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35
Intake
Identifying information
Presenting problem
Social and Family history
Developmental history
Important cultural factors
Medical history
Behavioral Observation/ Mental Status Exam
Diagnostic Impressions
Treatment recommendations
Differential
Diagnosis
Decision Tree
By Nathaniel Chapman, Psy.D.
Decision Tree
MALINGERING
SUBSTANCE USE
MEDICAL
CONDITIONS
Differential
Diagnosis
–The clinician is choosing a single
diagnosis from among a group of
competing, mutually exclusive diagnoses
to best explain a given symptom
presentation.
Step 1: Rule
Out
Malingering
and Factitious
Disorder
– Reasons to malinger- avoiding legal or military
responsibilities, obtaining drugs
Questions
– Are there clear incentives to being diagnosed
with a psychiatric condition
– Do patients’ descriptions sound like google?
– Do their symptoms drastically shift from one
encounter to the next?
– Does the patient appear to be manipulative?
– First question: Could a substance cause these symptoms?
– Single most common diagnostic error
Step 2: Rule
Out Substance
Etiology
1.
Determine whether the patient has been using a substance
2.
Determine whether there is a relationship between substance
use and symptomatology
a.
Are the symptoms present outside of substance use?
b. Duration, frequency, intensity
c.
If psychopathology begin prior to substance use it is probably
not substance related.
3. Substance use can be the consequence or an associated feature of
psychiatric conditions
4. Substance use could be a separate independent issue.
Step 3: Rule A
Disorder Due
to a General
Medical
Condition
1.
Symptoms of some psychiatric disorders and of many general
medical conditions can be identical
2.
Sometimes the first presenting symptoms of a general medical
condition are psychiatric
3.
The relationship between the general medical condition and
the psychiatric symptoms may be complicated
4.
Patients are often seen in settings in which there may be a low
familiarity with medical conditions.
Any psychiatric presentation can be caused by the direct
physiological effects of a general medical condition, and these are
diagnosed in DSM-5 as one of the Mental Disorders Due to Another
Medical Condition
Step 3: Rule
Out a Disorder
Due to a
General
Medical
Condition
– Once a medical condition is established, the next task is to
determine its etiological relationship, if any to the psychiatric
symptoms
1.
Explore the nature of the relationship
2.
Is the psychiatric presentation atypical
3.
Which DSM-5 Mental Disorder Due to Another Medical
Condition best describes the presentation.
Step 4:
Determine the
Specific
Primary
Disorder(s)
Step #4
• The problem is that many disorders share common
symptoms:
Insomnia
Acute Stress Disorder
Cyclothymic Disorder
Delirium
Dysthymic Disorder
GAD
Hypomanic Episode
Major Depressive Disorder
Manic Episode
Mixed Episode
Nightmare Disorder
PTSD
Schizoaffective Disorder
Schizophreniform Disorder
Schizophrenia
Substance Use/Withdrawal
Weight Loss
Anorexia Nervosa
Dysthymic Disorder
Hypomanic Episode
Major Depressive Disorder
Manic Episode
Mixed Episode
Substance Intoxication
Irritability
Acute Stress Disorder
ASPD
Attentional Deficit/Hyperactivity Disorder
BPD
Conduct Disorder
Cyclothymic Disorder
Delusional Disorder
Dysthymic Disorder
GAD
Hypomanic Episode
Major Depressive Disorder
Manic Episode
Mixed Episode
PTSD
Schizoaffective Disorder
Schizophreniform Disorder
Schizophrenia
Substance Use/Withdrawal
Step #4
• The problem is that many disorders share common
symptoms:
Insomnia
Acute Stress Disorder
Cyclothymic Disorder
Delirium
Dysthymic Disorder
GAD
Hypomanic Episode
Major Depressive Disorder
Manic Episode
Mixed Episode
Nightmare Disorder
PTSD
Schizoaffective Disorder
Schizophreniform Disorder
Schizophrenia
Substance Use/Withdrawal
Weight Loss
Anorexia Nervosa
Dysthymic Disorder
Hypomanic Episode
Major Depressive Disorder
Manic Episode
Mixed Episode
Substance Intoxication
Irritability
Acute Stress Disorder
ASPD
Attentional Deficit/Hyperactivity Disorder
BPD
Conduct Disorder
Cyclothymic Disorder
Delusional Disorder
Dysthymic Disorder
GAD
Hypomanic Episode
Major Depressive Disorder
Manic Episode
Mixed Episode
PTSD
Schizoaffective Disorder
Schizophreniform Disorder
Schizophrenia
Substance Use/Withdrawal
Step #4
• The problem is that many disorders share common
symptoms:
Insomnia
