EPSY 544

1. EPSY 544 Session 10

2. Schedule • DSM-IV-TR

3. DSM-IV-TR • Multiaxial System • Axis I:    Clinical Disorders,  most V-Codes,  and conditions that need Clinical attention.Diagnosis Flow Charts. • Axis II:Personality Disorders and Mental Retardation. • Axis III:    General Medical Conditions. • Axis IV:    Psychosocial and Environmental Problems. • Axis V:    Global Assessment of Functioning Scale.

4. Axis I Clinical Disorders • Egodystonic • 14 categories • Anxiety Disorders, • Childhood Disorders, • Cognitive Disorders, • Dissociative Disorders, • Eating Disorders, • Factitious Disorders, • Impulse Control Disorders, • Mood Disorders, • Psychotic Disorders, • Sexual and Gender Identity Disorders, • Sleep Disorders, • Somatoform Disorders, and • Substance-Related Disorders. • Other conditions, known as Adjustment Disorders, may also be a focus of clinical attention include Medication-Induced Movement Disorders, Relational Problems, Problems Related to Abuse or Neglect, Noncompliance with Treatment, Malingering, Adult Antisocial Behavior, Child or Adolescent Antisocial Behavior, Age-Related Cognitive Decline, Bereavement, Academic Problem, Occupational Problem, Identity Problem, Religious or Spiritual Problem, Acculturation Problem, and Phase of Life Problem. • Report all Axis I disorders. • If no Axis I disorder use code V71.09. • If Axis I diagnosis is deferred or pending more information use code 799.9.

5. V-Codes example • These identify conditions that are not considered a disorder • Relational Problems • V61.9 relational problems related to a mental disorder or general medical condition • V61.20 parent-child relational problem • V61.10 partner relational problem • V 61.8 sibling relational problem • V62.81 relational problem not otherwise specified

6. Axis II – Personality disorders and Mental Retardation • an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas: cognition (i.e., ways of perceiving and interpreting self, other people, and events); affectivity (i.e., the range, intensity, lability, and inappropriateness of emotional response); interpersonal functioning; and impulse control. • The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The individual's pattern is stable of long duration and its onset can be traced back at least to adolescence or early adulthood. • egosyntonic

7. Axis II – Personality Disorders • Cluster A: Odd eccentric Lack of relationships, restricted affect, peculiar ideas, suspicious • paranoid • schizoid • Schizotypal • Cluster B: Mood Lack of insight, impulsive, erratic, unstable behaviors, labile and heightened affect, wants some kind of intense interaction with the counselor • antisocial • borderline • histrionic • Narcissitic • Cluster C: Anxious-avoidant Rigid attempts to meet all demands by enduring, changing self, withdrawing • avoidant • dependent • obsessive-compulsive

8. Signs Indicative a Personality Disorder • The counseling seems to stall after making initial progress • The client does not seem to be aware of the effect of his/her behaviors on others • The client seems to accept the problems • The client is underresponsive or noncompliant with the counseling regimen • The client is often involved with intense conflictual relationships with institutional systems

9. Schizoid Personality Disorder • Pervasive pattern of detachment from social relationships and restricted range of emotions • Prefer to be alone and little desire for personal relationships • The appear indifferent to the approval of criticism of others and are not particularly concerned about what others think of them • Do not have close friend or confidants, except possibly first degree relative

10. Schizotypal Personality Disorder • Pervasive pattern of peculiar ideation and behavior with deficits in social and interpersonal relationships • Incorrectly interpret causal incidents as having particular and unusual meanings to the individual • They have odd beliefs or magical thinking that is inconsistent with subcultural norms (e.g., superstitions, belief in clairvoyance) • Paranoia, unusual perceptions, and odd beliefs are evident, but they do not reach the level of chronic delusional proportions

11. Cluster B • Very different from Cluster A • These individuals are quite emotional and try to impress the counselor • Behavior is erratic and unstable • Affect quiet heightened and changeable (labile)

12. Cluster B • Antisocial Personality Disorder • Pervasive pattern of disregard and violation of others’ rights • Disregard begins in childhood or adolescence and continues into adulthood • Diagnosis cannot be given until person is at least 18 years of age and has a history of some symptoms of Conduct Disorder before 15 • After age 15 the following must be evident • Repeated involvement in illegal behaviors • Deceitfulness, lying, or conning others • Being impulsive and not planning • Aggressiveness and repeated physical fights or assaults • Reckless disregard for the safety of self and others • Being consistently irresponsible • Lack of remorse

13. Borderline Personality Disorder • Pervasive pattern of instability in interpersonal relationships, self-image, and mood • Instability is accompanied by impulsiveness • Display frantic efforts to avoid real or imagined abandonment • Their relationships are unstable and intense, fluctuating between idealizing to devaluing the other person (shame, shame, blame, blame) • Marked and persistent disturbance of identity • May be recurring suicidal gestures or threats or other self-damaging behaviors • These individuals have tendency to over react with brief but intense episodes of depression, irritability or anxiety • Tendency to feel chronically empty and have anger control problems

14. Histrionic Personality Disorder • Excessive and pervasive emotionality and attention-seeking behaviors • Dissatisfied unless center of attention • Interactions with other may be inappropriately sexual or provocative • Emotions change rapidly and their behavior is often considered inappropriately exaggerated, sometimes to the point of being theatrical • Their speech is dramatic and impressionistic but also tends to lack detail • They are often quite suggestible and perceive relationships to be more intimate than they actually are

15. Narcissistic Personality Disorder • Pervasive pattern of grandiosity, need for admiration, and lack of empathy • Grandiose sense of self-importance and are preoccupied with their fantasies of success, brilliance, beauty, and ideal love • Expect special regards from others but often devalue others’ achievements and abilities • Require excessive admiration and expect to be catered to • Exploit others and generally have a lack of empathy towards others • Envious of others and expect that are others are envious of them in return

16. Axis II • Report all Personality Disorders and Mental Retardation • If no Axis II disorder use code V71.09. • If Axis II diagnosis is deferred or pending more information use code 799.9. • Include prominent maladaptive personality features. ( No code number used ) • Include the habitual use of maladaptive defense mechanisms. ( No code number used ) • A qualifying phase can be used if the individual has both a Axis I and a Axis II diagnosis as long as the Axis I is the principal diagnosis or the reason for the visit. • Principal Diagnosis. • Reason for Visit.

