D E S C R IP T IO N S TAK E N F ROM : D S M 5

BIPOLAR,
DEPRESSIVE
AND
ANXIETY
DISORDER

BIPOLARITY
Characterized by movement between
opposite poles: very elevated
moods (mania) and periods of
depression; previously known as
manic-depressive disorder

* Hypomania is a lower level of mania

SIGNS OF MANIA

Inflated self esteem (grandiosity)

Decreased need for sleep (3 hours or less)
Talkativeness
Racing thoughts
Distractibility
Increase in goal-directed
activity/agitation
Involvement in risky behaviors

DIFFERENCES BETWEEN
BIPOLARS 1 AND 2
A person with bipolar I has manic episodes, while someone
with bipolar II has hypomanic (watered down level) episodes.
*hypomania is not required for Bipolar 1 diagnosis
Mania may include psychotic symptoms - delusions or
hallucinations. Hypomania does not have psychotic
symptoms.
While hypomania may interfere to a degree with daily
functioning, in mania day-to-day life is significantly impaired.

The manic person has to be put in the hospital because of the

severity of symptoms.

OTHER BIPOLAR
DISORDERS

Substance/Medication-Induced
Bipolar
and
Related
Disorder
(coding
depending
on
substance)
Bipolar and Related Disorder Due to a General
Medical Condition (Coding follows ICD-10-CM
and can get complicated).
296.89 (F31.89) Other Specified Bipolar and
Related Disorder
296.80(F31.9) Unspecified Bipolar and Related
Disorder

Clients who are chronically both elated and depressed, but

do not fulfill criteria for hypomanic or major depressive
episodes.

Client has had hypomanic symptoms and low mood swings

for at least two years (at least 1 year for children and
adolescents).

Symptoms have been present for at least half the time;

longest client has been free of mood swings during two
year period is two months.

Client has never met criteria for major depressive, manic, or

hypomanic episodes

Typical exclusions (not due to GMC or substance use)

CYCLOTHYMIC
DISORDER

TREATMENT OF
BIPOLAR I & II
CBT
Family-focused treatment
Interpersonal psychotherapy
Psychoeducation about disorder
Chart the precipitants, nature, duration, frequency, and
seasonality of dysfunctional mood to avoid future episodes.

Medication
Lithium
Anticonvulsants (Depakote, Tegretol, Lamictal)
Atypical Antipsychotics (Risperdal, Seroquel)

ANXIETY
DISORDERS

ANXIETY DISORDERS

Definition
Anxiety is defined as a state of intense apprehension,
uncertainty, and fear resulting from the anticipation
of a threatening event or situation, often to a degree
that normal physical and psychological functioning
is disrupted (American Heritage Medical, 2007, p. 38).
The American Psychiatric Association (APA) purports that
each of the Anxiety Disorders share features of fear and
anxiety.
Fear is the emotional response to real or perceived
threat, whereas, anxiety is anticipation of future threat
(APA, 2013, p. 189).

CHARACTERISTICS OF
ANXIETY DISORDERS
Physiological symptoms include:
Muscle tension
Heart palpitations
Sweating
Dizziness
Shortness of breath

10

Emotional symptoms include:

Restlessness
Sense of impending doom
Fear of dying
Fear of embarrassment or humiliation
Fear of something terrible happening

PREVALENCE OF
ANXIETY DISORDERS
Each
year
Anxiety
Disorders
impact
approximately 18% (40 million) adults in the U.S.
(NIMH, 2013b; NIMH, 2013c).
Anxiety disorders have a lifetime prevalence of
approximately 30% (Kessler et al., 2005).

11

Close to 50% of individuals diagnosed with an

Anxiety Disorder also meet the criteria for a
Depressive Disorder (Batelaan, De Graaaf, Van
Balkom, Vollebergh, & Beekman, 2012).

