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Presentation on theme: "USING THE DSM-5 TO DEVELOP THE PROFESSIONAL IDENTITY AND CLINICAL COMPETENCE OF MENTAL HEALTH COUNSELORS UMHCA 2013 Annual Conference Jason H. King, PhD,"— Presentation transcript:


2 Goals 2 1. Explore professional identity 2. Understand clinical competence 3. Preview the DSM 5 DSM 5 - Jason H. King, PhD, DCMHS, ACS

3 Professional Identity DSM 5 - Jason H. King, PhD, DCMHS, ACS3

4 What is Professional Identity? The unique characteristics of ones selected profession that differentiates it from other professions (Weinrach, Thomas, & Chan, 2001, p. 168). ValuesBeliefsAssumptions 4DSM 5 - Jason H. King, PhD, DCMHS, ACS

5 What is Professional Identity? An individuals self- definition as a member of a profession ClientsWorkplaceColleagues Enactment of a professional role (Chreim, Williams, & Hinings, 2007; Cohen-Scali, 2003) 5DSM 5 - Jason H. King, PhD, DCMHS, ACS


7 Questions About Professional Identity As counselors, one of the major questions of our times is Who are we (Hendricks, 2008, p. 259)? What is the difference between being a mental health counselor and a social worker or marriage and family therapist? (Gerig, 2007, p. 6) What type of clientele should we serve? What counseling methodologies should be employed by the counselor? What is the goal of the profession of counseling (Palmo, 2006, p. 52)? 7DSM 5 - Jason H. King, PhD, DCMHS, ACS

8 Questions About Professional Identity Myers, Sweeney, and White (2002, p. 399) How does our identity converge with and diverge from that of other mental health professionals? Where is our niche, and how can this niche be emphasized and marketed to various public sectors? How are our specialty areas defined, and how do they relate to professional counseling in general? 8DSM 5 - Jason H. King, PhD, DCMHS, ACS

9 Clinical Competence DSM 5 - Jason H. King, PhD, DCMHS, ACS9

10 Clinical Competence 10 What is Clinical Mental Health Counseling? UMHCA (2011) "Clinical mental health counseling promotes optimal wellness for individuals, couples, families, and groups throughout the lifespan. Those educated and trained as clinical mental health counselors treat as well as prevent mental, emotional, and behavioral disorders through mental health assessments, diagnosis, prevention and treatment plans, and psychotherapeutic counseling interventions. AMHCA (2011) Standards for the Practice of Clinical Mental Health Counseling DSM 5 - Jason H. King, PhD, DCMHS, ACS

11 Clinical Competence 11 Vocational Rehabilitation September 30, 2011: USOR has determined that when we are paying for psychological testing, evaluation, assessment, and other activities leading to a DSM diagnosis, we will do so with the highest level of professional credential, education, and training. Our standard is a licensed Ph.D. level psychologist, or licensed medical doctor. I have reviewed the most current mental health licensing laws on DOPL. I find that the law does not allow LPC's, LCSW's, or Substance Abuse Counselors to conduct psychological testing, evaluation, leading to DSM diagnosis. If the profession, as a profession, has information otherwise, I would be happy to sit down with their professional organization and discuss and reconsider. Until then our standard is our standard. DSM 5 - Jason H. King, PhD, DCMHS, ACS

12 Clinical Competence 12 Mental Health Professional Practice Act Scope of practice – Limitations – PAGE 16 (1) A licensed clinical mental health counselor may engage in all acts and practices defined as the practice of professional counseling without supervision, in private and independent practice, or as an employee of another person, limited only by the licensee's education, training, and competence. Clinical Mental Health Counselor Licensing Act Rule (H) a minimum of two semester or three quarter hours in psychometric test and measurement theory; (I) a minimum of four semester or six quarter hours in assessment of mental status including the appraisal of DSM maladaptive and psychopathological behavior DSM 5 - Jason H. King, PhD, DCMHS, ACS

13 Clinical Competence 13 NCE Psychometric statistics – types of assessment scores, measures of central tendency, indices of variability, standard errors, and correlations NCMHCE Evaluation & Assessment Diagnosis & Treatment Planning AMHCA 2011 Code of Ethics Mental health counselors utilize tests (herein references educational, psychological, and career assessment instruments), interviews, and other assessment techniques and diagnostic tools in the counseling process for the purpose of determining the clients particular needs in the context of his/her situation. DSM 5 - Jason H. King, PhD, DCMHS, ACS

