Advancing Social Work Practice with Clients: Understanding the DSM 5

1. Advancing Social Work Practice with Clients: Understanding the DSM 5 Columbia University School of Social Work Conference December 6, 2013

2. For Personality Vulnerabilities Alternative DSM-5 Model Columbia University LM Pirro

3. Changes From DSM-IV-TR To the DSM-5 • The criteria for personality disorders in Section II of DSM-5 have not changed from those in DSM-IV. • An alternative approach to the diagnosis of personality disorders was developed for DSM-5 for further study and can be found in Section III (see “Alternative DSM-5 Model for Personality Disorders”). Source: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 1 June 2013]. dsm.psychiatryonline.org Columbia University LM Pirro

4. Key Considerations • What is personality? • How should one assess personality functioning? • What criteria should be used to distinguish health from illness? • How do we take into account variations in culture, ethnicity, and individual differences in assessing, diagnosing and treating personality disturbance? • What should drive our interventions and our evaluation of our effectiveness? • As clinical social workers, do we differ in our approach from other professionals? Columbia University LM Pirro

5. Three Aspects of Personality • Personality is our sense of self, our sense of purpose, motivation, and goal directedness, based on our sense of who we are (our own unique identity). • It is also how we relate to others, including our capacity to empathize with the thoughts, feelings, and experiences of those around us, and our desire and capacity for close relationships – in love, family, friendship, and community relatedness. This community relatedness encompasses our sense of purpose in the world at large and our obligation and commitment to the human family. • Another defining aspect of personality seems to be that amidst change, it is largely steadfast and secure, stably moored to an internal center. This center is multi-dimensional and evolves based on the aggregate unique personal and “felt” experience of each human being -- these facets of personality are borne of emotional, intellectual, biological, psychological, social, cultural, familial, and spiritual experiential markers. Columbia University LM Pirro

6. Defining Personality Health And Vulnerability • The level of satisfaction, self-esteem, self-regard, self compassion, and identity stability that characterizes an individual is an indicator of health. • One way of conceptualizing whether or not an individual would benefit from mental health care is to ask, “What is the level of distress in identity and interpersonal functioning?” • And, “Is the level of distress negatively impacting self-satisfaction, self-esteem, self-regard, self compassion, and identity stability?” Columbia University LM Pirro

7. Defining Personality Health And Vulnerability • Since personality is also how we relate to others, including our capacity to empathize with the thoughts, feelings, and experiences of those around us and our desire and capacity for close relationships, how shall we assess health in this domain? • One way to conceptualize this question is to ask, “Can the individual function in a way that respects others, that empathizes with the thoughts, feelings, and experiences of those around them, while achieving interpersonal fulfillment and satisfaction?” • And, “Can the individual trust another person enough to be vulnerable (to harm, rejection) and still maintain individual integrity and identity stability?” Columbia University LM Pirro

8. Defining Personality Health And Vulnerability • So when conceptualizing whether or not an individual would benefit from mental health care, we might ask, “What is the level of distress in interpersonal functioning?” • “Is the level of distress harming the person’s capacity for empathizing with the thoughts, feelings, and experiences of others and achieving interpersonal fulfillment and satisfaction?” • “Is the person’s capacity to be vulnerable significantly impaired such that is causes harm to self and or others and identity stability and integrity?” Columbia University LM Pirro

9. Reformulation of Personality Disorders in the DSM-5 • The new DSM formulation of personality disorders is meant to emphasize each person’s personal identity and the nature of each person’s capacity to trust others and form mutually rewarding and stable relationships. • Posits that personality vulnerabilities or disorders, in turn, should be understood as a result of heritable risk factors and environmental stressors, as is the case for many diseases and disorders in medicine. Columbia University LM Pirro

10. Proposed DSM-5 System • A hybrid dimensional-categorical model for (a “healthy”) personality. • Defines six personality disorders: A) Antisocial, B) Avoidant, C) Borderline, D) Narcissistic, E) Obsessive Compulsive and, F) Schizotypal. • Creates a Personality Disorder Trait Specified (PDTS) that is defined by significant impairment in personality functioning, and one or more pathological personality trait domains or trait facets. • Criteria are based on typical impairments in personality functioning and pathological personality traits in one or more trait domains. Source: dsm5.org - personality disorders Columbia University LM Pirro