MAJOR CHANGES IN
ANXIETY DISORDERS FROM
DSM-IV TR TO DSM-5
Includes Selective Mutism and Separation Anxiety
Changing the name of Social Phobia to Social Anxiety
Disorder
Removing Panic Attack as a specifier for Agoraphobia.

12

Assigning Panic Attack as a specifier that may be applied to

a wide array of DSM-5 diagnoses.

DIFFERENTIAL DIAGNOSIS OF
ANXIETY DISORDERS &
DEPRESSIVE DISORDERS

13

Challenging due to the high comorbidity (up to 50%) of

Anxiety Disorders with Depressive Disorders
Depressive Disorders are sometimes viewed as anxiousmisery with high incidences of sadness and anhedonia.
Anxiety Disorders often include anxiety anticipation, worry,
uncertainty, and fear (Craske et al., 2009)
Sleep disturbance, overall fatigue, and difficulty with
concentration can be symptoms of both anxiety and
depression (APA, 2013).

SEPARATION ANXIETY
DISORDER
Separation Anxiety Disorder was moved from Disorders
Usually First Diagnosed in Infancy, Childhood, or
Adolescence (DSM-IV TR) to the Anxiety Disorders chapter in
DSM-5.

14

The age-of-onset requirement (before age of 18 years) was

dropped, thus allowing for diagnosis of Separation Anxiety
Disorder in adults (Mohr & Schneider, 2013).

SEPARATION ANXIETY
DISORDER DEFINITION &
PREVELANCE
Required:
Duration of at least 6 months in adults (1 month in children).
Prevalence rates are as follows: children (4%); adolescents
(1.6%), and adults (0.9%- 1.9%)

15

Separation Anxiety Disorder is the most prevalent Anxiety

Disorder in children, with girls more susceptible than boys.
Functionality in school, work, or social settings is often
impaired (APA, 2013).

SELECTIVE MUTISM
This is a new diagnosis in the Anxiety Disorders chapter of
the DSM-5 due to the restructuring of the chapters and the
removal of the Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence (APA, 2013).

Selective Mutism is the voluntary refusal to speak

(typically occurs outside of the home or immediate
family).
Children with Selective Mutism will sometimes communicate
with non-verbals such as nodding or grunting, and these
children do not usually possess language deficits.

16

Selective Mutism usually has an age of onset of under 5 years

and is often first noticed in school settings (APA, 2013).

SPECIFIC PHOBIA
Specific Phobias represent the existence of fear or
anxiety in the presence of a specific situation or
object. This is called the phobic stimulus (APA,
2013).

17

This fear or anxiety must be markedly stronger

than the actual threat of the object or situation (i.e.,
likelihood of being stuck on a well-maintained
elevator).

SPECIFIC PHOBIAS
Specific Phobias can develop after a traumatic event
or from witnessing traumatic events.
Individuals with Specific Phobia will avoid situations
of exposure to the stimulus.
The fear or anxiety happens every time the person is
exposed to the stimulus and may include symptoms
of a panic attack.

18

The median age of onset for a diagnosis of Specific

Phobia is 13 years (APA, 2013).

SAMPLES OF PHOBIAS

Anthrophobia - Fear of flowers.

Megalophobia - Fear of large things.
Tachophobia - Fear of speed.
Cacophobia - Fear of ugliness.
Catoptrophobia - Fear of mirrors.
Xenophobia - Fear of strangers or foreigners.
Chronomentrophobia - Fear of clocks.
Heliophobia - Fear of the sun.
Ophidiophobia Fear of snakes.
Iatrophobia - Fear of doctors.

http://psychology.about.com/od/phobias/a/phobialist.htm

19

See more at:

SPECIFIC PHOBIA
CODING
Approximately 75% of individuals diagnosed with Specific Phobia fear
more than one object. When this occurs, more than one diagnosis is given.
300.29 (F40.228) Animal
300.29 (F40.228) Natural Environment
300.29 (F40.228) Blood-injection injury
F40.230 Fear of blood
F40.231 Fear of injections and transfusions
F40.232 Fear of other medical care
F40.233 Fear of injury
300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed spaces)

20

300.29 (F40.298) Other (situations that may lead to choking or vomiting; in

children, e.g., loud sounds or costumed characters).
In cases where individuals experience panic attacks in response to their
phobia, clinicians should add with panic attacks to the diagnosis.

