Communicating Symptoms Disorders to Other Professionals

1. Communicating Symptoms & Disorders to Other Professionals What do counselors need to know about the DSM? Charles Pemberton, Ed.D.,LPCC www.pembertoncounseling.com

2. History of the DSM? The first edition (DSM-I) was published in 1952, and had about 60 different disorders. DSM-II was published in 1968. Among the most noted examples of controversial diagnoses is the classifying in the DSM-II of homosexuality as a mental disorder, a classification that was removed by vote of the APA in 1973 (see also homosexuality and psychology).

3. In 1980, with DSM-III, the psychodynamic view was abandoned and the biomedical model became the primary approach, introducing a clear distinction between normal and abnormal. The DSM became atheoretical since it had no preferred etiology for mental disorders. In 1987 the DSM-III-R appeared as a revision of DSM-III. Many criteria were changed. In 1994, it evolved into DSM-IV. This work is currently in its fourth edition. The most recent version is the 'Text Revision' of the DSM-IV, also known as the DSM-IV-TR, published in 2000. The vast majority of the criteria for the diagoses were not changed from DSM-IV. The test in between the criteria was updated. DSM-V, is not scheduled for publication until 2011 or possibly later. The APA Division of Research does not expect to begin forming DSM development workgroups until 2007 or later.

4. Why do we need this book? Communication Classification Research Payment

5. Conceptualization of DSM Syndromes Criteria Normal vs. Abnormal Dimensional vs. Categorical Problems/Ethics Labeling Meeting some criteria Impairment??

6. Organization of DSM Major Groupings Childhood* Dementia Substance Schizophrenia Mood Anxiety Somatoform Factitious Dissociative Sexual and Gender Eating Sleep Adjustment Personality

7. Organization of each D/O Diagnostic Features Episode Associated Culture, Age and Gender Prevalence Familial Pattern Differential Diagnosis Criteria

8. 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.

9. 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

10. 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 Axis I includes majority of clinical disorders outlined in the DSM-IV Axis II- Includes Personality disorders and mental retardation. Personality disorders involve pervasive and long-term pattern of behavior, therefore is generally inappropriate for individuals under 18. PD organized into 3 clusters. Axis III- general medical conditions, examples include obesity, diabetes, hypertension Axis IV- Stressors in the environment which may be affecting diagnosis & treatment. Examples include primary support group problems, social environment, educational problems, occupational, housing, economic, problems with health care access, and legal difficulties. Axis V- GAF- number from 1 to 100 indicating overall level of functioning. Broken up into 10 ranges which are laid out in the DSM-IV with general criteria. Specifics within each range fall to clinician�s discretion. Often report both current GAF and highest GAF in last year to show complete clinical picture.Axis I includes majority of clinical disorders outlined in the DSM-IV Axis II- Includes Personality disorders and mental retardation. Personality disorders involve pervasive and long-term pattern of behavior, therefore is generally inappropriate for individuals under 18. PD organized into 3 clusters. Axis III- general medical conditions, examples include obesity, diabetes, hypertension Axis IV- Stressors in the environment which may be affecting diagnosis & treatment. Examples include primary support group problems, social environment, educational problems, occupational, housing, economic, problems with health care access, and legal difficulties. Axis V- GAF- number from 1 to 100 indicating overall level of functioning. Broken up into 10 ranges which are laid out in the DSM-IV with general criteria. Specifics within each range fall to clinician�s discretion. Often report both current GAF and highest GAF in last year to show complete clinical picture.

11. 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) Codes are necessary for record keeping & billing First 3 numbers generally indicate a particular group of disorders, one or two digits after decimal specify subtypes (Ex.- 312- impulse control d/o) Specifiers are important to give an accurate impression of the client�s presentation.Codes are necessary for record keeping & billing First 3 numbers generally indicate a particular group of disorders, one or two digits after decimal specify subtypes (Ex.- 312- impulse control d/o) Specifiers are important to give an accurate impression of the client�s presentation.

12. 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� This category is unique in that these disorders are grouped together based on time of onset rather than phenomenology.This category is unique in that these disorders are grouped together based on time of onset rather than phenomenology.

13. 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

14. Prevalence of ADHD Estimated at 3-7% of school age children More common in males than females Often diagnosed during elementary school years. ADHD occurs in various cultures Higher prevalence rate in Western countries might possibly be due to differences in diagnostic procedures as opposed to a true difference in prevalence. ADHD often co-morbid with Oppositional Defiant Disorder or Conduct DisorderADHD occurs in various cultures Higher prevalence rate in Western countries might possibly be due to differences in diagnostic procedures as opposed to a true difference in prevalence. ADHD often co-morbid with Oppositional Defiant Disorder or Conduct Disorder

15. 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 Is a child not completing tasks because he is unable, or because he truly has attention deficits? Stereotypic movement d/o will generally be very specific, recognizable behaviors as opposed to general hyperactivity.Is a child not completing tasks because he is unable, or because he truly has attention deficits? Stereotypic movement d/o will generally be very specific, recognizable behaviors as opposed to general hyperactivity.

16. 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

17. 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. Symptom presentation MUST persist for at least 6 months, this is often overlooked Often the hyperactive / impulsive behaviors are much easier to detect because these behaviors are disruptive. Inattentive behaviors are more likely to go unnoticed. Symptom presentation MUST persist for at least 6 months, this is often overlooked Often the hyperactive / impulsive behaviors are much easier to detect because these behaviors are disruptive. Inattentive behaviors are more likely to go unnoticed.

18. 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 Criteria B & C are often overlooked. For diagnosis to be appropriate, these criteria must be met. If the exhibited behaviors are only present in school, ADHD diagnosis is inappropriate. Important to consider how a child behaves at home, at daycare, in extracurricular activities, and other settings outside of school. D & E are general DSM criteria discussed earlier.Criteria B & C are often overlooked. For diagnosis to be appropriate, these criteria must be met. If the exhibited behaviors are only present in school, ADHD diagnosis is inappropriate. Important to consider how a child behaves at home, at daycare, in extracurricular activities, and other settings outside of school. D & E are general DSM criteria discussed earlier.

19. 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. The inattentive component is generally more difficult to observe, therefore it is harder to diagnose. Scales, such as Conners or ADDES, rate symptoms. While these measures are generally based on the diagnostic criteria outlines in the DSM-IV, it is NOT appropriate to diagnose based of the results of these scales. Data from scales should be considered supportive information, but are not meant to diagnose. Diagnosis is ultimately a clinical decision.The inattentive component is generally more difficult to observe, therefore it is harder to diagnose. Scales, such as Conners or ADDES, rate symptoms. While these measures are generally based on the diagnostic criteria outlines in the DSM-IV, it is NOT appropriate to diagnose based of the results of these scales. Data from scales should be considered supportive information, but are not meant to diagnose. Diagnosis is ultimately a clinical decision.

20. Autism vs. Asperger�s http://www.behavenet.com/capsules/disorders/dsm4TRclassification.htm http://BehaveNet� Clinical Capsule� Asperger's Disorder.htm http://www.behavenet.com/capsules/disorders/autistic.htm

21. 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. www.pembertoncounseling.com