Jason H. King, PhD, DCMHS , CCMHC, ACS Core Faculty – Walden University MHC Program

USING THE DSM-5 TO DEVELOP THE PROFESSIONAL IDENTITY AND CLINICAL COMPETENCE OF MENTAL HEALTH COUNSELORS

UMHCA 2013 Annual Conference

Jason H. King, PhD, DCMHS, CCMHC, ACSCore Faculty – Walden University MHC Program

Goals

2

1. Explore professional identity 2. Understand clinical competence 3. Preview the DSM 5

DSM 5 - Jason H. King, PhD, DCMHS, ACS

Professional Identity


3

What is Professional Identity?

“The unique characteristics of one’s selected profession that differentiates it from other professions” (Weinrach, Thomas, & Chan, 2001, p. 168).

4 DSM 5 - Jason H. King, PhD, DCMHS, ACS

What is Professional Identity?

(Chreim, Williams, & Hinings, 2007; Cohen-Scali, 2003) 5 DSM 5 - Jason H. King, PhD, DCMHS,

ACS

What is Professional Identity? CACREP (2009)

PROFESSIONAL ORIENTATION AND ETHICAL PRACTICE

SOCIAL AND CULTURAL DIVERSITY

HUMAN GROWTH AND DEVELOPMENT

CAREER DEVELOPMENT

CACREP (2009) HELPING

RELATIONSHIPS GROUP WORK ASSESSMENT RESEARCH AND

PROGRAM EVALUATION


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)?


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?


Clinical Competence


9

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


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.”


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 behaviorDSM 5 - Jason H. King, PhD, DCMHS,

ACS

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 client’s particular needs in the context of his/her situation.


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 DisordersDSM 5 - Jason H. King, PhD, DCMHS,

ACS

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

Clinical Competence

16

King (2012) HOW ETHICAL CODES DEFINE COUNSELOR

PROFESSIONAL IDENTITY

Weighted Key Word Frequencies in Ethical Codes

ACA APA AAMFT NASW

Assessment 1.47% 0.94% 0.00% 0.00%

Diagnose 0.04% 0.01% 0.02% 0.00%


Clinical Competence


17

"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)

DSM 5


18

DSM-IV-TR


19

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)

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

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

manual’s 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

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

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


24

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

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


Neurodevelopmental Disorders


26


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



28

Autism Spectrum Disorders Merger of the following from DSM-IV:

Autistic Disorder Asperger’s 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

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



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, Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder


Schizophrenia Spectrum and Other Psychotic Disorders


31

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




33


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


Depressive Disorders


35

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 6-18 3+ 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 yearsDSM 5 - Jason H. King, PhD, DCMHS,

ACS36

Anxiety Disorders


37

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


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 responseDSM 5 - Jason H. King, PhD, DCMHS,

ACS

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


Obsessive Compulsive and Related Disorders


41


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 conditionDSM 5 - Jason H. King, PhD, DCMHS,

ACS


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



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”



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

partner’s perceived infidelity Unspecified obsessive-compulsive and related

disorder


Trauma and Stressor-Related Disorders


46

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)

NothingDSM 5 - Jason H. King, PhD, DCMHS,

ACS47


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 person’s response involved intense fear, helplessness, or horror”) eliminated evidence that acute posttraumatic reactions are very

heterogeneous DSM-IV’s 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



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 behaviorDSM 5 - Jason H. King, PhD, DCMHS,

ACS


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 child’s 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


Dissociative Disorders


51

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

disruptionsDSM 5 - Jason H. King, PhD, DCMHS,

ACS

Somatic Symptom and Related Disorders


53


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



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



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



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



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


Feeding and Eating Disorders


59


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



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 changesDSM 5 - Jason H. King, PhD, DCMHS,

ACS

Sleep-Wake Disorders


62


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



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

evidenceDSM 5 - Jason H. King, PhD, DCMHS,

ACS

Sexual Dysfunctions


65

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


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


Gender Dysphoria


68

Gender Dysphoria

69

Reflects a change in conceptualization of the disorder’s 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 one’s gender) merged no supporting evidence from factor analytic studies supported

keeping the two separate


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


Disruptive, Impulse-Control, and Conduct Disorders


71


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 consequencesDSM 5 - Jason H. King, PhD, DCMHS,

ACS


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 relationshipsDSM 5 - Jason H. King, PhD, DCMHS,

ACS



74


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



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



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


Neurocognitive Disorders


78

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 Alzheimer’s disease, cerebrovascular disorders,

HIV, traumatic brain injury, Parkinson’s disease, Huntington’s disease, Pick’s disease, Creutzfeldt-Jakob disease, and other medical conditions specified

Updated listing of neurocognitive domains is also providedDSM 5 - Jason H. King, PhD, DCMHS,

ACS

Personality Disorders


80

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: http://www.dsm5.org/Documents/Personality%20Disorders/

DSM-IV%20and%20DSM-5%20Criteria%20for%20the%20Personality%20Disorders%205-1-12.pdf


Paraphilic Disorders


82

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


Cultural Formulation Interview


84

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 SeekingDSM 5 - Jason H. King, PhD, DCMHS, ACS

Conclusion


86

Conclusion


87

Jason H. King, PhD, DCMHS , CCMHC, ACS Core Faculty – Walden University MHC Program

Documents

professional counseling

dsm diagnosis

mental health assessments

mental health professionals

professional orientation

professional identitymyers

professional identity2

clinical competence3