SOCIAL ANXIETY
DISORDER (SAD)
Social Phobia was originally classified as a mental disorder
in the DSM-III and has been renamed Social Anxiety Disorder
(SAD) in the DSM-5.

The main feature of SAD is ongoing fear and

worry surrounding myriad of social situations
(Kerns, Corner, Pincus, & Hofmann, 2013).
The majority of diagnoses are made during childhood or
early adolescence (Kerns, et al., 2013; Marques et al., 2013).

21

SAD is often seen in conjunction with Major Depressive

Disorders, other Anxiety Disorders, and Substance Use
Disorders (APA, 2013).

SOCIAL ANXIETY DISORDERS

(SAD), CONTINUED
Individuals with SAD often fear negative evaluation
(e.g., being humiliated, embarrassed, or rejected)
by others, either unfamiliar or familiar, in
performance,
interaction,
or
observation
situations.

22

Children, adolescents, and adults now share the

same criteria for duration, and the criterion for
adult insight has been dropped (Mohr & Schneider,
2013).

SAD
New: A Performance only specifier has been added for SAD in the
DSM-5 and includes a minimum duration of 6 months.

The Performance only specifier is given if

anxiety is specific to speaking or performing in
public.

23

Individuals diagnosed with the Performance only specifier are

mainly impaired in regard to their occupational environments. They
may also display difficulty in school situations where public
speaking is a requirement.

PANIC DISORDER
Panic Disorder is defined as recurrent, unexpected
panic attacks and was initially classified in the
DSM-III.
There is a median age of onset ranging from 20 to
24 years with a small percentage of individuals
first diagnosed in childhood.

24

Panic Disorder is not usually first seen in

individuals over the age of 45.

PANIC DISORDER
DEFINED
Essential features of Panic Disorder

Persistent fear or concern of inappropriate fear

responses with recurrent and unexpected panic attacks
Includes physiological changes such as accelerated
heart rate, sweating, dizziness, trembling, and chest
pain.

25

Panic Disorder has physical and cognitive symptoms

and involves numerous, unexpected panic attacks
(although it is important to note that individuals with
Panic Disorder can have expected panic attacks, too).

PANIC DISORDER,
CONTINUED
Common differential diagnoses for Panic Disorder:
Other specified or Unspecified Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
Substance/Medication-Induced Anxiety Disorder
Other mental disorders with panic attacks as an association
feature (specifier).

26

Illness Anxiety Disorder, formerly known as hypochondriasis,

often shares features with an/or is comorbid with Panic
Disorder (Starcevic, 2013).

PANIC ATTACK
SPECIFIER
Panic Attack is not classified as a mental
disorder and does not have a diagnostic code.
Panic attacks are abrupt surges of intense fear; they can occur
with other mental disorders such as Depressive and Anxiety
Disorders and also be extant with physical disorders.
Panic attack is a specifier for both mental and physical
disorders; however, the elements of panic attack are contained
within the criteria for Panic Disorder so it is not a specifier for
that diagnosis.

27

An example of panic attack used as a specifier is Social Anxiety

Disorder, with Panic Attack (APA, 2013).

PANIC ATTACK
SPECIFIER

28

Essential Features
Panic Attacks represent intense fear or discomfort
that occurs abruptly and peaks rapidly.
Physical symptoms are predominate and must
include a minimum of four out of the thirteen
identified symptoms, listed on page 214 of the
DSM-5.
Panic Attacks have an 11.2% annual prevalence
rate in the general U.S. population (APA, 2013).