14 Clinical Competence 14 ACA 2005 Code of Ethics Section E: Evaluation, Assessment, and Interpretation Introduction Counselors use assessment instruments as one component of the counseling process, taking into account the client personal and cultural context. Counselors promote the well-being of individual clients or groups of clients by developing and using appropriate educational, psychological, and career assessment instruments. E.1.a. Assessment The primary purpose of educational, psychological, and career assessment is to provide measurements that are valid and reliable in either comparative or absolute terms. These include, but are not limited to, measurements of ability, personality, interest, intelligence, achievement, and performance. E. 5. Diagnosis of Mental Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

15 Clinical Competence 15 ACA 2014 Code of Ethics When possible use multiple forms of assessment, data, and/or instruments in forming conclusions, diagnoses or recommendations CACREP (2009) …Diagnostic interviews, mental status examinations, symptom inventories, and psychoeducational and personality assessments. …Psychological testing and behavioral observations. …Diagnostic process, including differential diagnosis, and the use of current diagnostic tools, such as the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) CACREP (2016) Use of informal assessments for diagnostic purposes Use of symptom checklists, personality, and psychological testing Use of assessment results to effectively diagnose developmental, behavioral, and mental disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS


17 Clinical Competence DSM 5 - Jason H. King, PhD, DCMHS, ACS17 "The specific diagnostic criteria included in the DSM-IV are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion" (p. xxxii)

18 DSM 5 DSM 5 - Jason H. King, PhD, DCMHS, ACS18

19 DSM-IV-TR DSM 5 - Jason H. King, PhD, DCMHS, ACS19 Why diagnose? Most common diagnostic myth? A common misconception is that a classification of mental disorders classifies people, when actually what are being classified are disorders that people have. For this reason, the text of the DSM-IV (as did the text of DSM-III-R) avoids the use of expressions such as a schizophrenic or an alcoholic and instead uses the more accurate, but admittedly more cumbersome, an individual with Schizophrenia or an individual with Alcohol Dependence. (DSM-IV-TR, 2000, p. xxxi)

20 DSM 5 20 Backlash The National Institute for Mental Health has launched a plan to replace the DSM-5 with a new Research Domain Criteria (RDoC) project incorporating genetics, imaging, cognitive science, and other levels of information Stating that the DSM is little more than a dictionary, that the DSM criteria are unreliable, and that those diagnosed with mental disorders deserve better, NIMH Director Dr. Thomas Insel made the announcement this past week With its 1.5 billion dollar budget, NIMH is the major source of mental health research in the United States DSM 5 - Jason H. King, PhD, DCMHS, ACS

21 DSM 5 21 Dimensional assessments Better recognizes the complexity of the interface between psychiatry and medicine Defines disorders on the basis of positive symptoms distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms Organizational Changes The proposed framework for DSM-5 re-orders the current manuals 16 chapters based on underlying vulnerabilities as well as symptom characteristics The chapters are arranged by general categories such as neurodevelopmental, emotional and somatic to reflect the potential commonalities in etiology within larger disorder groups Such changes are aimed at facilitating more comprehensive diagnosis and treatment approaches and encourage research across diagnostic criteria DSM 5 - Jason H. King, PhD, DCMHS, ACS

22 DSM 5 22 Work Groups Clarify the boundaries between mental disorders to reduce confusion of disorders with each other and to help guide effective treatment Consider cross-cutting symptoms (symptoms that commonly occur across different diagnoses) Demonstrate the strength of research for the recommendations on as many evidence levels as possible Clarify the boundaries between specific mental disorders and normal psychological functioning DSM 5 - Jason H. King, PhD, DCMHS, ACS

23 DSM 5 23 What is the most significant change? Roman numerals have been attached to DSM since the second edition of the manual was published more than four decades ago But in the 21st century, when technology allows immediate electronic dissemination of information worldwide, Roman numerals are especially limiting DSM 5 - Jason H. King, PhD, DCMHS, ACS