17. Cluster C • Characterized by client’s being anxious and avoidant • Rigidly respond to demands by passively enduring, changing self, or withdrawing

18. Avoidant Personality Disorder • Pervasive pattern of social inhibition, feelings of inadequacy and a fear of negative evaluation • Avoid work, school, or even promotion opportunities because of their fears • Unlikely to enter into relationships without strong guarantees of unrelenting acceptance • They are preoccupied with being criticized or rejected, so they a markedly low threshold for detecting such behaviors • See themselves as being socially inept, personally unappealing, or inferior

19. Dependent Personality Disorder • Pervasive pattern of excessive need to be taken care of • This need leads to submissive and clinging behaviors accompanied by fear of separation • Have great difficulty making decisions • They want others to take the lead and are fearful of disagreeing with them • Fearful of being alone and will go to excessive lengths to obtain nurturance and support from others • If relationship ends, they typically will urgently seek another relationship

20. Obsessive-Compulsive Personality Disorder • Pervasive pattern of preoccupation with orderliness, perfectionism, interpersonal and mental control • Overly stringent standard continually interfere with his/her ability to complete tasks or projects • Strive to make every detail perfect and display excessive devotion to work and productivity • Rarely take time for leisure, and when they do, the focus is on performing the leisure activity perfectly • Harsh judgments of others and oneself are common • Some have trouble discarding even unimportant objects and may be frugal in their spending in order to be prepared for a future disaster • Tend to be rigid and stubborn and contend there is only a single “right” way to perform

21. Axis III – General Medical Conditions • Report current medical conditions that are potentially relevant to the understanding or management of the individual's mental disorder. • The purpose of distinguishing General Medical Conditions is to encourage thoroughness in evaluation/assessment and to enhance communication among health care providers. • General Medical Conditions can be related to mental disorders in a variety of ways. • First, it is clear the medical condition is directly related to the development or worsening of the symptoms of the mental disorder. • Second, the relationship between the medical condition and mental disorder symptoms is insufficient. • Third, there are situations in which the medical condition is important to the overall understanding or treatment of the mental disorder.

22. Axis III • Report all General Medical Conditions. • If no General Medical Condition indicate. ( Axis III: None ) • If Axis III diagnosis is deferred or pending more information indicate. ( Axis III: Deferred. ) • Must be outside the ICD-9-CM Mental Disorder chapter and outside of chapter V of the ICD-10. • If a mental disorder is a direct physiological consequence of the general medical condition, include a Mental Disorder Due to a General Medical Condition in Axis I and a General Medical Condition should be included in Axis I and Axis III.

23. Axis IV – Psychosocial and Environmental Problems For reporting psychosocial and environmental stressors that may affect the diagnosis, treatment, and prognosis of mental disorders. A psychosocial or environmental problem may be a negative life event, an environmental difficulty or deficiency, a familial or other interpersonal stressor, an inadequacy of social support of personal resources, or other problems relating to the context in which an individual's difficulties have developed. Positive stressors, such as a job promotion, should be listed only if they constitute or lead to a problem, as when an individual has difficulty adapting to the new situation.

24. Axis IV Psychosocial and Environmental Problems fall into nine categories that are affecting an individual's ability to function in their daily activities of life. • Problems with primary support group • Problems related to the social environment • Educational problems • Occupational problems • Housing problems • Economic problems • Problems with access to health care services • Problems related to interaction with the legal system/crime • Other psychosocial and environmental problems

25. Axis V- Global Assessment of Functioning • For reporting the clinician's judgment of the individual's overall level of functioning and carrying out activities of daily living. • useful in planning treatment, measuring its impact, and in predicting outcome. • 100-point scale that measures a patients overall level of psychological, social, and occupational functioning on a hypothetical continuum. • Use the “current” or “past week” rating to indicate current management needs, the “at discharge” rating to document progress and quality of care, and the “highest level in past year” rating as a target for termination of treatment. • The GAF scale is useful for managed care-driven diagnostic evaluations to determine eligibility for treatment and disability benefits and to delineate the level of care required for patients. On completion of the GAF Report questions, a 10-point range is automatically determined. Then, using the sliding rating scale, you can quickly indicate the specific GAF rating within this 10-point range, using clinical judgment and hypothetical comparison with other patients in the range.

26. Multiaxial Diagnosis AXIS I: Clinical Disorders Other Conditions That May be a Focus of Clinical Attention AXIS II: Personality Disorders Mental Retardation AXIS III: General Medical Conditions AXIS IV: Psychosocial and Environmental Problems Problems with primary support group Problems related to the social environment Educational problems Occupational problems Housing problems Economic problems Problems with access to health care services Problems related to interaction with the legal system/crime Other psychosocial and environmental problems AXIS V: Global Assessment of Functioning Scale Score: Time Frame:

27. Example: Sarah Axis I Axis II Axis III Axis IV Problems related to the social environment Educational problems Occupational problems Housing problems Economic problems Problems with access to health care services Problems related to interaction with the legal system/crime Other psychosocial and environmental problems Axis V Current