AGORAPHOBIA

29

Agoraphobia is a newly codeable disorder in the

DSM-5 and represents an intense fear resultant
from real or imagined exposure to a wide range of
situations.
There is a 1.7% prevalence rate for the diagnosis of
Agoraphobia for adolescents through middle-aged
adults.
Agoraphobia lends to moderate to severe
impairment in functioning with over 33% of
individuals diagnosed with Agoraphobia restricted
to home environments (APA, 2013).

Agoraphobia represents fear of situations where

escape from bad things is difficult. This response
happens almost every time an individual is exposed
to the situations or event (it is not Agoraphobia if the
response occurs only some of the time). Avoidance of
the event or situation must also be present and can
include cognitive or behavioral aspects (APA, 2013).
Acute stress disorder and Posttraumatic Stress
Disorder can be distinguished from Agoraphobia in
that the avoidance occurs only from situations that
trigger a memory of the traumatic event, such as
driving or riding in a car after a motor vehicle
accident (APA, 2013).

30

AGORAPHOBIA:
ESSENTIAL FEATURES

GENERAL ANXIETY
DISORDER (GAD)
GAD has been in existence since the DSM III

31

GAD is one of the most common of all mental

disorders with an annual prevalence rate of 2.9%
among adults in U.S.
Excessive worry or anxiety about a number of events
is the key feature of GAD with the experience of the
anxiety or worry in discord with the actual or expected
event.
Although the DSM-5 Task Force proposed changes to
GAD that would have resulted in a lowered diagnostic
threshold, this disorder remains largely unchanged
from the DSM-IV TR.

GAD, CONTINUED
Essential features include anxiety or worry that takes place across a
number of settings and more days than not for at least six month.

32

The individual experiences at least three characteristic symptoms

including (as defined by the APA, 2013):
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
Many of the Anxiety Disorders outlined in this chapter along with
Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder,
Adjustment Disorders, Depressive Disorders, and psychotic disorders
possess similar features to GAD.

SUBSTANCE-INDUCED
ANXIETY DISORDER
Anxiety caused by substance utilization is the primary
criterion for the diagnosis of substance/medication induced
Anxiety Disorder.
Panic or anxiety must have developed during or soon after
substance/medication usage and be in excess of what would
be expected to be associated with intoxication or withdrawal
from that specific substance.
Prevalence rates for this disorder are low (.002%).

33

It is important for clinicians to tease out substances used to

self-medicate anxious symptoms with anxiety resultant from
substance usage or withdrawal.

ANXIETY DISORDER DUE TO

ANOTHER MEDICAL
CONDITION

34

Medical conditions can cause the development of an Anxiety

Disorder, but they must cause clinically significant distress.
APA reports are unclear about prevalence of Anxiety
Disorder Due to Another Medical Condition resultant from
the extreme difficulty with differential diagnosis for this
category (APA, 2013).
It is especially important for clinicians to carefully rule out
differential diagnosis and consult with a physician before
using the diagnosis of Anxiety Disorder Due to Another
Medical Condition.

ANXIETY DISORDER DUE TO

ANOTHER MEDICAL
CONDITION

35

Essential Features
Marked anxiety attacks occur and can be directly attributed to
an existing medical condition. The development of the anxiety
can parallel the course of the illness.
Examples of medical conditions that can cause Anxiety
Disorder Due to Another Medical Condition: endocrine
disease, cardiovascular disorders, respiratory illness,
metabolic disturbance, and neurological illness (APA, 2013).
The key to discernment regarding Anxiety Disorder Due to
Another Medical Condition is that the anxiety symptoms must
be attributed to the physiological effects of the medical
condition.

TREATMENT
Although tending towards chronicity, Anxiety Disorders are
responsive to psychotherapeutic treatment modalities.
It is important for counselors to note that severe anxiety is a
risk factor for suicide (Fawcett, 2013).