Acute Stress Disorder
Cyclothymic Disorder
Delirium
Dysthymic Disorder
GAD
Hypomanic Episode
Major Depressive Disorder
Manic Episode
Mixed Episode
Nightmare Disorder
PTSD
Schizoaffective Disorder
Schizophreniform Disorder
Schizophrenia
Substance Use/Withdrawal
Weight Loss
Anorexia Nervosa
Dysthymic Disorder
Hypomanic Episode
Major Depressive Disorder
Manic Episode
Mixed Episode
Substance Intoxication
Irritability
Acute Stress Disorder
ASPD
Attentional Deficit/Hyperactivity Disorder
BPD
Conduct Disorder
Cyclothymic Disorder
Delusional Disorder
Dysthymic Disorder
GAD
Hypomanic Episode
Major Depressive Disorder
Manic Episode
Mixed Episode
PTSD
Schizoaffective Disorder
Schizophreniform Disorder
Schizophrenia
Substance Use/Withdrawal
Step 5:
Differentiate
Adjustment
Disorders
From the
Residual Other
Specified or
Unspecified
Disorders
– If the clinical judgment is made that the
symptoms have developed as a maladaptive
response to a psychosocial stressor
– If it is judged that a stressor is not responsible
for the development of the clinically significant
symptoms, then the relevant Other Specified
or Unspecified category may be diagnosed
Step 6:
Establish the
Boundary With
No Mental
Disorder
– Set by clinical judgment
– Cultural context
INTAKE
PRESENTED BY NATHANIEL
CHAPMAN, PSY.D.
INTAKE
IDENTIFYING DATA
PRESENTING
PROBLEM
PSYCHOSOCIAL
HISTORY
DIAGNOSIS AND
TREATMENT PLAN
INTAKE BASICS
¡ It is a part of a medical chart
¡ Clear and concise
¡ Keep in mind the audience (court, the client, insurance, family
members, other providers)
DEMOGRAPHICS
¡ Parents (age, occupation, education, religion, sexual orientation, martial status, ses)
PRESENTING PROBLEM/REASON FOR REFERRAL
¡ What brings the client in?
¡ Avoid personal judgements
¡ Be brief (but provide relevant and necessary detail)
¡ Be objective
¡ Be specific
¡ Use person first language (avoid labels)
¡ Use direct quotes if relevant
PRECIPITATING FACTORS
PSYCHOSOCIAL HISTORY
SOCIAL HISTORY
¡ Childhood family history (how were they disciplined, sibling relationships,
relationships with parents)
¡ Developmental milestones (specifically-birth complications, walking, talking,
early illnesses)
¡ Child physical abuse, verbal abuse, sexual abuse
¡ Relationships (current and past)
¡ Family history of medical conditions and mental health conditions
¡ Support system
EDUCATIONAL BACKGROUND
¡ Academic experience
¡ Academic completion
¡ Relationships in school
¡ Subjects they liked and disliked
¡ Any IEP
¡ Any learning difficulties or diagnoses
MEDICAL HISTORY
¡ Family history of medical conditions and mental health conditions
¡ Medical conditions
¡ Physical health
¡ Get releases from medical providers
SUBSTANCE USE HISTORY
LEGAL HISTORY
ADDRESSING MODEL – HAYS, P. A. (2001)
¡
Age and Generational Influences
¡
Developmental Disability
¡
Disability Acquired Later in Life
¡
Religion and Spiritual Orientation
¡
Ethnicity/Race Identity
¡
Socioeconomic Status
¡
Sexual Orientation
¡
Indigenous Heritage
¡
National Origin
¡
Gender
INTAKE: PSYCHIATRIC HISTORY
History of mental health symptoms (frequency, intensity and duration)
Current mental health symptoms (frequency, intensity and duration)
Psychotropic medications (list dosage and prescribing physician)
Hospitalizations (list where, and diagnosis given)
Suicidal and Homicidal Ideation Assessment (note the risk)
MENTAL STATUS
EXAM
ABC STAMP
LICKER
¡ Appearance
¡ Behavior
¡ Cooperation
ABC STAMP LICKER
Speech
Thought-form and content
Affect (moment-to-moment variation in emotions)
Mood (subjective emotional tone during the interview)
Perception-in all sensory modalities
ABC STAMP LICKER
Level of Consciousness
Insight & Judgment
Cognitive Functions & Sensorium (Orientation, Memory, Attention & Concentration, Reading & Writing)
Knowledge base (general knowledge. Note if problematic)
Endings-suicidal and/or homicidal ideation
Reliability of the information provided (Note if you have reason to believe the information given is unreliable)
APPEARANCE
1. Gender (As they identify)
2. Cultural Background
3. Actual age and apparent age “ Appears older than the stated age”
¡ Serious and/or prolonged physical illnesses
¡ Exposure to the elements (weather)/homelessness
¡ Smoking, alcohol, or other substance abuse
¡ Chronic and/or severe psychiatric disorder
APPEARANCE
¡ Appearance is too important a feature to not include in the Mental
Status Exam.