24 DSM 5 DSM 5 - Jason H. King, PhD, DCMHS, ACS24 New definition of mental disorder A behavioral or psychological syndrome or pattern that occurs in an individual That reflects an underlying psychobiological dysfunction The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals) That is not primarily a result of social deviance or conflicts with society DSM IV-TR definition of mental disorder Mental Disorder unfortunately implies a distinction between 'mental' disorders and 'physical disorders' that is a reductionistic anachronism of mind/body dualism. A compelling literature documents that there is much 'physical' in 'mental disorders' and much 'mental' in 'physical' disorders Mental Disorders can generally be categorized as a clinically significant behavior or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom

25 DSM 5 25 Chapter Layout 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 Chapter Layout Somatic Symptom and Related Disorders Feeding and Eating Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse-Control, and Conduct Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

26 Neurodevelopmental Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS26

27 Neurodevelopmental Disorders 27 Intellectual Developmental Disorder Assessment of both cognitive capacity (IQ) and adaptive functioning – severity Communication Disorders Language disorder (which combines DSM-IV expressive and mixed receptive-expressive language disorders) Speech sound disorder (a new name for phonological 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 DSM 5 - Jason H. King, PhD, DCMHS, ACS

28 Neurodevelopmental Disorders 28 Autism Spectrum Disorders Merger of the following from DSM-IV: Autistic Disorder Aspergers Disorder Childhood Disintegrative Disorder, Pervasive Developmental Disorder Not Otherwise Specified ASD is characterized by 1) deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities (RRBs) Because both components are required for diagnosis of ASD, Social Communication Disorder is diagnosed if no RRBs are present DSM-IV was skewing Autism diagnoses towards children with social and communication difficulties As the APA puts it "delays in language are not unique nor universal in ASD" Lifting age requirement of 3 years Including sensory processing issues 1-3 Severity Rating (support, substantial, very substantial) DSM 5 - Jason H. King, PhD, DCMHS, ACS

29 Neurodevelopmental Disorders 29 ADHD Still 18 symptoms, cross-situational requirement strengthened to several symptoms in each setting Examples added to the criterion to facilitate application across the life span Age of onset: Several noticeable inattentive or hyperactive- impulsive symptoms were present by age 12 Presentations instead of Subtypes Comorbid diagnosis with ASD is now allowed Symptom threshold change for adults reflects their substantial evidence of clinically significant ADHD impairment with the cutoff for ADHD of five symptoms, instead of six required for younger persons, both for inattention and for hyperactivity and impulsivity DSM 5 - Jason H. King, PhD, DCMHS, ACS

30 Neurodevelopmental Disorders 30 Specific Learning Disorder Combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified Coded specifiers Motor Disorders Developmental coordination disorder, stereotypic movement disorder, Tourettes disorder, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder DSM 5 - Jason H. King, PhD, DCMHS, ACS

31 Schizophrenia Spectrum and Other Psychotic Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS31

32 Schizophrenia Spectrum and Other Psychotic Disorders 32 New Chapter Organization Schizotypal Personality Disorder Psychotic Disorder Associated with Medical Condition, Substance or Catatonia Changes Dropped subtypes Elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing) Addition of a requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech Clarification of negative symptoms Avolition Expressive deficits DSM 5 - Jason H. King, PhD, DCMHS, ACS

33 Bipolar and Related Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS33

34 Bipolar and Related Disorders 34 Overview Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood With mixed features 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) 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 Intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria DSM 5 - Jason H. King, PhD, DCMHS, ACS

35 Depressive Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS35

36 Depressive Disorders Disruptive Mood Dysregulation Disorder Underserved children who are often misdiagnosed as having Pediatric Bipolar NOS They do not show the same characteristics of individuals with classic bipolar disorder (ex: episodic grandiosity/elevated mood/manic episodes) Have developmentally inappropriate and significant difficulties Ages times per week for 12 months of verbal rages or physical aggression Premenstrual Dysphoric Disorder Major Depressive Disorder Chronic Depressive Disorder – the new Dysthymic Disorder Bereavement Exclusion 2 months versus 1-2 years DSM 5 - Jason H. King, PhD, DCMHS, ACS36

37 Anxiety Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS37

38 Anxiety Disorders 38 Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia) Deletion of the requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable This change is based on evidence that individuals with such disorders often overestimate the danger in phobic situations and that older individuals often misattribute phobic fears to aging Instead, the anxiety must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account 6-month duration, which was limited to individuals under age 18 in DSM-IV, is now extended to all ages Intended to minimize overdiagnosis of transient fears Panic Disorder Situationally bound/cued, situationally predisposed, and unexpected/uncued is replaced with unexpected and expected panic attacks DSM 5 - Jason H. King, PhD, DCMHS, ACS

