Sophia F. Dziegielewski, Ph.D., LISW

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Identify the diversity, necessity, and limitations for usage of the
DSM-IV-TR in the practice environment.
List specific changes between the DSM-III-R, DSM-IV, and DSM-IV-
TR.
Utilize the multi-axis diagnostic system with children, adolescents, and adults.
Acquire familiarity with the major diagnostic categories and the criteria for proper diagnostic assessments and evaluations.
Acquire several different practice strategies currently being used to address the diagnostic categories provided.
Identify the DSM disorders as viewed within the context of the DSM-
IV Text Revisions published in 2000 and expected changes for DSM-
5.
Identify criteria through case applications within the multi-axis diagnostic system with children, adolescents, and adults.

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The DSM-IV-TR (2000) replaced the DSM-IV and the DSM-III-R with coding changes remaining the same since January 1995.
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Next edition scheduled for May 2013.
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Use of the DSM is recommended for trained professionals.

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Cultural Issues and Cultural-bound
Syndromes
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Research and Clinical Field Trials
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Clinical Findings and Supportive
Information
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DSM-5 expected publication 2013

Culture-bound Syndromes: these conditions resemble the symptoms of a mental disorder but are related directly to the cultural context as relevant to clinical care
 brain fag
 ataque de nervios
 rootwork

Research Changes:
(1)
(2)
(3) literature reviews data analysis and re-analysis field trials
DSM-IV-TR clearly reflects the importance of research to differentiate the diagnostic categories.

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Research Changes:
DSM-5
“Still Very Much a Work in Progress”
For a short-time period (till April 20, 2010) the proposed criteria were available for public comment: http://www.dsm5.org
13 Work groups in process
Task force of 27 members is overseeing the process

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Overview of Suggested Changes for DSM-5
Possibly eliminate Axis I, II, and III
Use a dimensional system where various disorders will be coded as mild, moderate, and severe
Introduce new suicide assessment scales, one for adolescents and one for adults
Several new disorders proposed and some name changes to existing disorders
Personality disorders will be completely restructured

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Appendix for Behavioral Addictions
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Gambling (thus far is the sole disorder)
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Internet Addiction (is being considered)
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Introducing a new section on suicide scales to help assess adults and adolescents

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New “risk syndromes” category designed to help clinicians identify stages of some serious mental health disorders with scales that include research-based criteria

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Diagnosis Deferred: information is inadequate to make a formal diagnostic judgment.
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Rule Out

Axis I
Axis II
Axis III
Axis IV
Axis V

DSM-IV-TR: Pervasive Developmental Disorders,
Learning Disorders, Motor Skills Disorders,
Communication Disorders, and Other Conditions that may be Focus of Clinical Attention
Generally, all clinical syndromes are coded here (e.g.,
Mood Disorders, Schizophrenia, Dementia, Anxiety
Disorders, Substance Disorders, Disruptive Behavior
Disorders, etc.) and all other codes that are not attributed to a mental disorder but are the focus of treatment (e.g., V codes).

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Academic Problem: underachievers
Childhood or Adolescent Antisocial Behavior: isolated acts
Adult Antisocial Behavior: e.g., professional thieves, dealers
Borderline Intellectual Functioning: IQ between 71 and 84
Malingering: voluntary mental or exaggerated physical symptoms, with an obvious recognizable goal
Bereavement
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Medication-induced Movement Disorders:
Neuroleptic Malignant Syndrome and Tardive Dyskinesia
Acculturation Problem: exposure to living in a new culture
Aging Associated Cognitive Decline: normal aging causes stress or impairment

Personality Disorders
Mental Retardation

General Medical Conditions
• Hearing Impairment
• Vision Impairment
• Mixing Medical and Mental
Physical (medical) conditions relevant to the condition being treated are listed here.

