA318.2 Mathematics Disorders SCA318.3 Disorders of Written Expression SCA318.4 Nonverbal Learning Disabilities SCA318.5 Social-Emotional Learning Disabilities Psychophysiologic Disorders SCA319. Bulimia SCA320. Anorexia Developmental Disorders SCA321. Regulatory Disorders SCA322. Feeding Problems of Childhood SCA323. Elimination Disorders SCA323.1 Encopresis SCA323.2 Enuresis SCA324. Sleep Disorders SCA325. Attachment Disorders SCA326. Pervasive Developmental Disorders SCA326.1 Autism SCA326.2 Asperger’s Syndrome SCA326.3 Pervasive Developmental Disorder (PDD) Not Otherwise Specified Other Disorders SCA327. Gender Identity Disorders 90

92 Disorders of Infancy and Early Childhood – Axis I - Primary Axis IEC100 Series- Interactive Disorders IEC101. Anxiety Disorders IEC102. Developmental Anxiety Disorders IEC103. Disorders of Emotional Range and Stability IEC104. Disruptive Behavior and Oppositional Disorders IEC105. Depressive Disorders IEC106. Mood Dysregulation: A Unique Type of Interactive and Mixed Regulatory-Sensory Processing Disorder Characterized by Bipolar Patterns IEC107. Attentional Disorders IEC108. Prolonged Grief Reaction IEC109. Reactive Attachment Disorders IEC110. Traumatic Stress Disorders IEC111. Adjustment Disorders IEC112. Gender Identity Disorders IEC113. Selective Mutism IEC114. Sleep Disorders IEC115. Eating Disorders IEC116. Elimination Disorders 91

93 IEC200 Series - Regulatory-Sensory Processing Disorders (RSPD) Clinical Evidence and Prevalence of Regulatory-Sensory Processing Differences Sensory Modulation Difficulties (Type I) IEC201. Overresponsive, Fearful, Anxious Pattern IEC202. Overresponsive, Negative, Stubborn Pattern IEC203. Underresponsive, Self-Absorbed Pattern IEC203.1 Self-Absorbed and Difficult-to-Engage Type IEC203.2 Self-Absorbed and Creative Type IEC204. Active, Sensory Seeking Pattern Sensory Discrimination Difficulties (Type II) and Sensory-Based Motor Difficulties (Type III) IEC205. Inattentive, Disorganized Pattern IEC205.1 With Sensory Discrimination Difficulties IEC205.2 With Postural Control Difficulties IEC205.3 With Dyspraxia IEC205.4 With Combinations of All Three IEC206. Compromised School and/or Academic Performance Pattern IEC206.1 With Sensory Discrimination Difficulties IEC206.2 With Postural Control Difficulties IEC206.3 With Dyspraxia IEC206.4 With Combinations of All Three Contributing Sensory Discrimination and Sensory-Based Motor Difficulties 92

94 IEC207. Mixed Regulatory-Sensory Processing Patterns IEC207.1 Attentional Problems IEC207.2 Disruptive Behavioral Problems IEC207.3 Sleep Problems IEC207.4 Eating Problems IEC207.5 Elimination Problems IEC207.6 Selective Mutism IEC207.7 Mood Dysregulation, including Bipolar Patterns IEC207.8 Other Emotional and Behavioral Problems Related to Mixed Regulatory-Sensory Processing Difficulties IEC207.9 Mixed Regulatory-Sensory Processing Patterns where Behavioral or Emotional Problems Are Not Yet In Evidence IEC300 Series - Neurodevelopmental Disorders of Relating and Communicating IEC301. Type I: Early Symbolic, with Constrictions IEC302. Type II: Purposeful Problem-Solving, with Constrictions IEC303. Type III: Intermittently Engaged and Purposeful IEC304. Type IV: Aimless and Unpurposeful Other Neurodevelopmental Disorders (Including Genetic and Metabolic Syndromes) 93

95 Reactions to the PDM The PDM was introduced to 192 psychologists in a several ethics and MMPI-2 workshops (65 Psychodynamic, 76 CBT and 51 Other) Overall the psychologists gave the PDM a 90% favorable rating. Gordon, R.M. (2009). Reactions to the Psychodynamic Diagnostic Manual (PDM) by Psychodynamic, CBT and Other Non- Psychodynamic Psychologists. Issues in Psychoanalytic Psychology, 31,1,

96 Nancy McWilliams ( 2011) Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process McWilliams’ taxonomy is fundamentally based on two dimensions: 1. Personality Organization and 2. Character Organization. Gordon, R.M. (2013) book review in Division/Review and at Amazon books 95