39 Anxiety Disorders 39 Agoraphobia This change recognizes that a substantial number of individuals with agoraphobia do not experience panic symptoms Endorsement of fears from two or more agoraphobia situations is now required, because this is a robust means for distinguishing agoraphobia from specific phobias Criteria for agoraphobia are extended to be consistent with criteria sets for other anxiety disorders (e.g., clinician judgment of the fears as being out of proportion to the actual danger in the situation, with a typical duration of 6 months or more) Social Anxiety Disorder (Social Phobia) Generalized specifier replaced with a performance only specifier problematic in that fears include most social situations was difficult to operationalize distinct subset of social anxiety disorder in terms of etiology, age at onset, physiological response, and treatment response DSM 5 - Jason H. King, PhD, DCMHS, ACS

40 Anxiety Disorders 40 Separation Anxiety Disorder Core features remain mostly unchanged Wording of the criteria has been modified to more adequately represent the expression of separation anxiety symptoms in adulthood For example, attachment figures may include the children of adults with separation anxiety disorder, and avoidance behaviors may occur in the workplace as well as at school Diagnostic criteria no longer specify that age at onset must be before 18 years, because a substantial number of adults report onset of separation anxiety after age 18 Selective Mutism DSM 5 - Jason H. King, PhD, DCMHS, ACS

41 Obsessive Compulsive and Related Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS41

42 Obsessive Compulsive and Related Disorders 42 Clinical utility of grouping these disorders in the same chapter Reflects the increasing evidence that these disorders are related to one another in terms of a range of diagnostic validators With poor insight specifier refined to allow a distinction between individuals with good or fair insight, poor insight, and absent insight/delusional obsessive-compulsive disorder beliefs Tic-related specifier New disorders Hoarding disorder Excoriation (skin-picking) disorder Substance-/medication-induced obsessive-compulsive and related disorder Obsessive-compulsive and related disorder due to another medical condition DSM 5 - Jason H. King, PhD, DCMHS, ACS

43 Obsessive Compulsive and Related Disorders 43 Body Dysmorphic Disorder Diagnostic criterion describing repetitive behaviors or mental acts in response to preoccupations with perceived defects or flaws in physical appearance added consistent with data indicating the prevalence and importance of this symptom A with muscle dysmorphia specifier added reflects growing literature on the diagnostic validity and clinical utility of making this distinction in individuals with body dysmorphic disorder The delusional variant of body dysmorphic disorder no longer coded as both delusional disorder, somatic type, and body dysmorphic disorder DSM 5 - Jason H. King, PhD, DCMHS, ACS

44 Obsessive Compulsive and Related Disorders 44 Hoarding Disorder Available data do not indicate that hoarding is a variant of obsessive- compulsive disorder or another mental disorder evidence for the diagnostic validity and clinical utility of a separate diagnosis of hoarding disorder which reflects persistent difficulty discarding or parting with possessions due to a perceived need to save the items and distress associated with discarding them Hoarding disorder may have unique neurobiological correlates associated with significant impairment Excoriation (Skin-Picking) Disorder AKA: Dermatillomania, neurotic excoriation, pathologic skin picking compulsive skin picking, or psychogenic excoriation Repetitive and compulsive picking of skin which results in tissue damage DSM 5 - Jason H. King, PhD, DCMHS, ACS

45 Obsessive Compulsive and Related Disorders 45 Trichotillomania is now termed Trichotillomania (hair- pulling disorder) Other Specified and Unspecified Obsessive-Compulsive and Related Disorders Body-focused repetitive behavior disorder Characterized by recurrent behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors Obsessional jealousy Characterized by nondelusional preoccupation with a partners perceived infidelity Unspecified obsessive-compulsive and related disorder DSM 5 - Jason H. King, PhD, DCMHS, ACS