11. Proposed DSM-5 System Guide to Implementation Proposes the following components as most central in comprising a personality functioning continuum: SELF: IdentityandSelf-direction INTERPERSONAL:Empathyand Intimacy Source: DSM-5 Table I Elements of Personality Functioning. http://dsm.psychiatryonline.org/content.aspx?bookid=556&sectionid=41101793 Columbia University LM Pirro

12. ASSESSING PERSONALITY FUNCTIONING • A person must have significant impairment in two areas of personality functioning – the “self” and “interpersonal” domain. • In the proposed model a clinician would rate a person’s level of personality functioning - level of impairment - in these domains by indicating one of five levels that most closely characterizes the patient’s functioning.   Columbia University LM Pirro

13. Level of Personality Functioning Scale RATING SCALE LEVEL: 0 Little or No Impairment LEVEL: 1 Some Impairment LEVEL: 2 Moderate Impairment LEVEL: 3 Severe Impairment LEVEL: 4 Extreme Impairment Clinician indicates the level that most closely characterizes the patient’s functioning in the self and interpersonal domains. Columbia University LM Pirro

14. Rates 5 Trait Domains For a Personality Overview In addition, pathological personality traits must be present in at least one of five broad areas. E.g., • Negative Affectivity • Detachment:(vs. Extraversion) • Antagonism (vs. Agreeableness) Columbia University LM Pirro

15. Also Provides Opportunity to Assess 25 Subsets of Trait Domains DSM-5 Trait Facets For example • Emotional Lability • Anxiousness • Perseveration • Anhedonia • Depressivity • Restricted Affectivity • Grandiosity • Attention Seeking • Eccentricity • Cognitive and perceptual dysregulation Columbia University LM Pirro

16. ALTERNATIVE MODELGeneral Criteria for Personality Disorder The essential features of a personality disorder are: • Moderate or greater impairment in functioning. • One or more pathological personality traits. Columbia University LM Pirro

17. Essence of Criteria C-G: • Relatively inflexible and pervasive across situations • Relatively stable across time, • Not better explained by another mental disorder • Not better understood as normal development Columbia University LM Pirro

18. Personality Disorder - Trait Specified Moderate or greater impairment in personality functioning, manifested by difficulties in two or more of the following four areas: • Identity • Self-direction • Empathy • Intimacy PD-TS: One or more pathological personality trait domains OR specific trait facets within domains, considering ALL of the trait domains Columbia University LM Pirro

19. DSM-5 Alternate Model Borderline Personality Disorder The Case of Rory Columbia University LM Pirro

20. Illustrative borderline patient rated at level 3 of functioning Columbia University LM Pirro

21. Bearing Witness to the Texture of Distress DSM-5

22. DSM-5 Section II Diagnostic Criteria and Codes • Other Conditions That May Be a Focus of Clinical Attention or That May Otherwise Affect the Diagnosis, Course, Prognosis, or Treatment of an Individual’s Mental Health Vulnerability. (ICD-9-CM: Usually “V” Codes and ICD-10-CM, Usually “Z” Codes) Source: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [Access date: 1 June 2013], dsm.psychiatryonline.org. Columbia University LM Pirro

23. Other Conditions That May Be a Focus of Clinical Attention E.g., 1. Relational Problems 3. Educational and Occupational Problems 4. Housing and Economic Problems 6. Problems Related to Crime or Interaction With the Legal System 7. Other Health Service Encounters for Counseling and Medical Advice Columbia University LM Pirro

24. What the “Other” Codes Represent 1 • Nine broad areas of human experience (and suffering). • Conditions that my be a focus of clinical attention. • Problems or distress that may affect the diagnosis, course, prognosis, or treatment of an individual’s mental health vulnerability. • They represent core areas of social work practice. Columbia University LM Pirro

