Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR)

Ken Murray, LCSW, ACSW

murrayk@apsu.edu 931-980-9496

DSM-IV-TR

A Mental Disorder: Is clinically important sx that cause distress, disability or increased risk of suffering pain, disability, death or the loss of freedom May look a whole lot like normalcy Traits vs meeting criteria its a spectrum

Its only a problem if its a problem (in social, occupational or other important areas)
murrayk@apsu.edu 931-980-9496

DSM-IV-TR

Words of Caution This book contains labels Labels most often are damaging Just because I can give a diagnosis, doesnt mean that I should Choose the least damaging option The person with the diagnosis is the client, not the insurance companies

murrayk@apsu.edu 931-980-9496

DSM-IV-TR

But the Insurance Company Wants a Dx! Diagnosis is counterproductive in the everyday psychotherapy of less severely impaired patients. (p. 4) Why? Therapy is an unfolding where the therapist gets to know the client over timea diagnosis is limiting and can act as a selffulfilling prophecy.
Irvin D. Yalom, in The Gift of Therapy

Mental disorders describe disease processes, not people!

murrayk@apsu.edu 931-980-9496

DSM-IV-TR

So Why Do I Need to Know This? Language of the behavioral health professions Your clients often come to you with labels It is the standard across multiple disciplines Credibility

murrayk@apsu.edu 931-980-9496

DSM-IV-TR

Cautionary Statement
The DSM has had six dramatic changes since 1952.
Changes were initially consensus based and often politically influenced Methodological errors exist in the research the book is based on DSM-IV had 120 more conditions than -III Its all about to change

Just because I can give a diagnosis, doesnt mean that I should The person with the diagnosis is the client, not the American Psychiatric Association
murrayk@apsu.edu 931-980-9496

DSM-IV-TR

Organization of the DSM-IV-TR Introductory stuff (including directions for use) DSM Classification (list of codes and categories) Multiaxial assessment system Diagnostic criterion and description for disorders Appendices x 11

murrayk@apsu.edu 931-980-9496

DSM-IV-TR

Major Categories of Disorders

Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence Delirium, Dementia, and Amnestic and Other Cognitive Disorders Mental Disorders Due to a General Medical Condition Not Elsewhere Classified Substance Related Disorders Schizophrenia and Other Psychotic Disorders Mood Disorders Anxiety Disorders Somatoform Disorders Factitious Disorders Dissociative Disorders Sexual and Gender Identity Disorders Eating Disorders Sleep Disorders Impulse Control Disorders Not Elsewhere Classified Adjustment Disorders Personality Disorders Other Conditions That May Be the Focus of Clinical Attention (V Codes)
murrayk@apsu.edu 931-980-9496

DSM-IV-TR

Multi-axial System
Axis I: Clinical disorders, including major mental disorders, and learning disorders, Substance Use Disorders Axis II: Personality disorders and intellectual disabilities Axis III: Acute medical conditions and physical disorders (that affect Axis I dx) Axis IV: Psychosocial and environmental factors contributing to the disorder (SW Axis) Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18
murrayk@apsu.edu 931-980-9496

DSM-IV-TR

Global Assessment of Functioning

91 - 100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. 81 - 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). 71 - 80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). 61 - 70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. 51 - 60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). 41 - 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). 31 - 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). 21 - 30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends) 11 - 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute). 1 - 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.

murrayk@apsu.edu 931-980-9496

DSM-IV-TR

Axis II Subgrouping (Personality Disorders)

Cluster A (Odd or eccentric)
Paranoid Schizoid Schizotypal

Cluster B (Dramatic, emotional or erratic)

Antisocial Borderline Histrionic Narcissistic
1. Extreme and distorted thinking patterns 2. Problematic emotional response patterns 3. Impulse control problems 4. Significant interpersonal problems

Cluster C (Anxious or Fearful)

Avoidant Dependent Obsessive Compulsive
murrayk@apsu.edu 931-980-9496

DSM-IV-TR

Kens Twitchy Point OCD vs. OCPD

Get em straight

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DSM-IV-TR

At the Party
Paranoid: suspicious, argumentative, paranoid, continually on the lookout for trickery and abuse, jealous, tendency to blame others, cold and humorless Schizoid: has few friends; a "loner"; indifferent to praise and criticism of others; unable to form close relationships; no warm or tender feelings for other people Schizotypal: also aloof and indifferent like the schizoid; magical thinking; superstitious beliefs; uses unusual words and has peculiar ideas; a very mild form of schizophrenia Borderline: very unstable relationships; erratic emotions; self- damaging behavior; impulsive; unpredictable aggressive and sexual behavior; monophobia; easily angered Histrionic: overly dramatic; attention seekers; easily angered; seductive; dependent on others; vain, shallow, and manipulative; displays intense, but often false emotions Narcissistic: grandiose; crave admiration of others; extremely self-centered; feel they are privileged and special; expects favors from others; emotions are not erratic OCPD: perfectionists; preoccupied with details, rules, schedules; more concerned about work than pleasure; serious and formal; cannot express tender feelings

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DSM-IV-TR

Acute Stress Reaction vs PTSD Same-same, except for time

Criterion
Trauma Reexperiencing Emotional numbing Avoidance Hyperarousal

murrayk@apsu.edu 931-980-9496

DSM-IV-TR

Important stuff insurance doesnt pay for V Codes

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DSM-IV-TR

Open Discussion Talk to me

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DSM-IV-TR