46 Trauma and Stressor-Related Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS46

47 Trauma and Stressor-Related Disorders AMHCA (2011) Standards for the Practice of CMHC Trauma training standards CACREP (2009) and (2016) PROFESSIONAL ORIENTATION AND ETHICAL PRACTICE c. counselors roles and responsibilities as members of an interdisciplinary emergency management response team during a local, regional, or national crisis, disaster or other trauma-causing event HUMAN GROWTH AND DEVELOPMENT c. effects of crises, disasters, and other trauma-causing events on persons of all ages APA-CoA (2007) Nothing COAMFTE (2005) Nothing CSWE (2008) Nothing DSM 5 - Jason H. King, PhD, DCMHS, ACS47

48 Trauma and Stressor-Related Disorders 48 Acute Stress Disorder Stressor criterion (Criterion A) changed requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly Criterion A2 regarding the subjective reaction to the traumatic event (e.g., the persons response involved intense fear, helplessness, or horror) eliminated evidence that acute posttraumatic reactions are very heterogeneous DSM-IVs emphasis on dissociative symptoms is overly restrictive Exhibit any 9 of 14 listed symptoms in these categories: intrusion, negative mood, dissociation, avoidance, and arousal Adjustment Disorders Reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing event Subtypes unchanged DSM 5 - Jason H. King, PhD, DCMHS, ACS

49 Trauma and Stressor-Related Disorders 49 Posttraumatic Stress Disorder Stressor criterion (Criterion A) is more explicit Criterion A2 (subjective reaction) eliminated Diagnostic thresholds lowered for children and adolescents separate criteria for children age 6 years or younger Now four symptom clusters in DSM-5 1. Reexperiencing 2. Avoidance Now with persistent negative alterations in cognitions and mood 3. Numbing includes new or reconceptualized symptoms & persistent negative emotional states 4. Arousal and reactivity includes irritable or aggressive behavior and reckless or self-destructive behavior DSM 5 - Jason H. King, PhD, DCMHS, ACS

50 Trauma and Stressor-Related Disorders 50 Reactive Attachment Disorder DSM-IV subtypes emotionally withdrawn/inhibited and indiscriminately social/disinhibited is now two DSM-5 distinct disorders result of social neglect or other situations that limit a young childs opportunity to form selective attachments 1. Reactive Attachment Disorder dampened positive affect more closely resembles internalizing disorders essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults 2. Disinhibited Social Engagement disorder more closely resembles ADHD may occur in children who do not necessarily lack attachments and may have established or even secure attachments DSM 5 - Jason H. King, PhD, DCMHS, ACS

51 Dissociative Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS51

52 Dissociative Disorders 52 Derealization Now included in the name and symptom structure of what previously was called Depersonalization Disorder and is now called Depersonalization/Derealization Disorder Dissociative Fugue Now a specifier of dissociative amnesia rather than a separate diagnosis Dissociative Identity Disorder Criterion A expanded includes certain possession-form phenomena functional neurological symptoms to account for more diverse presentations of the disorder Symptoms of disruption of identity may be reported as well as observed Gaps in the recall of events may occur for everyday Experiences of pathological possession in some cultures included Other text modifications clarify the nature and course of disruptions DSM 5 - Jason H. King, PhD, DCMHS, ACS

53 Somatic Symptom and Related Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS53

54 Somatic Symptom and Related Disorders 54 In DSM-IV, there is significant overlap across the somatoform disorders and a lack of clarity about their boundaries These disorders are primarily seen in medical settings, and nonpsychiatric physicians found the DSM-IV somatoform diagnoses problematic to use The DSM-5 classification reduces the number of these disorders and subcategories to avoid problematic overlap Removed Somatization Disorder Hypochondriasis Pain Disorder Undifferentiated Somatoform Disorder DSM 5 - Jason H. King, PhD, DCMHS, ACS

55 Somatic Symptom and Related Disorders 55 Somatic Symptom Disorder (Somatization Disorder and Undifferentiated Somatoform Disorder) Individuals with somatic symptoms plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed medical condition The relationship between somatic symptoms and psychopathology exists along a spectrum the arbitrarily high symptom count required for DSM-IV somatization disorder did not accommodate this spectrum The diagnosis of somatization disorder was essentially based on a long and complex symptom count of medically unexplained symptoms Maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to somatic symptoms DSM 5 - Jason H. King, PhD, DCMHS, ACS

