Counselors & The DSM- IV-TR

Counselors & The DSM- IV-TRCharles Pemberton, Ed.D.,LPCC

Robin Adams

Why do we need this book? Communication Classification Research Payment

Conceptualization of DSM Syndromes Criteria Normal vs. Abnormal Dimensional vs. Categorical Problems

Labeling Meeting some criteria Impairment??

Organization of DSM Major Groupings

Childhood* Dementia Substance Schizophrenia Mood Anxiety Somatoform Factitious

Dissociative Sexual and Gender Eating Sleep Adjustment Personality

Organization of each D/O Diagnostic Features

Episode Associated Culture, Age and Gender

Prevalence Familial Pattern Differential Diagnosis Criteria

General Criteria of DSM (these apply to all disorders)

Disorder not due to direct effects of a substance.

Disorder not due to direct effects of a general medical condition.

Disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Precedence of Dx “not due to the direct effects of a

substance…” “has never met the criteria for…”bipolar vs. MDD

“does not meet the criteria for…”ODD vs. CD

“does not occur exclusively during the course of ….”ADHD vs. PDD

“not better accounted for by…”ADHD vs. Mood/Anxiety

AXIS Axis I : Clinical Disorders Axis II: Personality Disorder and Mental

Retardation Axis III: General Medical Condition Axis IV: Psychosocial and Environmental

Problems Axis V: Global Assessment of Functioning

Numbering System and Specifiers Numbers

Follows ICD 10 format First three numbers Last two numbers

Text Specifiers Severity (Mild, Moderate, Severe) Timing (Seasonal, Rapid Cycling, Partial/Full

Remission)

Attention Deficit Hyperactivity Disorder

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

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

turn, etc.) Fidgetiness Excessive talking

Prevalence of ADHD

Estimated at 3-7% of school age children More common in males than females Often diagnosed during elementary school

years.

Differential Diagnosis of ADHD Must distinguish from age-appropriate

behaviors Mental Retardation or Learning Disability Oppositional behavior (ODD, Conduct D/O) Stereotypic Movement D/O Behavior due to medications Mood or Anxiety D/O

Subtypes of ADHD 314.01 ADHD, Combined Type

Criteria A1 & A2 both met for past 6 months 314.00 ADHD, Inattentive Type

Criteria A1 met, but not A2 314.01 ADHD, Hyperactive-Impulsive Type

Criteria A2 met, but not A1 314.9 ADHD NOS

Prominent symptoms but do not meet diagnostic criteria

Diagnostic Criteria for ADHD A 1. Must exhibit 6 or more symptoms of

inattention, persisting for minimum of 6 months: from list of 9 items, a through i.

A 2. Must exhibit 6 or more symptoms of hyperactivity-impulsivity, persisting for minimum of 6 months, from list of 9 items, a through i.

Diagnostic Criteria, cont’d: B. symptom onset PRIOR to age 7 years C. impairment present in two or more

environments D. clear clinically significant impairment in

functioning E. cannot be accounted for by other mental

disorder

Diagnostic Presentation of ADHD Symptoms will vary based on age. More common in males than females. Hyperactivity may manifest as internal feeling of

restlessness for older individuals, versus fidgeting. No test exists to “diagnose” ADHD. Several

instruments measure symptomatology that is associated with ADHD, but only way to diagnose is through clinical impression and observation.

Mood Disorders

• “disorders that have a disturbance in mood as the predominant feature”

• Divided into Depressive Disorders and Bipolar Disorders

Other Mood Disorders Major depressive Disorder Dysthymic Disorder Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder

MDD, Major Diagnostic Features One or more Major Depressive Episodes No Hx of Manic, Mixed or Hypomanic Single Episode or Recurrent Severity:

Mild – 5 or 6 symptoms, Moderate Severe – most of symptoms are met

Severe can be with or without psychotic features

Prevalence of MDD

Lifetime estimates of 10% – 25% for women and 5% - 12% for men

Appear unrelated to ethnicity, education, income or martial status

Differential Diagnosis of MDD Mood D/O due to General Medical Condition Substance-Induced Mood D/O MDD and Dysthymic D/O differentiated by

severity, chronicity and persistence Schizoaffective D/O has delusions or

hallucinations

Major Depressive Episode Five or more in same 2 week period and change

from previous functioning: Depressed mood most of the day, nearly every day Diminished interest or pleasure in almost all activities Significant weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Loss of energy Feelings of worthlessness or guilt Diminished ability to think or concentrate Recurrent thoughts of death

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

Diagnostic Criteria for MDD A. Presence of Major Depressive Episode B. Not better accounted fore by

Schizoaffective D/O, not superimposed on Schizophrenia, Schizophreniform Delusional or psychotic D/O NOS

C. Never been a Mixed, Manic or Hypomanic Episode

Diagnostic Criteria Recurrent: Same with two or more Major Depressive

Episodes

Specifiers Mild Moderate Severe without Psychotic Features Severe with Psychotic Features

Mood Congruent Mood Incongruent

In partial Remission In Full Remission

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

References American Psychiatric Association: Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

Fauman, M. A. (2002). Study Guide to DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.