DSM-IV-TR: Psychosocial and Environmental
Problems/Stressors
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The stressors can be clarified with specifics: problems with primary support problems related to social environment educational problems occupational problems
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• housing problems economic problems problems with access to health care services
• problems related to interaction with the legal system and other psychosocial problems

Global Assessment of Functioning (GAF)
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GAF is a scale of 100 points
The higher the number the higher the level of functioning
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The GAF still covers both symptomology and level of functioning.
The highest level of functioning is determined and rated.
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CGAF and FARS are two assessment measures used with children to supplement the DSM

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Mental Retardation (will probably change to
Intellectual Disability)
Pervasive Mental Disorders (will probably change to Autism Spectrum Disorders)
Conduct and Oppositional Defiant Disorder
Elimination Disorders
ADHD

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The majority of Mental Health Professionals agree: that diagnosing in children is a difficult and delicate task that any professional other than a specialist trained in the area should not diagnosis that the younger the child the more difficult the task many children are taking medications and over 80% of the WORLD’S supply of Ritalin (for ADHD) is given in the United States
Exercise, diet, and sleep

IQ 71-84, Code on Axis II.

If present, always diagnose it.
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Must have significantly sub-average intelligence and deficits in adaptive functioning.
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Adaptive functioning means how individuals cope with life demands and meet expectations of activities of daily living.
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Definition is compatible with AAMR definition except for sub-typing.

Onset prior to age 18 — if after it is Dementia.
Must have IQ of 70 or below on an individual IQ test (5 point error margin).
This disorder is slightly more common in males.

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MILD:
IQ approximately (50-55) 55 to 70, considered educable , able to perform at 6th grade level, can use minimal assistance may need some supervision and guidance, live in community or in supervised settings
MODERATE:
IQ approximately (35-40) 35 to 55 (50-55), considered trainable , able to perform at 2nd grade level, with moderate supervision can attend to their own personal care, can perform unskilled or semi-skilled work, can live in the community
SEVERE:
IQ approximately (20-25) 20 to 35, (35-40) generally institutionalized, have little or no communicative speech, possible group home
PROFOUND:
IQ below 20, generally total care

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Involve multiple functions and behaviors that are not considered normal at any age.
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Qualitative impairment in: reciprocal interaction, verbal and nonverbal skills, imaginative activity, and intellectual skills.

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Severe form, onset in infancy or childhood, self-stimulating, and self-injuring behaviors often present, (i.e., rocking, spinning, head banging)
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2/3 of Autistic are mentally retarded/moderate range
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Facilitative communication is used
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NO PROOF THAT CONDITION IS RELATED TO PARENTING
STYLES
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Age of onset requirement in DSM-IV is age 3

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Rett’s Disorder
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Childhood Disintegrative Disorder
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Asperger's Disorder

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Only in females
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Deceleration of head growth, start out normal and 5 to 24 months problems develop
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Loss of previously acquired hand skills, loss of social engagement, appearance of stereotyped movements, impaired language functioning Generally associated with severe or profound mental retardation
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DSM-IV-TR highlights now that many of these cases are related to a specific genetic mutation

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Normal development for two years then a drastic decline
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Followed by a loss of previously acquired skills and development of autistic like symptoms

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Autistic-like symptoms
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Severely impaired social interaction
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DSM-IV-TR Since this is a new category major revisions have been made to this section

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Asperger’s
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Autism

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Will suggest new categories for the learning disorders and create a category called Autism
Spectrum Disorders, will incorporate aspects of all the current disorders.
ASD will be categorized as mild, moderate, and severe
Groups in opposition have already been formed.

Learning Disabilities: These disorders have significant difficulties in acquisition of listening, speaking, reading, writing, reasoning, and math.
• Significant delay in skill level (2 standard deviations below the mean)
• Generally noted between ages of 8 and 13
• More common in boys than girls
• Kids don't always catch up—continues into adulthood
• Involve specific functions—not multiple like pervasive—the behavior is characteristic of an earlier state of development
Social Work Treatment: Generally behavioral in nature

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Symptoms now in grouped in four categories:
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Aggression to people and animals
Destruction of property
Deceitfulness or theft
Serious violations of rules

Two items were added to increase applicability to females:
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Staying out at night
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Intimidating others

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New subtypes based on age of onset
Childhood onset and adolescent onset
Onset before age 10 has a poor prognosis
When 18 used to be diagnosed anti-social but now can remain into early 20s because not all conduct disorders become antisocials

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Based on research deleted from the criteria "uses obscene language."
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Also increased clarification on clearly establishing the deviation from what could be considered normal.
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DSM-IV-TR clarifies that many children with
Oppositional Disorder do not develop conduct disorder.