APPEARANCE: ATTIRE
4. Attire: how the patient is dressed, and how they present themselves during the intake. Attire reflects many things….
¡ Socioeconomic status
¡ Occupation
¡ Self-esteem ability and interest in attending to convention
¡ Include a comment on overall impression, and the details of how patient is dressed. “The patient was meticulously
dressed”
¡ Statements should be as close to factual as possible
APPEARANCE: GROOMING & HYGIENE
5. Grooming & Hygiene “ reflects the patient’s overall level of self care.
¡ Hair, attention to facial hair, skin condition, nails, body odor, oral hygiene and condition of clothing
are major aspects surveyed
¡ Descriptors: Disheveled (truffled as if by a strong wind), unkempt (poor attention to grooming)
¡ Conditions that can be seen via personal appearance: OCD,NPD, Schizophrenia
APPEARANCE: BODY
¡ thin or slim body build
¡ muscular or sturdy build
¡ heavy or portly body build
¡ Descriptors “ average weight and height”
PHYSICAL ABNORMALITIES
¡ Should be noted, as well as the resulting limitations, and the need for any assistive devices
Questions
¡ Is it congenital or acquired
¡ If congenital, what difficulties did this pose during development?
¡ If acquired, how was it acquired?
¡ What limitations does it impose?
¡ How has the patient adjusted to the loss?
¡ What are the psychological consequences to this person regarding the physical impairment?
APPEARANCE: JEWELRY AND COSMETIC USE
¡ Bizarrely applied makeup could be an indicator of a
psychiatric condition.
APPEARANCE: TATTOOS
¡ Tattoos reflect a myriad of meanings. People seek to express themselves through their appearance.
Questions
¡ What is the tattoo? What does it represent?
¡ What was going on in your life when you got the tattoo?
¡ What made the person/group/event so significant?
What you learn
Significant relationships, impulse control, insight, judgment
BEHAVIOR
¡ Agitation
¡ Hyperactivity
¡ Psychomotor Retardation
¡ Specific movements (compulsions, tics, negative symptoms)
¡ Describe activity level as increased, decreased or WNL
COOPERATION AND RELIABILITY
¡ Eye contact (continuous, good, intermittent, fleeting or absent)
¡ Attitude and demeanor toward the interview and interviewer
¡ Described as cooperative, uncooperative (i.e. entitled, controlling,
defensive, guarded, withdrawn)
¡ Attentive or inattentive
COOPERATION AND RELIABILITY: AFFECT
¡ The observable emotional state
¡ The moment-to-moment variability of visible emotions based
on what is occurring in the interview
SPEECH
¡ Speech: verbal expression
¡ Language: communication of comprehensible ideas
¡ Though process: The way ideas are produced and organized.
¡ Thought content what is being talked about
SPEECH
1. Is the patient’s speech abnormal?
2. In what way is it abnormal?
3. Was the patient’s speech ever normal?
4. Is anything else abnormal in addition to speech?
SPEECH
¡ Accent & Dialect
¡ Amount of speech (increased: verbose, loquacious, talkative)
(decreased: improvised, minimally responsive)
¡ Articulation (slurring, mechanical problems) (described as unclear,
mumbled)
¡ Modulation: loudness or softness of speech.