36

Additionally, Anxiety Disorders are the most common

disorders in youth (Sood, Mendez, & Kendall, 2012) and have
a median age of onset of 11 years.

37

38

IMPLICATIONS FOR
COUNSELORS
Due to the prevalence of Anxiety Disorders in the general
population, these diagnoses are frequently the focus of clinical
attention for counselors and are often diagnosed within
counseling settings (ADAA, 2013).
Individuals with Anxiety Disorders generally respond well to
clinical intervention with effective treatments including CognitiveBehavioral Therapy (CBT), Behavior Therapy (BT), and relaxation
training (AADA, 2013).

39

Numerous research studies reveal that positive treatment

outcomes for Anxiety Disorders are maintained longer for
individuals, including children and adolescents, who have
participated in CBT and BT (Hausmann et al., 2007; Hofmann &
Smits, 2008; Silverman, Pina, & Viswesvaran, 2008).

DEPRESSIVE
DISORDER IN DSM-5
Organization of Chapter
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder
Persistent Depressive Disorder
Premenstrual Dysphoric Disorder
Substance/Medication Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition
Other Specified Depressive Disorder

40

Unspecified Depressive Disorder

DISRUPTIVE MOOD
DYSREGULATION DISORDER
(DMDD)
Rationale for adding new disorder
Essential feature: Severe temper outbursts with underlying
persistent angry or irritable mood
Temper Outburst Frequency: Three or more times in a week
Duration: Temper outbursts and the persistently irritable mood
between outbursts lasts at least 12 months.
Severity: Present in two settings and severe in at least one
Onset: Before age 10, but do not diagnose before age 6. Cannot
diagnose for the first time after age 18.
Common rule-outs:

41

Bipolar disorder, intermittent explosive disorder, depressive

disorder, ADHD, autism spectrum disorder, separation anxiety
disorder, substance, medication, or medical condition
If ODD present, do not diagnose DMDD.

ISSUES WITH DMDD

More common in males
No empirically supported treatments yet.
Need more research

42

Avoid bipolar medications

Consider CBT treatments used for depression in children:
Coping skills for thoughts, feelings, and behavior
Parent training
Parent support group

MAJOR DEPRESSIVE
EPISODE
Essential features: Either depressed mood OR loss of
interest or pleasure plus four other depressive symptoms
Duration: At least two weeks

43

Common rule-outs: medical condition, medications,

substance use, bipolar disorder, or a psychotic disorder.
Note: Be careful about diagnosing major depression
following a significant loss, because normal grief may
resemble a depressive episode.

Grief

Major Depression

Dominant affect is feelings of

emptiness and loss

Dominant affect is a depressed

mood

Dysphoria occurs in waves,

vacillates with exposure to
reminders and decreases with time

Persistent dysphoria that is

accompanied by self-critical
preoccupation and negative
thoughts about the future

Capacity for positive emotional

experiences

Limited capacity to experience

happiness or pleasure

Self-esteem preserved

Worthlessness clouds esteem

Fleeting thoughts of joining

deceased

Suicidal ideas about escaping life

versus joining a loved one.

44

GRIEF VS. A MAJOR

DEPRESSIVE EPISODE IN
DSM-5

DIAGNOSING MAJOR
DEPRESSIVE DISORDER
Essential Features:
Meets criteria for a Major Depressive Episode
No history of a Manic or Hypomanic Episode
Coding Steps:

45

1. Start with noting whether it is a single episode or recurrent

(see columns on pg 162).
2. The code # indicates the type of episode (single or
recurrent) as well as the severity, presence of psychotic
features and remission status (partial or full). Find the correct
code number by dropping down your selected episode column
to locate the applicable severity, psychosis, or remission term.
For a recurrent episode that is moderate severity you would
use this code:
296.32 Major Depressive Disorder, Recurrent episode