56 Somatic Symptom and Related Disorders 56 Hypochondriasis Eliminated as a disorder, in part because the name was perceived as pejorative and not conducive to an effective therapeutic relationship Most individuals who would previously have been diagnosed with hypochondriasis have significant somatic symptoms in addition to their high health anxiety now receive a DSM-5 diagnosis of somatic symptom disorder Illness Anxiety Disorder In DSM-5, individuals with high health anxiety without somatic symptoms receive this diagnosis unless their health anxiety was better explained by a primary anxiety disorder, such as generalized anxiety disorder DSM 5 - Jason H. King, PhD, DCMHS, ACS

57 Somatic Symptom and Related Disorders 57 Pain Disorder In DSM-IV, this diagnoses assumes that some pains are associated solely with psychological factors, some with medical diseases or injuries, and some with both There is a lack of evidence that such distinctions can be made with reliability and validity, and a large body of research has demonstrated that psychological factors influence all forms of pain Most individuals with chronic pain attribute their pain to a combination of factors, including somatic, psychological, and environmental influences In DSM-5, some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain DSM 5 - Jason H. King, PhD, DCMHS, ACS

58 Somatic Symptom and Related Disorders 58 Psychological Factors Affecting Other Medical Conditions and Factitious Disorder Formerly included in the DSM-IV chapter Other Conditions That May Be a Focus of Clinical Attention Conversion Disorder (Functional Neurological Symptom Disorder) Criteria modified to emphasize the essential importance of the neurological examination, and in recognition that relevant psychological factors may not be demonstrable at the time of diagnosis DSM 5 - Jason H. King, PhD, DCMHS, ACS

59 Feeding and Eating Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS59

60 Feeding and Eating Disorders 60 Pica and Rumination Disorder The DSM-IV criteria for pica and for rumination disorder have been revised for clarity and to indicate that the diagnoses can be made for individuals of any age Avoidant/Restrictive Food Intake Disorder (DSM-IV Feeding Disorder of Infancy or Early Childhood) Was rarely used, and limited information is available on the characteristics, course, and outcome of children with this disorder A large number of individuals substantially restrict their food intake and experience significant associated physiological or psychosocial problems but do not meet criteria for any DSM-IV eating disorder Anorexia Nervosa Requirement for amenorrhea eliminated The wording of the criterion is changed for clarity, and guidance Criterion B is expanded to include overtly expressed fear of weight gain and persistent behavior that interferes with weight gain DSM 5 - Jason H. King, PhD, DCMHS, ACS

61 Feeding and Eating Disorders 61 Bulimia Nervosa Reduction in the required minimum average frequency of binge eating and inappropriate compensatory behavior frequency from twice to once weekly over 3 months, from 6 months Binge-Eating Disorder Extensive research followed the promulgation of preliminary criteria for binge eating disorder in Appendix B of DSM-IV, and findings supported the clinical utility and validity of binge-eating disorder Same time duration as Bulimia Nervosa Elimination Disorders No significant changes DSM 5 - Jason H. King, PhD, DCMHS, ACS

62 Sleep-Wake Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS62

63 Sleep-Wake Disorders 63 Overview Pediatric and developmental criteria and text are integrated where existing neurobiological and genetic evidence support such integration Greater specification of coexisting conditions is provided Primary Insomnia renamed Insomnia Disorder Distinguishes narcolepsy Which is now known to be associated with hypocretin deficiency, from other forms of hypersomnolence Removed Sleep disorders related to another mental disorder Sleep disorder related to a general medical condition this change underscores that the individual has a sleep disorder warranting independent clinical attention DSM 5 - Jason H. King, PhD, DCMHS, ACS

64 Sleep-Wake Disorders 64 Breathing-Related Sleep Disorders Obstructive Sleep Apnea Hypopnea Central Sleep Apnea Sleep-Related Hypoventilation this change reflects the growing understanding of their pathophysiology Circadian Rhythm Sleep-Wake Disorders Expanded to include… advanced sleep phase syndrome irregular sleep-wake type non-24-hour sleep-wake type, jet lag type removed Rapid Eye Movement Sleep Behavior Disorder and Restless Legs Syndrome In DSM-IV both are included under Dyssomnia Not Otherwise Specified Their full diagnostic status is supported by research evidence DSM 5 - Jason H. King, PhD, DCMHS, ACS

