DSM 5 What AALs and GALs Need to Know

1. DSM 5 What AALs and GALs Need to Know Norma Villanueva, LCSW, DCSW Modern View Clinical & Forensic Services n.villa@modernviewonline.com

2. Multiaxial to Single Axis • Perhaps the most significant change in the DSM-5 was the return to a single-axis diagnosis First, the separation of personality disorders to Axis II under DSM-IV gave these disorders undeserved status and the misguided belief that they were largely untreatable (Good, 2012; Krueger & Eaton, 2010). Clients who met the criteria for an Axis II diagnosis may now find it easier to navigate mental health treatment. • Medical conditions are no longer listed on a separate axis (Axis III in DSM-IV). Thus, they will likely take a more significant role in mental health diagnosis. • Psychosocial and environmental stressors, will be listed alongside mental disorders and physical health issues. In fact, DSM-5 has increased the number of “V codes” (Z codes in ICD-10), which are considered nondisordered conditions that sometimes are the focus of treatment and often are reflective of a host of psychosocial and environmental issues. • As for the GAF score, previously on Axis V of DSM-IV, the APA intended to replace this historically unreliable tool with a different scaling assessment altogether.

3. Systematic Changes CHILDREN FAMLIES COMMUNITY

4. Case Example • What the child wants . . . • What the child needs . . .

5. Case – First Phase

6. Dynamics – Hints & Initial View • The FIRST view of POSSIBLE mental health factors and family Dynamics is: • Removal Affidavit • Determination for FBSS

7. Case – First Phase

8. Case – First Phase

9. Comparative Example

10. Case – Second Phase

11. Risk • 78.3% Perpetrator is parent • Child Vulnerability • Home & Social Environment • Caregiver Capability • Quality of Care • Maltreatment Pattern • Response to CPS • Protective Capacities • 25.5% Turnover rate – case workers 2013 TDFPS-CPS Data Book

12. Case – Second Phase

13. Case – Second Phase

14. Case Example

15. Diagnosis • Criterion for Clinical Significance • WHO & DSM 5 Task force: distinguish between disability and mental disorder. • Separate normal from pathological symptoms • Function: “the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning”

16. Nonaxial Format • Axis I, II & III: Primary Diagnosis, and others in order of significance • Axis IV replaced by V codes Z codes • Only if focus of treatment • Axis V replaced by self report measures if utilized

17. Work Toward Accurate Diagnosis Assess level of functioning Self report distress & Impairment Self Report Despair & Sx Severity Presenting Symptoms Level of Functioning in Major Roles

19. Diagnosis • Thorough Psychosocial History • Mental Status Exam • History: Presenting Problem, specific symptoms, complaints • Identify duration and severity of symptoms • Functioning in major roles, ADL’s • Mental Health History • Relevant medical history • Family History: MH, stressors • Social History: school/work, social/community • Diagnosis + specifiers

20. Trauma & Stressor Related Disorders

21. Trauma & Stressor related Disorders • PTSD: Changed definition of traumatic event Eliminated criterion of how person responds to trauma • Exposure to actual or threatened a)death, b) serious injury, c) sexual violation, in 1 or more of the following ways • Directly experiencing • Witnessing, in person, as they occur to others • Learning event occurred to a close family member or friend; actual or threatened death must have been violent or accidental • Experiencing repeated or extreme exposure to aversive details of traumatic events (not electronic media, tv, movies unless work related)

22. Trauma & Stress Related Disorder: Clusters and Subtypes 4 Symptom Clusters • Intrusion • Avoidance • Negative alterations in cognition and mood • Marked alterations in arousal and reactivity Different Subtypes Eliminating Acute versus chronic Addition of Preschool subtype Addition of Dissociative Subtype

23. Trauma & Stress Related Disorder: Diagnostic Criteria A. Stressor B. 1 or more intrusion symptoms C. 1 or more avoidance of stimuli D. Negative alterations in cognition and mood (2 new) E. Marked altercations in arousal and reactivity 2 or more Persistent, distorted blame of self or others about the cause or consequences of the traumatic event(s) Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame)

24. PTSD in Preschool Children The first developmental subtype of a diagnosis Criterion Deleted: reaction to event, inability to recall, foreshortened future Intrusion Sxs: Intrusive thoughts + neutral reaction Avoidance Sxs: cognition & mood alterations 1 symptom in avoidance or cognitive/mood Diminished interest = constricted play Detachment – behaviorally social withdrawal Increased Arousal: addition of extreme temper tantrums.

25. Neurodevelopmental Disorders

26. Neurodevelopmentalcont. Diagnostic criteria: must assess cognitive capacity & adaptive functioning – determines Severity. Domains reduced from 3 to 2 • Social/communication deficits • Fixed Interests/repetitive behaviors • Merged Communication & Social interaction • Require 2 versus 3 behavioral markers • Onset: early childhood • Categorize by need for support • Removed language delay criterion

27. ADHD

28. ADHDcont. • Subtypes: Combined, Primarily Inattentive, Inattentive, Predominantly hyperactive/impulsive • Criterion items are applied across the lifespan • Cross-Situational requirement strengthened to several symptoms in each setting • Adult Symptom threshold reflects significant impairment

29. Specific Learning Disorders

30. Specific Learning Disorderscont. Specific Criteria for each: Can be combined • Reading: accuracy, rate, comprehension Writing: accuracy of spelling, grammar & punctuation, legible handwriting, clarity of written expression Math: memorizing facts, accurate calculations, effective math reasoning. Written Expression: spelling, grammar, punctuation, clarity, organization

31. Disruptive, Impulse-Control & Conduct Disorders