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Do not meet the full criteria for conduct or oppositional disorder but have clinically significant impairment

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Severe mood dysregulation
Helps to distinguish children who have recurrent behavioral outbursts (severe and inappropriate)
Helps adolescents from bipolar and severe mood dysregulation, irritability, and behavior outbursts

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Diagnosis explosion of bipolar in children since 1994
Severe irritability and handling behavior outbursts that could be considered/confused with mania
Outbursts need to be severe and developmentally inappropriate

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ADHD—TDDD is more aggressive
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Bipolar—TDDD more continuous and not cyclic
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Disruptive Behavior Disorder—mood is more labile

ALWAYS GET A PHYSICAL FIRST
NOT DUE TO A PHYSICAL or MEDICAL DISORDER
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Enuresis:
Elimination of urine during day or night
Must be age 5 before it can be diagnosed
Remember that a diagnosis can be made before thresholds are met, if clinical significance can be established
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Encopresis:
Repeated elimination of feces in inappropriate places
One time a month for 3 months (used to be 6 months)
Must be at least four years of age to diagnose

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Must last at least six months
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Predominately inattentive, hyperactivityimpulsivity
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Combined symptoms required in two or more situations: home, work, or at school

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Can occur in adulthood but must have onset in childhood (generally before age 7)
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Not intellectual deficits just attention and concentration
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Etiology: unknown, hereditary link, tends to run in families, more common in males

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Will make it easier to diagnose ADHD in adults
Number of symptoms will be reduced from six to three
In adults will no longer have to have symptoms before the age of 7 will probably change to 12 years old

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Evaluate by a neurologist or physician
(medical check)
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Exercise, sleep habits, and diet
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Medication

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Short-acting
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Long-acting
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Non-stimulant

It is compelling to think about changing to a new long-acting medication because of the convenience of once-a-day dosing and their long lasting effects, but it is important to remember that they shouldn't be any more effective than a short-acting medicine.

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Ritalin (Methylphenidate HCl)
Methylin Chewable Tablet and Oral Solution
Metadate ER
Methylin ER
Focalin
Dexedrine (Dextroamphetamine sulfate)
Dextrostat
Adderall
Adderall (generic)
Dexedrine Spansules

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Ritalin, Metadate (age 6 and older)
Ritalin-SR (Methylphenidate) (age 6 and older)
Concerta (Methylphenidate Extended Release) (age 6 and older)
Adderall (Dextroamphetamine and Amphetamine) (age 3 and older)
Desoxyn (Methamphetamine)
Provigil (Modafanil)
Cylert* (Pemoline) (age 6 and older)
*because of potential for serious side effects to the liver, not usually used as a first line for ADHD
Focalin (dexmethlphenidate) (age 6 and older)

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The long-acting stimulants generally have a duration of 8-12 hours and can be used just once a day.
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They are especially useful for children who are unable or unwilling to take a dose at school.

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The latest medication to get approval to treat ADHD is Vyvanse, a long-acting stimulant.
This stimulant is similar to Adderall with a main ingredient of lisdexamfetamine dimesylate, a derivative of one of the ingredients in Adderall.
Initially available in 30mg, 50mg, and 70mg capsules, newer 20mg, 40mg, and 60mg capsules.

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This is a methyphenidate or Ritalin patch.
The patch is available in 10mg, 15mg, 20mg, and 30mg dosages.
Patch can be worn for about nine hours at a time on a child's hip.
The medication works for a few more hours once you take the patch off.

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Approved for use in children over the age of six years, although regular Adderall can be used in younger children from 3-5 years of age.
Adderall XR is a sustained release form of Adderall, a popular stimulant which contains dextroamphetamine and amphetamine.
Available as a 10mg, 15mg, 20mg, 25mg, and
30mg capsule.
The capsule can be opened and sprinkled onto applesauce if your child can't swallow a pill.

When medication alone is not enough consider:
(A) Is there an accurate diagnosis?
(B) Help families deal with the child at home (e.g., parenting styles reinforce negative behaviors).
(C) Help teachers deal with child at school (e.g., sit in least distracting section of the class, away from the door).
(D) May need academic "catch up" help (e.g., computers are an excellent tool for these children).
(E) Allow these children "more time" to complete tasks.
(F) Address self-esteem issues in counseling.