THOUGHT FORM AND PROCESS
¡ Circumstantiality: overinclusive of detail
¡ Tangentiality: does not address point
¡ Flight of Ideas: rapid and frequent shifts in topics
¡ Rambling: cluster of sentences remain goal-directed but are
interspersed with groups that are not goal directed.
¡ Loose associations: the connections between ideas is unclear or
nonsensical
THOUGHT FORM AND PROCESS: NORMAL
¡ Tightness of thought: well organized, tangential, loosely connected or
incoherent
¡ Flow of speech: spontaneous, hesitant, interrupted or halting
¡ Directness of replies: Informative and relevant, embellished, or
overinclusive
¡ Flow of ideas: logical and with variability, restricted or repetitive
¡ Vocabulary: descriptive , restricted, or idiosyncratic use of words
¡ Flow of information: Good exchange, adequate, vague or disorganized
THOUGHT CONTENT
¡ Delusions (non–bizarre: at least possible, bizarre: impossible)
¡ Overvalued ideas (superstitions)
¡ Obsessions
¡ Phobias
¡ Thought of harming self or others
¡ https://www.youtube.com/watch?v=u2vMnyTiwp4
SOS MADE PLAIN FOR A DR
¡
Sex (gender)
¡
Occupational status
¡
Stress level
¡
Mental Illness
¡
Age
¡
Drug abuse
¡
Effects of medication
¡
Precipitants
¡
Lethality of Method
¡
Antidepressant
¡
Isolation
¡
Note written
SOS MADE PLAIN FOR A DR
¡ Family history
¡ Organic conditions-chronic medical illness
¡ Relationship difficulties
¡ Akathasia: restlessness (usually side effect of an antipsychotic)
¡ Dates
¡ Repeated attempts
¡ https://www.youtube.com/watch?v=bWaFqw8XnpA
AFFECT AND MOOD
¡ The predominant emotion expressed
¡ The extend to which the emotion varies throughout the interview
¡ Intensity of the emotion expressed
¡ Appropriateness of emotion
¡ Congruence
PERCEPTION
¡ Hallucinations
¡ Illusions: misperceptions of stimuli
INSIGHT AND JUDGEMENT
¡ Good
¡ Fair
¡ Poor
COGNITIVE FUNCTIONING
¡ Orientation (Time, place, person)
¡ Attention ( the ability to direct mental energy when fully alert) and
concentration ( the sustained focus of attention for a period of time)
¡ Assess Attention -digit span 4 to 6 numbers. Concentration series
seven
¡ Memory (immediate, short term, long term)
¡ Assess-Immediate and short term. They should be given three to five
words and asked to repeat them after about five minutes.
THE CASE OF SIMBA
BEHAVIORAL OBSERVATION AND MENTAL STATUS EXAM
Simba presented as an age-appropriate and receptive adolescent. He was appropriately dressed and groomed. His
eye contact was adequate and appropriate. Gait and posture were unremarkable. Fine and gross motor skills
appeared to be adequately developed. His mood was dysthymic, and his affect was appropriate and congruent with his
mood. He was alert and oriented to person, place, time, and situation. Thought content appeared unremarkable.
Simba’s thought process was logical and goal-directed. There was no evidence of hallucinations or any other
perceptual disturbance. Hearing appeared to be adequate, as was his vision. Memory appeared intact. Rate and tone
of speech were within normal limits. There were no mannerisms, tics, or gestures indicative of any psychopathology or
physical distress.
Overall, Simba was well contained within the therapeutic boundaries and was friendly, cooperative, and readily
engaged throughout the entire assessment process.
DSM 5/DSM 5TR
Presented by Nathaniel Chapman, Psy.D.
DSM
â–  The Diagnostic and Statistical Manual of Mental Disorders (DSM) was created in
1952 by the American Psychiatric Association so that mental health professionals in
the United States would have a common language to use when diagnosing
individuals with mental disorders.
â–  After World War II, classification
was in a chaotic state.
â–  Was for mental health policy and
to regulate the treatment of the
institutionalized mentally ill
DSM
â–  It was biologically-oriented, linking
abnormal behavior to organic
brain dysfunctions.
â–  Clinicians practiced in mental
asylums.