DIAGNOSING MAJOR
DEPRESSIVE DISORDER,
CONTINUED

46

3. Now state the severity, psychosis, or remission status

term right after single or recurrent episode:
296.32 Major Depressive Disorder, recurrent episode,
moderate severity
4. Finally, add any of the specifiers that apply
With anxious stress, with mixed features, with melancholic
features, with atypical features, with mood-congruent
psychotic features or with mood-incongruent psychotic
features, with catatonia (code separately), with peripartum
onset, or with seasonal pattern
296.32 Major Depressive Disorder, recurrent episode,
moderate severity, with peripartum onset

PERSISTENT DEPRESSIVE
DISORDER (DYSTHYMIA)
Essential Feature: Depressed mood plus at least two other
depressive symptoms
Duration: The symptoms persist for at least two years (one
year for children and adolescents).

47

May include periods of major depressive episodes (double

depression).
Rule outs: Be sure it is not due to another psychotic
disorder, substance, medication, or medical condition.

SPECIFIERS FOR
PERSISTENT DEPRESSIVE
DISORDER
Severity: Mild, moderate, or severe
Remission status: In partial or full remission (if applicable)
Onset: Early (before 21), or late (21 or older)
Specify mood features: With anxious distress, mixed features,
melancholic features, atypical features, mood-congruent or moodincongruent psychotic features, and peripartum onset

48

Course specifiers: with pure dysthymic syndrome, with persistent

major depressive episode, with intermittent major depressive
episodes with current episode, with intermittent major depressive
episodes without current episode.

49

PREMENSTRUAL DYSPHORIC
DISORDER (PMDD)
Essential Feature: Significant affective symptoms that
emerge in the week prior to menses and quickly disappear
with the onset of menses.
Symptoms threshold: At least five symptoms which include
marked affective lability, depressed mood, irritability, or
tension.
Duration: Present in all menstrual cycles in the past year and
documented prospectively for two menstrual cycles.
Impairment: Clinically significant distress or impairment

50

Rule outs: An existing mental disorder (e.g., MDD), another

medical condition, (e.g., migraines that worsen during the
premenstrual phase) or substance or medication use.

PMDD UPDATE
Whats the difference between PMDD and PMS?
Why is it clinically significant to note from a mental health
stand-point?
Increased risk of postpartum depression
Increased risk of suicidal thinking, planning, and gestures
Impact on the individuals quality of life
Impact on psychosocial functioning
Treatments:

51

Diet
SSRIs
CBT

FINAL THOUGHTS

52

Depressive Disorders are common and treatable

Be sure your diagnosis is part of an overall case formulation
Remember, to understand the disorder, you need to
understand the person (Hippocrates).

53

PERSONALITY DISORDER:
HISTORY OF THEIR
INCLUSION IN DSM-IV-TR
Each personality disorder included in the DSM-IV TR was the
subject of a literature review performed by Work Group
members and advisors.
The reviews revealed that antisocial/psychopathic,
borderline, and schizotypal personality disorders had the
most extensive empirical evidence of validity and clinical
utility.
Almost NO empirical research backed paranoid, schizoid, or
histrionic personality disorders explicitly.

54

And, there was NO significant co-morbidity.

PERSONALITY DISORDERS IN
DSM-5
THE PROPOSAL
Original draft of DSM-5 eliminated 4 Personality Disorders:
1. Paranoid Personality Disorder
2. Schizoid Personality Disorder
3. Histrionic Personality Disorder
4. Dependent Personality Disorder
*An earlier draft also eliminated Narcissistic Personality
Disorder & Borderline Personality Disorder.

55

Very controversial topic!

PERSONALITY
DISORDERS: RESEARCH
Personality Disorders with the most research behind them:
1. Anti-social Personality Disorder
2. Borderline Personality Disorder
3. Schizotypal Personality Disorder
These could not be eliminated in good conscience.