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PICA
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Anorexia Nervosa: intense fear of gaining weight, usually underweight, disturbance in body image, won’t eat, overexercise, often have amenorrhea, refusal to maintain minimum normal body weight, resistance to treatment with strong denial, onset during late adolescence (12-18) and can go into 30s, individuals can die from starvation, 1/2 anorectics are bulimics, common co-conditions: substance abuse and depression
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Bulimia Nervosa: episodes of binge eating (recurring), selfinduced vomiting with laxatives, diuretics or fasting, sense of lack of control during eating binges, chronic concern with body weight and shape, two binges per week for three months

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Substance Abuse: viewed as less severe, continued use, knowing it is causing harm, does not apply to caffeine and nicotine
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Substance Dependence: taking larger amounts with unsuccessful attempts to quit
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Substance Intoxication: the development of a substance specific (reversible) syndrome, condition related to recent ingestion of psychoactive substance
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Substance Withdrawal: follows termination of a psychoactive substance (Abstinence Syndrome)

Types of Substances Include: alcohol, amphetamines, cocaine, caffeine, hallucinogens, inhalants, nicotine, opioids, phencyclidine (PCP), cannabis, and sedatives-hypnoticsanxiolytics
Polysubstance Dependence: the criteria for abuse or dependence for any one substance is not met, the client abuses more than one substance and groups them together

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Will eliminate substance abuse and dependence and replace it with a new category “addiction and the related disorders.”
Will include substance use disorders with each drug identified in its own category.
Eliminate the category of dependence, will help to differentiate between those that are drug seeking and those that have developed tolerance (from withdrawal).

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Each drug will have its own category
A new category of behavioral addictions will be added (behavioral addictions, only one so far and internet addiction is mentioned in the appendix)
Discontinuation syndromes: related to TCA’s and the SSRI’s

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When NOT working in the area of substance use/abuse a social worker should never counsel a client actively using and influenced by a substance.
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The client needs to be referred for detoxification, or rescheduled when not under the influence.
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Twelve months is required for a client to achieve sustained remission.

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In the DSM-IV-TR all substance related conditions are now grouped in one category and in DSM-IV-TR much clarification was used to outline the different areas and substances.

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Be sure the relationship between dependence and withdrawal is noted
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Almost always when dependence is an issue treat the substance first

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This section brings together three sections listed separately in DSM-III-R Schizophrenia, Delusional Disorder, and
Psychotic Disorder: Not Elsewhere Classified.
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Active phase has been increased from one week to one month. Now also includes two new negative symptoms: alogia
(i.e., fluency and productivity of speech) and volition (i.e., goal directed behavior and drive).
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DSM-IV-TR subtypes not clearly supported in research.
Added concept of SCHIZOPHRENIA SPECTRUM: represents the range of disorders that are more likely to occur in family members of individuals with schizophrenia (Schizoaffective
Disorder, Schizotypal Personality Disorder, etc.).

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Hallucinations
Delusions
Associative Disturbances
Affect and Mood
Alogia
Avolition
Ambivalence
Autism

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Brief Reactive Psychosis: 3-day-schizophrenia, symptoms have existed no longer than a month (at least a few hours) sudden onset
**no longer must have direct link to a severe psychosocial stressor
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Schizophreniform Disorder: less than six months
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Schizoaffective Disorder: mood disorder and schizophrenia. Now it focuses on an uninterrupted phase of illness rather than a lifetime pattern of symptoms. In this disorder the schizophrenia is described with periods of major depressive, manic, or mixed episodes
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Shared Psychotic Disorder/Induced Psychotic Disorder: Folie a Deux, a delusion develops in one related to the delusional belief of another
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Substance Induced Psychotic Disorder: includes both organic delusional disorder and organic hallucinosis

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Possibly add new diagnosis
Psychosis Risk Syndrome
Subtype categories will be eliminated

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Chlorpromazine (Thorazine) (introduced in the
1950s)
Thioridazine (Mellaril) (age 2 and older)
Trifluoperazine (Stelazine)
Phenazine (Prolixin)
Haloperidol (Haldol) (age 3 and older)
Loxapine (Loxitane)
Thiothixene (Navane)

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Clozaril (Clozapine) (Introduced again in 1990)
(age 18 and older)
Risperdal (Risperidone) (age 18 and older)
Zyprexa (Olanzapine) (age 18 and older)
Seroquel (Quetiapine) (age 18 and older)
Geodon (Ziprasidone)
Abilify (Aripiprazole)—Schizophrenia,
Alzheimer's, psychosis
Orap (Pimozide) (age 12 and older for
Tourette’s) (side effects: weight gain and diabetes)
*Brand names listed first.