â–  Psychoanalytic theory was the
leading school of thought by
American Board of Psychiatry
DSM
â–  The history of the DSM is a practical example of the scientific
progress to categorize psychopathology
Introduction:
Diagnostic & Statistical Manual of
Mental Disorders
1952: DSM-I
1968: DSM-II
1980: DSM-III
1987: DSM-III-R
1994: DSM-IV
2000: DSM-IV-TR
2013: DSM-5
2022: DSM-5TR
5
Major Changes in Evolution of DSM
â–  Shift in the conceptualization of mental disorders from a bio-psychosocial model to
a research-oriented, medical model.
â–  Development of the multi-axial diagnostic system that facilitated a rise in biomedical
findings based upon the five axes and the relation(s) between them.
â–  The inclusion of new disorders and expansion of previously defined disorders.
■ A “lateral” reorganization of disorders into discrete, broad categories that entailed
merging several disorders and eliminating others.
â–  A paradigm shift that was first evidenced in the DSM-III, that reinforced the
descriptive, somatic orientation that then became the norm in all subsequent DSMs.
DSM-I
■ Differentiated organic brain syndromes from “functional” disorders
â–  The functional disorders were further subdivided into Psychotic, Neurotic and
Character disorders.
â–  These descriptions were very short, rarely over 200 words, and added little to what
meaning could be derived from the name of the disorder
â–  102 broadly-construed diagnostic categories
â–  Not necessarily relevant to outpatient
DSM-II
â–  Unlike the DSM-I, many of the new categories added in the
DSM-II were categories of relevance to outpatient mental
health efforts.
â–  Anxiety disorders, depressive disorders, personality
disorders, and disorders of childhood/adolescence
â–  Increased systematic categorization and specificity
DSM-II
■ Permanent removal of the category “Homosexuality” from the
DSM-II.
â–  The change was originally made upon the publication of the
seventh printing of the DSM II in 1973, following a vote by the
American Psychiatric Association.
â–  It was contended that the earlier classifications of
homosexuality-as-disorder were shaped by politically and socioculturally contingent notions of deviance, rather than scientific
corroboration
DSM-III
â– 
Increase from 182 in the DSM-II to 265 in
the DSM-III
From DSMII-DSMIII
â–  Proposed relatively specific, operational
definitions for these categories in the form of
diagnostic criteria.
â–  They argued that any future research on these
fifteen mental disorders should use these
diagnostic criteria to identify patient samples
DSM-III
â–  Negative critiques of psychiatry during the 1960s thru the mid 1970s
â–  Relatively low reliability of psychiatric diagnoses, were sharply
criticized both within the psychiatric community and from without.
■ Thomas Szasz’s 1961 challenge to the fundamental premise that all
psychiatric conditions were “true illnesses”, which by extension, cast
skepticism upon the legitimacy of psychiatry as a medical discipline.
â–  Substantive advances in psychometric instruments for quantitative
psychiatric assessment, such as rating scales and checklists for
anxiety and depression, become more popular in mental health
research and practice.
â–  Growth of psychotropics
DSM III
The DSM-III contained diagnostic criteria to specify the meaning of the categories.
In addition, for each category, there was
â– 
a description of the typical demographic profile of patients experiencing this
disorder
â–  a lengthy explanation of what the category meant
â– 
a description of how to differentiate the target category from any other category
with which it might be confused.
â–  a brief discussion of what was known, if anything about the course and onset of the
disorder.
DSM III
â–  Each patient was expected to be diagnosed along five
separate axes:
Axis I the descriptive presentation of the patient (i.e., the
mental disorder categories),
Axis II the underlying personality and/or intellectual disorder,
Axis III any associated medical disorder that was relevant to
the patient’s psychiatric presentation
Axis IV the psychosocial stressors in the patient’s environment,
and
Axis V the patient’s highest level of adaptive functioning in the
past year.
DSM-III
â–  Prior to the DSM-III, psychiatry was dominated by
psychoanalytically trained psychiatrists.
â–  DSM-III allowed for the incorporation of empirical data into
the classification of several disorders.
â–  Began to include information gathered from studies of the
pathophysiology of mental disorders,
â–  Begin the subdivision of disorders
â–  Relatively good diagnostic reliability
DSM III
â– 
Third Edition (DSM–III) revealed inconsistencies in
the system and instances in which the diagnostic
criteria were not clear
DSM-IV
■ DSM–IV was published in 1994. It was the culmination of a six–year
effort that involved more than 1,000 individuals and numerous
professional organizations.