25. What the “Other” Codes Represent 2 • 130 client concerns (133 at last count) that might be the focus of attention in a psychotherapy partnership. • These are situational variables, not mental disorders, which add texture, and otherwise fill-in the emotional tapestry of a clinical portrait. Columbia University LM Pirro

26. The Significance of Documenting the Texture of Distress • Recording such information in the client record can underscore critical elements of a treatment plan, or a request for services to an authorizing body. • It also, de facto, acknowledges that comorbidity is the rule, not only for many serious mental disorders, but also for what vulnerable clients typically bring to the table – that is, often very material and manifoldburdens. Columbia University LM Pirro

27. Seizing the Opportunity to Bear Witness Documenting the Texture of Distress • Place code and the clinician’s note explaining the client problem directly alongside the diagnostic code for the mental disorder. • Highlight the concern if it is a reason for a current visit or helps to explain the need for an evaluation, test, procedure, or treatment. • DSM-IV-TR: Identified concerns were smaller in number, not centrally located, and indicated on Axis IV, Psychosocial and Environmental Problems. • The multi-axial format has been eliminated in the DSM-5. Columbia University LM Pirro

28. Documenting the Texture of Distress Example • Problem related to living alone. Mrs. Katz has no family nearby and few living relatives that are able to care for her should her condition deteriorate. Her brother has hired a home attendant for two hours, per day, to prepare nutritious meals and check in on her. The aide has emergency contact numbers at her disposal. Columbia University LM Pirro

29. Documenting the Texture of DistressExample • Academic or Educational Problem Client withdrew from university in his second year as a biochemistry scholar due to impact of initial manic episode associated with bipolar disorder. Re-engaging in his education is the focus of clinical attention due to concomitant anxiety with application process and a fear of humiliation and stigma from “students who saw me ‘lose it’ and who don’t have any problems….I’m petrified that they think I’m some weird dude who is going to shoot up the place. I never hurt so much as a flea. Getting sick wasn’t in my plan! I hope I get a second chance.” Columbia University LM Pirro

30. Documenting the Texture of DistressExample • Insufficient Social Insurance or Welfare Support. Client is a 55 year-old, HIV positive, Caucasian male, who entered an artist training program through an entitlement program and has been successfully employed as a creator of designer wall-paper for 20 hours a week for the last 7 years. He recently received a correspondence from the Social Security administration that he was being investigated and owed back benefits of $70,000. • Social worker assisted client in querying SSI. Current status: SSI reduced amount to $35,000 due to as yet unexplained system error. SW has referred client to pro-bono legal counsel who will pursue resolution. • Clinician continues to treat client for related emotional distress due to his fear that he will be homeless, lose his benefits, or be required to cease employment that he “adores”… “It is the love of my life. I don’t know what I’d do if I couldn’t create beautiful wallpaper that transforms “mere space” to a place of harmony.” Columbia University LM Pirro

31. Documenting the Texture of Distress Example) • Spouse or Partner Abuse, Psychological, ConfirmedSubsequent encounter. During the last 7 months, acts of psychological abuse by male partner have included berating and humiliating client; interrogating her as to her activities of daily living and of caring for 10 year-old male child; restricting the victim’s ability to come and go freely; obstructing the victim’s access to assistance (e.g., medical resources - partner refused to provide client with insurance card for three days, to pick up antibiotics, stating client was “not worth the paper the Rx. was printed on”); threatening client with sexual assault if she wasn’t the “useful” partner he deserved; threatening to harm client’s new kitten and to burn her photo album with pictures of family members abroad; unwarranted restriction of client’s access to economic resources (money to buy groceries and personal hygiene products); isolating the victim from family, friends, and trying to make client think that “she is crazy”. Columbia University LM Pirro

32. Documenting the Texture of Distress Is Emblematic of Client-Centered Practice • Recording psychosocial and environmental problems has always had the intent of systematically documenting critical information that might impact client care (a partner in therapy). • It remains an essential component of clinical documentation in the DSM-5, and if utilized wisely and vigorously, has the potential of uniquely characterizing clinical social work practice as emblematic of holistic, client-centered engagement. Columbia University LM Pirro