Parkinsonian or Extra-Pyramidal (EPS) Side Effects include:
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Dystonia—Acute contractions of the tongue (stiff or thick tongue)
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Akathisia—Most common form of EPS (e.g., inner restlessness)
Tardive Dyskinesia—This is a permanent neurological condition that can result from using the older antipsychotic medications and not taking anything to help control the EPS side effects

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Combines active ingredients of two well-known brand medications—Prozac and Zyprexa.
As of 2006, approved for treatment resistant depression.
Prior to this, used for symptoms of schizophrenia and the down-phase of bipolar disorder.
Since NEW use, monitor/report resultant side effects.
Combines both drugs and has same types of warning and concerns for both drugs. For example, Symbyak is not approved for use with elderly individuals that suffer from dementia similar to Zyprexa (NIMH, 2009).

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Major Depressive Episode: loss of interest and pleasure for at least 2 weeks
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Manic Episode: elevated an expansive mood for at least 1 week
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Mixed Episode: alternating moods that last at least 1 week, must
 meet criteria for both manic and depressive almost daily
Hypomanic Episode: expansive, irritable, and elevated mood that lasts at least 4 days

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Bipolar I
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Bipolar II
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Cyclothymia
(We expect major changes in this criteria with regard to children in DSM-5)
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Major Depressive Disorder
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Dysthymia (different criteria for children)

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Bipolar I Disorder: one or more manic episodes, usually with a history of depressive episodes (can have psychotic aspects)
Bipolar II Disorder: one or more depressive with at least one hypomanic episode, no psychosis
Cyclothymic Disorder: persistent mood disturbance lasting at least two years, must not be without for two months, less severity than bipolar
Bipolar Disorder NOS

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Major Depressive Disorder: one or more major depressive episodes, episodes must last at least two weeks
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Dysthymia: two-year history of depressed mood, must not be without for two months, less severity than major depression, constant for a period of two years (children one year agitated depression)

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More information on co-morbidity of alcohol and substance abuse (Bipolar Disorders)
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Major Depressive Disorder: now the symptoms must last two months after loss of a loved one
(used to be two weeks) tried to separate from condition called Bereavement.
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Dysthymia—in DSM-IV-TR—outcome is better with active treatment

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New diagnosis proposed: mixed anxiety depression.
Each mood disorder diagnosis is accompanied by some type of anxiety dimension.
A rating of anxiety should be included from 0
(no anxiety) to 4 (severely anxious with 5 symptoms and motor agitation).

Tricyclics (TCA): Examples of TCAs include:
• Tofranil (generic name Imipramine)
• Elavil/Amitriptyline
MAO Inhibitors: Many dietary restrictions, no foods with the chemical tyramine (e.g., cheese, beef or chicken liver, pickled herring, red wine, chocolate, coffee, raisins, pineapple, bananas)
• Eldepryl (Selegiline)
Other Anti-Depressants: Selective Serotonin Re-uptake Inhibitors (SSRIs).
• Prozac/Fluoxetine
• Paxil/Paroxetine hydrochloride
• Zoloft
Side effect of the SSRIs: sexual disinterest and ORGASMIC DELAY

In 2004, the FDA ordered the strongest safety warning possible:
Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. (Prozac is the exception.)
In 2006 added “young adults.”