â–  Much of the effort involved conducting a comprehensive review of the
literature to establish a firm empirical basis for making modifications.
â–  Numerous changes were made to the classification (e.g., disorders
were added, deleted, and reorganized), to the diagnostic criteria sets,
and to the descriptive text. Developers of DSM–IV and the 10th
edition of the ICD worked closely to coordinate their efforts, resulting
in increased congruence between the two systems and fewer
meaningless differences in wording. ICD–10 was published in 1992.
DSM IV
■ “Culture-bound Syndromes”
DSM 5
DSM-5
■ DSM-5’s Task Force (28 members) and 13 Work Groups
â–  More than 160 mental health and medical professionals
â–  100 psychiatrists, 47 psychologists, two pediatric neurologists and three
statisticians/epidemiologists.
â–  More than 300 outside advisers.
â–  National Institutes of Mental Health, the World Health Organization (WHO) and the
World Psychiatric Association
â–  Was open for public review three times
More Heat Than Light:
Top 10 Most Significant Changes in the DSM-5
1. Discontinuation of the Multi-axial Diagnosis
2. Greater (bio)medical orientation
3. Inclusion of Section III: Emerging Measures &
Models
4. Dimensionalizing Disorders (e.g. ASD, Schiz)
5. Reclassification & Re-combination of Disorders
6. Addition of Non-Substance Addictive Disorders
7. Designed to articulate with the ICD
NEURODEVELOPMENTAL DISORDERS
Autism Spectrum Disorder
Social (Pragmatic) Communication Disorder
Specific Learning Disorder
Attention-Deficit/Hyperactivity Disorder
Intellectual Disability (Intellectual Developmental Disorder)
22
Autism Spectrum Disorder
■ Encompasses autistic disorder, Asperger’s disorder, childhood disintegrative
disorder, & pervasive developmental disorder NOS.
â–  Symptoms in two core areas:
A. deficits in social communication & social interaction
B. restricted repetitive behaviors, interests, & activities
Autism Spectrum Disorder (ASD)
(Neurodevelopmental Disorders)
â–  Rationale: Clinicians had been applying the DSM-IV criteria for
these disorders inconsistently and incorrectly; consequently,
reliability data to support their continued separation was very
poor.
– Specifiers can be used to describe variants of ASD (e.g.,
the former diagnosis of Asperger’s can now be diagnosed
as autism spectrum disorder, without intellectual
impairment and without structural language impairment).
Copyright © 2013. American Psychiatric Association.
Autism Spectrum Disorder
Severity specifiers:
â–  Based on social communication impairments and restricted, repetitive behavior
patterns.
â–  Assessed using new dimensional assessment
â–  Severity Levels:
1. Requiring Support
2. Requiring Substantial Support
3. Requiring Very Substantial Support
Specific Learning Disorder
â–  Now presented as a single disorder with coded
specifiers for specific deficits in reading, writing, and
mathematics
â–  Rationale: There was widespread concern among clinicians and researchers
that clinical reality did not support DSM-IV’s three independent learning
disorders.
â–  By reclassifying these as a single disorder, separate
specifiers can be used to code the level of deficits present
in each of the three areas for any person.
Copyright © 2013. American Psychiatric Association.
Attention-Deficit/Hyperactivity Disorder
â–  Two symptom domains:
1. inattention
2. hyperactivity/impulsivity
â–  At least 6 symptoms in one domain required
(adults: 5 symptoms)
â–  Onset prior to age 12
â–  Subtypes replaced by specifiers
Attention-Deficit/Hyperactivity Disorder
â–  Age of onset was raised from 7 years to 12 years

Rationale: Numerous large-scale studies indicate that, in many cases, onset is
not identified until after age 7 years, when challenged by school requirements.
Recall of onset is more accurate at 12 years
â–  The symptom threshold for adults age 17 years and
older was reduced to five
– Rationale: The reduction in symptom threshold was for adults only and
was made based on longitudinal studies showing that patients tend to
have fewer symptoms in adulthood than in childhood.
Copyright © 2013. American Psychiatric Association.