56

Personality Disorders with the least research behind them:

1. Paranoid Personality Disorder
2. Histrionic Personality Disorder
3. Schizoid Personality Disorder

PERSONALITY
DISORDERS IN DSM-5
No significant co-morbidity was found between the
disordersso a compromise was made:
TO ELIMINATE NOTHING!
ORGANIZATION OF PERSONALITY DISORDERS became the
focus for DSM-5. Personality disorders do not fall along a
developmental continuum, as the rest of the DSM-5 had
been organized.

57

Personality Disorders was tacked on to the end of the

manual.

PERSONALITY DISORDER:
ORGANIZATION IN THE
MANUAL
The cluster arrangement of these disorders remains the same.
The beginning of the chapter discusses the features that are
present in all of the personality disorders.
Each disorder is more specifically discussed under their own
heading.
Common features among all disorders:
1. Cognition-ways of perceiving and interpreting self, others,
and events
2. Affectivity-the range, intensity, lability, and appropriateness
of emotional response
3. Interpersonal functioning

58

4. Impulse control issues

10 PERSONALITY
DISORDERS
Paranoid Personality Disorder
Schizoid Personality Disorder

Cluster A

Schizotypal Personality Disorder

Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder

Cluster B

Narcissistic Personality Disorder

Avoidant Personality Disorder
Dependent Personality Disorder

Cluster C

59

Obsessive-Compulsive Personality Disorder

DEFINITION OF
PERSONALITY DISORDER

60

A personality disorder is an
enduring pattern of inner experience
and behavior that deviates markedly
from the expectations of the
individuals culture, is pervasive and
inflexible, has onset in adolescence
or in early adulthood, is stable over
time, and leads to distress or
impairment. (APA, 2013, p. 645).

GENERAL PERSONALITY
DISORDER DIAGNOSIS
CRITERIA
There are no significant changes to the diagnosis criteria in
the DSM-5!
NEW: Culture Related Diagnostic Issues
More predominantly culturally aware in the DSM-5.
Examples in Personality Disorders:
Schizotypal: Voodoo, speaking in tongues, belief in an afterlife.
Antisocial: tends to be over-diagnosed in clients from lower
SES.
Avoidant: Acculturation issues
Dependent: Some cultures foster this

61

OCPD: Work and productivity in some cultures vary

62

NO CHANGES YET
BUT,
The present system is not sufficient.
Not enough empirical support for many of the personality
disorders. (We need more research!)
Frustration with an overarching organizational system

63

Does the system go far enough?

PERSONALITY
DISORDERS: DSM-5
The task force wanted to move to a dimensional model vs. a
categorical model for personality disorders.
Section III includes the new approach that addresses many
of the major shortcomings of the current approach.
Criterion A includes assessment of personality functioning
towards self (identity, self-direction), and interpersonally
(empathy, intimacy).

64

Criterion B includes Pathological Personality Traits

5 Broad Traits: negative affectivity, detachment, antagonism,
disinhibition, and psychotic features (and 25 trait facets).

PERSONALITY DISORDERS:
DSM-5, CONTINUED

65

Criterion C & D includes the assessment of pervasiveness

(different areas of life) and stability (going back to
adolescence).
Criterion E, F, & G is an assessment of alternative
explanations for personality pathology (Differential
Diagnosis). Includes not better explained by another mental
illness, not attributable to substances or medical condition,
or not better understood by an individuals developmental
stage or sociocultural environment.

PROPOSAL
CONTINUED, ICD-11
ICD-11 is proposing an even more radical approach (2015-16)
that would abolish all individual categories of personality
disorder and replace by 4 severity levels qualified by trait
domains that have no age limits.
Trait domains proposed:
Internalizing (neurotic), Externalizing (sociopathic), Schizoid,
Anankastic (obsessive/compulsive in some way).