Anafranil (clomipramine)
Asendin (amoxapine)
Aventyl (nortriptyline)
Celexa (citalopram hydrobromide)
Cymbalta (duloxetine)
Desyrel (trazodone HCl)
Effexor (venlafaxine HCl)
Elavil (amitriptyline)
Etrafon (perphenazine/amitriptyline)
Fluvoxamine maleate
Lexapro (escitalopram hydrobromide)
Limbitrol (chlordiazepoxide/amitriptyline)
Ludiomil (maprotiline)
Marplan (isocarboxazid)
Nardil (phenelzine sulfate)
Norpramin (desipramine HCl)
Pamelor (nortriptyline)
Parnate (tranylcypromine sulfate)
Paxil (paroxetine HCl)
Pexeva (paroxetine mesylate)
Prozac (fluoxetine HCl)
Remeron (mirtazapine)
Sarafem (fluoxetine HCl)
Serzone (nefazodone HCl)
Sinequan (doxepin)
Surmontil (trimipramine)
Symbyax (olanzapine/fluoxetine)
Tofranil (imipramine)
Tofranil-PM (imipramine pamoate)
Triavil (perphenazine/amitriptyline)
Vivactil (protriptyline)
Wellbutrin (bupropion HCl)
Zoloft (sertraline HCl)
Zyban (bupropion HCl)

No Harm No Risk Agreements

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Complete a comprehensive safety plan with clear documentation.
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No Harm-No Risk Agreements as Standard of
Practice

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I will not harm myself or someone else, if I feel as though I could harm myself or someone else I will immediately go to the nearest emergency room at _________.
Have family member acknowledge and document acknowledgement.
If children at risk call CPS.

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Suicide risk scale takes into account 7 risk factor groups, add them together for risk level (1-no concern to 4; 5-7 items with high concern)
Risk Factors: history of suicide attempt, tendency to lose temper with little provocation, living alone, chronic severe pain, recent significant loss, recent psychiatric hospital admission/discharge, 1 st dx of major depression, bipolar or schizophrenia, recent alcohol abuse or worsening of depression, current preoccupation of plans for suicide, current psychomotor agitation, feelings of anxiety and hopelessness

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DSM-IV-TR information on relative co-morbidity & associated features added
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DSM-5: Major changes to this section.
A grouping of these disorders will be termed
Obsessive-Compulsive Spectrum Disorders
Delete Agoraphobia without history of panic disorder
Numerous clarifications and changes to almost all diagnoses in this category

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Social Phobia: now includes avoidant disorder of childhood.
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Specific Phobia was called Simple Phobia: must now have marked excessive or unreasonable fear. Based on research, now added sub-types.

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Obsessive-Compulsive Disorder: the definition between the obsession and compulsion has been clarified, the obsession causes distress and the compulsion is a way to try to handle it.

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New Name:
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Anxiety and Obsessive-Compulsive Spectrum
Disorders
Will also include trichotillomania and possible other conditions
Obsessions to be described as urges rather than impulses
Term “impulses” is problematic as how do you distinguish them from impulse control disorders, so will change term

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Panic Disorder With or Without
Agoraphobia: recent attacks involving at least one month of consistent concern, the thresholds have been changed for both.
Agoraphobia with History of Panic Disorder: fear of being in places where escape may be difficult.
Generalized Anxiety Disorder: now includes over-anxious disorder.

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Post-Traumatic Stress Disorder: symptoms must last at least one month, if more that 6 months after event should specify delayed onset (no longer must be must be outside of range of usual experience, often relive situation, now has acute and chronic specified, must cause distress).
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Acute Stress Disorder: This new category was added into the DSM-IV to address acute reactions to extreme stress (occurring within four weeks of the stressor and lasting from 2 days to 4 weeks). This may help predict the development of PTSD.

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The trauma experienced in acute stress disorder will not include:
Witnessing events on television
Witnessing events through electronic media
Will also drop the criteria that the person must experience intense fear
Symptoms may no longer need to involve feelings of dissociation

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Developmental manifestations of PTSD are still being developed.
The term 'developmental manifestation' in DSM-5 refers to age-specific expressions of one or another criteria that is used to make a diagnosis across age groups.
For children, inclusion of loss of a parent or other attachment figure is being considered.
The optimal number of required symptoms for both adults and children will be further examined with empirical data.