97 Robert M. Gordon and Robert F. Bornstein (2012) 96

98 PDC Is A User Friendly Guide to the Adult Section of the PDM Short- 3pages Easy- all scales are 1-10 Intuitive and Empirical Categorical and Dimensional Flexible-can do part or all Integrates with the DSM and ICD Good Reliability and Construct Validity-preliminary field evidence (Gordon and Stoffey 2013 in press) 97

99 PDC’s Taxonomy: From Larger to Smaller Units Cultural-Contextual Issues ICD Symptoms Mental Functioning Personality Patterns Personality Organization 98

100 Clinical Example Using the PDC “Bana” is a 28 year old woman from Syria. Her husband was killed in the war and she has no children. Her brother was able to get her to the US this year. 1. Level of Personality Organization- is 7 (Neurotic Level). Her capacity scores are mainly in the 6-9 range. Her lowest rating is in Affect Tolerance (5) which may be due to her PTSD. She is a good candidate for PDT. 2. Personality Patterns or Disorders- mainly Hysterical/Inhibited type at the Moderate level of severity (6) with some obsessional and dependent features. 3. Mental Functioning- most of the 9 capacities are in the high range. She has a masters in education, her marriage was good, she has average self esteem, she can go from inhibited to overly excited expression of affect, her favored defenses are repression and intellectualization, she has a warm relationship with her mother and both sets of grandparents, her father was killed when she was a child, good level of differentiation and integration, very insightful and excellent moral reasoning. 4. Manifest Symptoms- ICD-10: (F43.1) Post-traumatic stress disorder 5. Cultural, Contextual Issues- recent death of husband, war trauma, loss of father, leaving much of her family and friends behind, immigration fears and guilt. 99

101 Testing Dimensional and Categorical Qualities of Personality Organization Hysteria scale and Schizophrenia scale correlate.01 with male sample and.15 with female sample. They are independent representations of very different character structures. The Ego Strength scale measures responsiveness to psychotherapy. I found that the Es scale significantly increased (p<.001, Cohen’s d =.80) after an average of 3 years of PDT for 55 borderline patients (Gordon, 2001). 100

102 Testing Dimensional and Categorical Qualities of Personality Organization with 3 Scales (L+Pa+Sc)-(Hy+Pt)Es Sc, Hy and Es 101

103 MMPI-2 Hysteria-Hy, Schizophrenia-Sc, and Ego Strength-Es Scales within the Psychotic, Borderline, and Neurotic Categories of the Personality Organization Scale Psychotic (ratings 1-3, n = 13), Borderline (4-6, n = 52), and Neurotic (7-10, n = 33). Psychotic: Sc >> Hy>> Es; Borderline: (Sc ~ Hy) >> Es; Neurotic: (Sc ~ Hy) > Es all in the average to moderate range. 102

104 Example of a Psychotic Level Personality: Schizotypal In ICD-10, Schizotypal disorder is classified as a clinical disorder associated with schizophrenia rather than a personality disorder as with DSM-IV and 5. It is not in the PDM. 103

105 Percent of Practitioners Rating the PDC Dimensions as “Helpful—Very Helpful” in Understanding Their Patient 104

106 Current PDM Study Data collected from 13 workshops from Nov July Estimated N= 500+ practitioners and doctoral students Lead researcher Robert M. Gordon 105

107 Psychodynamic Diagnostic Prototypes (PDP) Francesco Gazzillo, PhD Department of Dynamic and Clinical Psychology «Sapienza» University of Rome 106

108 PDP narrative description P105.1 Intermediate Manifestation: Sadomasochistic Personality Disorders Some individuals alternate between sadistic and sadomasochistic attitudes and behaviors (Kernberg, 1988). Patients with this psychology are much more emotionally alive and capable of attachment than those with primary psychopathic, narcissistic, or sadistic personality structures. Their relationships, however, are intense and explosive. Sometimes they let themselves be dominated to an extreme extent, and sometimes they viciously attack the person to whom they previously capitulated. They tend to see themselves as victims of others’ aggression whose only choices are to surrender their will entirely or to fight back belligerently. The “help- rejecting complainer” described by Frank and his colleagues (Frank, Margolin, Nash, Stone, Varon & Ascher, 1952) is one version of this psychology. In psychotherapy, such patients tend to alternate between attacking the therapist and feeling insulted and demeaned by him or her. Because sadomasochistic personality disorder is found at the borderline level of severity, treatment considerations include those for borderline patients generally. 107