65 Sexual Dysfunctions DSM 5 - Jason H. King, PhD, DCMHS, ACS65

66 Sexual Dysfunctions 66 Overview In DSM-IV, sexual dysfunctions referred to sexual pain or to a disturbance in one or more phases of the sexual response cycle. Research suggests that sexual response is not always a linear, uniform process and that the distinction between certain phases (e.g., desire and arousal) may be artificial Gender-specific sexual dysfunctions added For females, sexual desire and arousal disorders have been combined into one disorder: female sexual interest/arousal disorder To improve precision regarding duration and severity criteria and to reduce the likelihood of overdiagnosis, all of the DSM-5 sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require a minimum duration of approximately 6 months and more precise severity criteria DSM 5 - Jason H. King, PhD, DCMHS, ACS

67 Sexual Dysfunctions 67 Genito-Pelvic Pain/Penetration Disorder Represents a merging of the DSM-IV categories of Vaginismus and Dyspareunia, which were highly comorbid and difficult to distinguish Sexual Aversion Disorder removed due to rare use and lack of supporting research Subtypes Includes only lifelong versus acquired and generalized versus situational subtypes To indicate the presence and degree of medical and other nonmedical correlates: partner factors, relationship factors, individual vulnerability factors, cultural or religious factors, and medical factors DSM 5 - Jason H. King, PhD, DCMHS, ACS

68 Gender Dysphoria DSM 5 - Jason H. King, PhD, DCMHS, ACS68

69 Gender Dysphoria 69 Reflects a change in conceptualization of the disorders defining features by emphasizing the phenomenon of gender incongruence rather than cross-gender identification per se, as was the case in DSM-IV gender identity disorder Considered to be a multicategory concept rather than a dichotomy Acknowledges the wide variation of gender-incongruent conditions In the wording of the criteria, the other sex is replaced by some alternative gender Gender instead of sex is used systematically because the concept sex is inadequate when referring to individuals with a disorder of sex development Criterion A (cross-gender identification) and Criterion B (aversion toward ones gender) merged no supporting evidence from factor analytic studies supported keeping the two separate DSM 5 - Jason H. King, PhD, DCMHS, ACS

70 Gender Dysphoria 70 Separate criteria sets are provided for Gender Dysphoria in children and in adolescents and adults Child criteria strong desire to be of the other gender replaces the previous repeatedly stated desire to capture the situation of some children who, in a coercive environment, may not verbalize the desire to be of another gender Criterion A1 (a strong desire to be of the other gender or an insistence that he or she is the other gender...) is now necessary (but not sufficient), which makes the diagnosis more restrictive and conservative Subtypes and Specifiers The subtyping on the basis of sexual orientation removed A posttransition specifier added many individuals, after transition, no longer meet criteria for gender dysphoria; however, they continue to undergo various treatments to facilitate life in the desired gender DSM 5 - Jason H. King, PhD, DCMHS, ACS

71 Disruptive, Impulse-Control, and Conduct Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS71

72 Disruptive, Impulse-Control, and Conduct Disorders 72 Overview These disorders are all characterized by problems in emotional and behavioral self-control Antisocial Personality Disorder has dual listing in this chapter and in the chapter on personality disorders ADHD is frequently comorbid with the disorders in this chapter but is listed with the neurodevelopmental disorder Intermittent Explosive Disorder Minimum age of 6 years (or equivalent developmental level) now required Physical aggression, verbal aggression, and nondestructive/ noninjurious physical aggression specific criteria defining frequency needed to meet criteria and specifies that the aggressive outbursts are impulsive and/or anger based in nature must cause marked distress, impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences DSM 5 - Jason H. King, PhD, DCMHS, ACS

73 Disruptive, Impulse-Control, and Conduct Disorders 73 Oppositional Defiant Disorder Four refinements 1. symptoms are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness This change highlights that the disorder reflects both emotional and behavioral symptomatology 2. exclusion criterion for conduct disorder removed 3. a note added to the criteria to provide guidance on the frequency typically needed for a behavior to be considered symptomatic of the disorder 4. a severity rating added to reflect research showing that the degree of pervasiveness of symptoms across settings is an important indicator of severity Conduct Disorder A descriptive features specifier with limited prosocial emotions callous and unemotional interpersonal style across multiple settings and relationships DSM 5 - Jason H. King, PhD, DCMHS, ACS