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GENERIC/BRAND
Librium/Temezepam
Valium/Diazepam
Dalmane/Flurazepam
Xanax/Alprazolam
Restoril/Temazepam
Halcion/Triazolam
DURATION OF ACTION DOSE (MG)
Long Acting, 15-75 mg day
Long Acting, 4-30 mg day
Long Acting, 15-30 mg day
Short Acting, 0.5-1.5 mg day
Short Acting, 15 - 30 mg day
Short Acting, 0.125 - 0.5 mg
Serax/Clorazepate), Tranxene/Diazepam,
Klonopin/Clonazepam

The benzodiazepine is a central nervous system depressant so do not mix it with alcohol or significant depression can result.
Consider Buspar (Buspirone HCL) if history of drug seeking or abuse behavior is suspected.

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Personality Traits: inflexible and maladaptive that cause significant impairment and distress
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Stable pattern of long duration must be able to trace back to adolescence or early adulthood
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May be applied to children in RARE instances when patterns are pervasive, persistent, and not related to developmental state (excluding Antisocial PD)

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Enduring pattern of behavior that deviates markedly from expectations of individuals culture.
Manifested in two of the following: cognition, affect, interpersonal functioning, impulse control
Pattern is inflexible and pervasive
Pattern leads to distress or impairment
Stable pattern over a long duration

The following often have odd/eccentric behavior:
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Paranoid Personality Disorder
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Schizoid Personality Disorder
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Schizotypal Personality Disorder

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The following often have dramatic, emotional and/or erratic behavior:
Antisocial Personality Disorder: some criterion changes on parenting style and failure to maintain a monogamous relationship
Borderline Personality Disorder: some new criterion
DSM-IV-TR, prognosis with treatment is GOOD
Narcissistic Personality Disorder
Histrionic Personality Disorder

The following have anxious or fearful behavior:
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Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive Compulsive Personality Disorder: want to maintain a sense of control in all areas of their life, hoarding is not extreme or dangerous;
DSM-IV-TR further clarifies relationship between
OCD and OCPD

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A differentiation is made between personality traits and having a disorder, as severe traits can exist without a disorder
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Each category must have SIGNIFICANT problems with selfidentity and interpersonal functioning
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Impaired functioning is linked directly to an extreme personality trait
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Adaptive failure is manifested in one or both of the following:
Failure to develop a sense of self-identity
Failure to develop effective interpersonal functioning

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Antisocial
Obsessive compulsive
Avoidant
Borderline
Schizotypal
Specify the traits that stand out (six traits that can be made more specific)
Does the client meet the threshold for having a PD?

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Assess level of functioning (0-no impairment to 4-extreme impairment)
Match five personality types from the narrative description (antisocial, obsessive compulsive, avoidant, borderline, schizotypal)
Assess for trait profiles for any type of PD and list all moderate or extreme traits
Cumulate totals and decide if the client meets the criteria for a diagnosis of PD

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Academic Problem: underachievers
Childhood or Adolescent Antisocial Behavior: isolated acts
Borderline Intellectual Functioning: IQ between 71 and
84 *(this is only V Code that goes on Axis II)
Malingering: voluntary produce symptoms in presence of exaggerated voluntary physical symptoms, there is an obvious recognizable goal
Bereavement
Problems Related to Abuse and Neglect: child physical abuse, child sexual abuse, neglect of child, adult physical abuse, and adult sexual abuse

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Related to the death of a loved one
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May present similar to Major Depressive Disorder
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Sadness, insomnia, poor appetite, and weight loss
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Timeframe can vary based on culture
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If symptoms persist two months after the loss may consider Major Depressive Disorder

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Non-compliance with treatment for either a mental disorder or a medical condition
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Should only use this when severe enough to warrant independent clinical attention
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Reasons include: medications side-effects, expense of treatment, cultural beliefs, value judgments, etc.

Problems Related to Abuse and Neglect:
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Can be coded for perpetrator of the abuse or the relational unit (person affected) in which it occurs.
Physical Abuse of a Child
Sexual Abuse of a Child
Neglect of a Child
Physical Abuse of an Adult
Sexual Abuse of an Adult

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Acting Out
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Denial
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Projection and Projective Identification
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Sublimation
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Displacement

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When using medications, “Anything
Strong Enough to Create an Action, is
CLEARLY Strong Enough to Create a
Reaction”
There are no “quick fixes”
Start where the client is
Be careful as a label can last a lifetime