109 The validation of Psychodynamic Diagnostic Prototypes (PDP; Gazzillo, Lingiardi, Del Corno, 2010) The Prototypic Assessment of the Psychodynamic Diagnostic Prototype 5 Very good match (patient exemplifies this disorder; prototypical case) 4 Good match (patient has this disorder; diagnosis applies) 3 Moderate match (patient has significant features of this disorder) 2 Slight match (patient has minor features of this disorder) 1 No match (description does not apply) The evaluation of all 21 disorders takes about minutes 108

110 Hypotheses 1. Norms for PDP and PDC 2. Concurrent validity between PDP and PDC 3. How PDM Dx inform about boundaries and countertransference issues 4. How theoretical orientation affects value of various taxa (PO, PD, MF, Symptoms, Context) 5. Which PD are commonly found at which level of PO. 109

111 110

112 1. Level of Personality Structure- Rating Healthy Personality- characterized by 9-10 scores, life problems never get out of hand and enough flexibility to accommodate to challenging realities. Neurotic Level- characterized by mainly 6-8 scores, rigidity and limited range of defenses and coping mechanisms, basically a good sense of identity, healthy intimacies, good reality testing, fair resiliency, fair affect tolerance and regulation, favors repression. Borderline Level- characterized by mainly 3-5 scores, recurrent relational problems, difficulty with affect tolerance and regulation, poor impulse control, poor sense of identity, poor resiliency, favors primitive defenses such as denial, splitting and projective identification. Psychotic Level- characterized by mainly 1-2 scores, delusional thinking, sometimes hallucinations, poor reality testing and mood regulation, extreme difficulty functioning in work and relationships. Overall Personality Structure Based on the 7 ratings above, rate person’s overall personality structure from 1 (Psychotic) to 10 (Healthy) 111

113 2. Personality Patterns or Disorders- Scoring Review the P axis in the PDM for the personality patterns most descriptive of your client (use the PDP). Begin by checking off as many descriptors that apply. Then decide on the most dominant personality patterns or disorders, and the level of severity (1-10). 112

114 PDM Categories: Schizoid Paranoid Psychopathic (antisocial); Subtypes - passive/parasitic or aggressive Narcissistic; Subtypes - arrogant/entitled or depressed/depleted; Sadistic (and intermediate manifestation, sadomasochistic) Masochistic (self-defeating); Subtypes - moral masochistic or relational masochistic Depressive; Subtypes - introjective or anaclitic; Converse manifestation - hypomanic Somatizing Dependent (and passive-aggressive versions of dependent); Converse manifestation - counterdependent Phobic (avoidant); Converse manifestation - counterphobic Anxious Obsessive-compulsive; Subtypes - obsessive or compulsive Hysterical (histrionic); Subtypes - inhibited or demonstrative/ flamboyant Dissociative Mixed/other Rate: Dominate Personality Disorder or Maladaptive Traits & Overall Severity of Impairment 113

115 3. Mental Functioning 1. Capacity for Attention, Memory, Learning, and Intelligence 2. Capacity for Relationships and Intimacy (including depth, range, and consistency) 3. Quality of Internal Experience (level of confidence and self-regard) 4. Affective Comprehension, Expression, and Communication 5. Level of Defensive or Coping Patterns 1-2: Psychotic level (e.g., delusional projection, psychotic denial, psychotic distortion) 3-5: Borderline level (e.g., splitting, projective identification, idealization/devaluation, denial, acting out) 6-8: Neurotic level (e.g., repression, reaction formation, rationalization, displacement, undoing) 9-10: Healthy level (e.g., anticipation, sublimation, altruism, and humor) 6. Capacity to Form Internal Representations (sense of self and others are realistic and guiding) 7. Capacity for Differentiation and Integration (self, others, time, internal experiences and external reality are all well distinguished) 8. Self-Observing Capacity (psychological mindedness) 9. Realistic sense of Morality 114

116 4. ICD or DSM SYMPTOMS Symptoms are considered in the context of: 1. level of personality structure, 2. personality pattern or disorder 3. mental functioning. Here you may use the symptoms that may be the focus of the chief complaint and necessary for third party reimbursement. 115

117 5. Cultural, Contextual, and Other Relevant Considerations This is a qualitative section where the practitioner may write how cultural or contextual factors contribute to symptoms. 116

118 For Free Copies: For copies of the PDP and PDC, search for: “Psychodiagnostic Chart” 117

119 In addition, use whatever system is most helpful to you in understanding and helping the client/patient 118


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