Severity Categories:

66

No Personality Disturbance
Personality Difficulty (not coding)
Personality Disorder (1st level of clinical severity)
Complex Personality Disorder (more difficulty with interpersonal
functions)
Severe Personality Disorder

EXAMPLE DIAGNOSIS:
AVOIDANT PERSONALITY
DISORDER
A. Moderate or greater impairment in personality functioning, manifest
by characteristic difficulties in two or more of the following four areas:
1. Identity: low self-esteem associated with self-appraisal as socially
inept, personally unappealing or inferior; excessive feelings of shame
2. Self-Direction: unrealistic standards for behavior associated with
reluctance to pursue goals, take personal risks, or engage in new
activities involving interpersonal contact.
3. Empathy: Preoccupation with, and sensitivity to criticism or
rejection, associated with distorted inferences.
4. Intimacy: Reluctance to get involved with people unless being
certain of being liked.
B. Three or more of the four pathological personality traits, one of
which must be anxiousness:

67

1. Anxiousness; 2. Withdrawal; 3. Anhedonia; 4. Intimacy Avoidance

POTENTIAL NEW GROUPINGS OF

DISORDERS ACCORDING TO
SCIENTIFIC VALIDATORS:
Shared neural substrates
Family traits
Genetic risk factors
Specific environmental risk factors
Biomarkers
Temperamental antecedents
Abnormalities of emotional or cognitive processing
Symptom similarity
Course of illness
High comorbidity

68

Shared treatment response

FUTURE CHANGES
Clustering diagnoses according to internalizing vs.
externalizing groups.
Internalizing: disorders with prominent anxiety, depressive
and somatic symptoms. Characterized by depressed mood,
anxiety and related physiological and cognitive symptoms.

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Externalizing: disorders with prominent impulsive disruptive

conduct, substance use symptoms. Characterized by antisocial behavior, conduct disturbances, addictions, and
impulse control disorder.

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AREAS FOR FURTHER

STUDY
1. Attenuated Psychosis Syndrome
2. Depressive Episodes with Short-Duration Hypomania
3. Persistent Complex Bereavement Disorder

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4. Caffeine Use Disorder

5. Internet Gaming Disorder
6. Neurobehavioral Disorder Associated with Prenatal
Alcohol Exposure
7. Suicidal Behavioral Disorder
8. Non-suicidal Self Injury

WHAT DID APA GET

RIGHT IN DSM-5?
APA listened, to a degree, especially about Personality
Disorders.
Advanced the place of culture in diagnosis
Made some thoughtful changes to the organization and
diagnosis criteria that may end up being very beneficial
Sparked conversations among professionals that needed to
happen (and those conversations must continue).

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Identified 8 areas professionals can focus their passions in

research

WHAT SHOULD
COUNSELORS DO?
Get a copy, start with the basics! p.5 to 25
& highlights of changes p 809 to 816
Study the new sections of DSM-5 that are used most in your
practice or profession.
Study the cultural interview and WHODAS assessment.
Learn the ICD-10 well (and prepare for the ICD-11).

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Advance counseling science to contribute to the field. We

need more empirical data and counselors can be a huge
contributor to that research base.

WHAT SHOULD
COUNSELORS DO?

74

MOST IMPORTANT- Actively engage clients in collaborative

discussion about diagnosis and mental health so that it
becomes a hopeful and proactive force in promoting
changes desired by the client. Diagnosis is a useless
exercise if it does not assist in the change process.

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FINAL
THOUGHTS
?

REFERENCES
Cross cutting and diagnostic severity measures go to:
www.psychiatry.org/dsm5
Thorough summary of changes go to:
http://tnicholson2013.files.wordpress.com/2013/09dsm-5changes.pdf
For the WHODAS 2.0 and many assessment measures go to:
www.psyciatry.org/practice/dsm/dsm5/onlineassessmentmea
sures
they are also in the back of the DSM 5
ACA Webinar
Idaho Mental Health Counselors Webinar

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You Tube free 4 hour seminar

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