74 Substance-Related and Addictive Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS74

75 Substance-Related and Addictive Disorders 75 Substance Use Disorder No more Substance Abuse and Substance Dependence Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system Utah DOPL "Substance Use Disorder Counselor Criteria nearly identical to the DSM-IV substance abuse and dependence criteria combined into a single list threshold = 2 removed: recurrent legal problems criterion added: craving or a strong desire or urge to use a substance Criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

76 Substance-Related and Addictive Disorders 76 Substance Use Disorder Remission specifiers No more partial and full Early remission = at least 3 but less than 12 months without substance use disorder criteria (except craving) Sustained remission = at least 12 months without criteria (except craving) Severity ratings 2–3 criteria indicate = a mild disorder 4–5 criteria = moderate disorder 6 or more = a severe disorder Substance Use Disorder Removed Polysubstance Abuse/Dependence Amphetamine Cocaine Specifier for a physiological subtype On agonist therapy Added Caffeine Withdrawal Cannabis Withdrawal Tobacco-Related Disorder Stimulant –Related Disorder On maintenance therapy DSM 5 - Jason H. King, PhD, DCMHS, ACS

77 Substance-Related and Addictive Disorders 77 Gambling Disorder This change reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance use disorders to a certain extent Lowering of the pathological gambling threshold to 4 symptoms Removal of the illegal acts criterion for the disorder Why not other Addictive Disorders such as Process Addictions proposed by Dr. Kevin McCauley? Sex Relationships Codependency Cults Performance Compulsive spending Rage/violence Media/entertainment DSM 5 - Jason H. King, PhD, DCMHS, ACS

78 Neurocognitive Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS78

79 Neurocognitive Disorders 79 Delirium The criteria for delirium have been updated and clarified on the basis of currently available evidence Major and Mild Neurocognitive Disorder (NCD) Dementia and Amnestic Disorder are subsumed The term dementia is not precluded from use in the etiological subtypes where that term is standard Diagnostic criteria are provided for both major NCD and mild NCD, followed by diagnostic criteria for the different etiological subtypes Threshold between mild NCD and major NCD is inherently arbitrary Individuals with Alzheimers disease, cerebrovascular disorders, HIV, traumatic brain injury, Parkinsons disease, Huntingtons disease, Picks disease, Creutzfeldt-Jakob disease, and other medical conditions specified Updated listing of neurocognitive domains is also provided DSM 5 - Jason H. King, PhD, DCMHS, ACS

80 Personality Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS80

81 Personality Disorders 81 Overview The criteria has not changed from those in DSM-IV Revised personality functioning criterion (Criterion A) developed based on a literature review of reliable clinical measures of core impairments central to personality pathology With a single assessment of level of personality functioning, a clinician can determine whether a full assessment for personality disorder is necessary Diagnostic thresholds for both Criterion A and Criterion B set empirically to minimize change in disorder prevalence and overlap with other personality disorders and to maximize relations with psychosocial impairment 2012 proposed criteria: IV%20and%20DSM- 5%20Criteria%20for%20the%20Personality%20Disorders% pdf DSM 5 - Jason H. King, PhD, DCMHS, ACS

82 Paraphilic Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS82

83 Paraphilic Disorders 83 Specifiers in a controlled environment and in remission Change to Diagnostic Names In DSM-5, paraphilias are not ipso facto mental disorders There is a distinction between paraphilias and paraphilic disorders A paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others A paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, A paraphilia by itself does not automatically justify or require clinical intervention Thus, for example, DSM-IV Pedophilia has become DSM-5 Pedophilic Disorder DSM 5 - Jason H. King, PhD, DCMHS, ACS

84 Cultural Formulation Interview DSM 5 - Jason H. King, PhD, DCMHS, ACS84

85 Cultural Formulation Interview (CFI) 85 Set of fourteen questions that clinicians may use to obtain information during a mental health assessment about the impact of culture on key aspects of care The CFI emphasizes four main domains: 1. Cultural Definition of the Problem 2. Cultural Perceptions of Cause, Context, and Support 3. Cultural Factors Affecting Self Coping & Past Help Seeking 4. Current Help Seeking DSM 5 - Jason H. King, PhD, DCMHS, ACS

86 Conclusion DSM 5 - Jason H. King, PhD, DCMHS, ACS86

87 Conclusion DSM 5 - Jason H. King, PhD, DCMHS, ACS87


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