Intellectual Disability (Intellectual
Developmental Disorder)
â–  Name change
â–  Severity specifiers:
â–  determined by adaptive functioning rather than IQ score
â–  Adaptive functioning includes
1. Conceptual domain
2. Social domain
3. Practical domain
â–  Assessed using new dimensional assessment
â–  Severity Levels: Mild, Moderate, Severe, Profound
Intellectual Disability (Intellectual Developmental
Disorder)
â–  Mental retardation was renamed intellectual disability
(intellectual developmental disorder)
– Rationale: The term intellectual disability reflects the wording adopted
into U.S. law in 2010 (Rosa’s Law), in use in professional journals, and
endorsed by certain patient advocacy groups. The term intellectual
developmental disorder is consistent with language proposed for ICD-11.
â–  Greater emphasis on adaptive functioning deficits rather than IQ
scores alone
– Rationale: Standardized IQ test scores were over-emphasized as the
determining factor of abilities in DSM-IV. Consideration of functioning
provides a more comprehensive assessment of the individual.
Copyright © 2013. American Psychiatric Association.
OTHER PSYCHOTIC
DISORDERS
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophrenia
Schizoaffective Disorder
Schizotypal Personality Disorder
31
Schizophrenia (cont’d)
â–  Deletion of specific subtypes
■ Rationale: DSM-IV’s subtypes were shown to have very poor reliability and
validity. They also failed to differentiate from one another based on
treatment response and course
Copyright © 2013. American Psychiatric Association.
Schizophrenia Spectrum &
Other Psychotic Disorders
Schizotypal
Schizoaffective Disorder
â–  Criterion A requires that a major mood episode be present for the
majority of the disorder’s duration.
Delusional Disorder
■ Criterion A no longer requires that delusions be “non-bizarre.”
Catatonia
â–  A specifier that can be added to psychotic, bipolar, depressive, or
other medical disorder, or an unidentified medical condition.
RELATED
DISORDERS
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Substance/medication induced bipolar
& related disorder
Other specified bipolar and related disorder
Unspecified bipolar and related disorder
34
Bipolar I Disorder
â–  At least one manic episode, which may be preceded by or followed by a
hypomanic or major depressive episode.
â–  Changes:
– Criterion A for Manic Episode and Hypomanic Episode emphasizes
changes in activity and energy, as well as mood
– Dropped “mixed episode”
– Added “mixed specifier”
– Added “with anxious distress” specifier
DEPRESSIVE
DISORDERS
Disruptive mood dysregulation disorder
Major depressive disorder
Persistent depressive disorder (dysthymia)
Premenstrual dysphoric disorder
36
Disruptive Mood
Dysregulation Disorder (DMDD)
â–  Temper outbursts involving yelling, rages or
physical aggression
â–  Overreacting to common stressors
â–  Temper outbursts occurring on average 3 or more
times a week for at least 12 months (not symptom-free for more than 3
months at a time)
â–  Children age 6 to 18 years
â–  Introduced by Brotman (2006) as Severe Mood Dysregulation Disorder; DSM5 considered
“Temper Dysregulation Disorder”
Disruptive Mood Dysregulation Disorder (DMDD)
â–  Newly added to DSM-5
– Rationale: This addresses the disturbing increase in pediatric bipolar
diagnoses over the past two decades, which is due in large part to the
incorrect characterization of non-episodic irritability as a hallmark
symptom of mania. DMDD provides a diagnosis for children with
extreme behavioral dyscontrol but persistent, rather than episodic,
irritability and reduces the likelihood of such children being
inappropriately prescribed antipsychotic medication. These criteria do
not allow a dual diagnosis with oppositional-defiant disorder (ODD) or
intermittent explosive disorder (IED), but it can be diagnosed with
conduct disorder (CD)
Copyright © 2013. American Psychiatric Association.
Premenstrual Dysphoric Disorder
â–  Moved from DSM-IV Appendix (for further study) to DSM-5 Section II
â–  Mood, irritability, dysphoria and anxiety symptoms that occur during the majority of
menstrual cycles.
Panic Attacks Specifier
â–  Now a specifier for any mental disorder
– Rationale: Panic attacks can predict the onset severity and course of
mental disorders, including anxiety disorders, bipolar disorder,
depression, psychosis, substance use disorders, and personality
disorders.
Copyright © 2013. American Psychiatric Association.
TRAUMA- & STRESS-RELATED
DISORDERS
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
41
RAD and DSED
■ DSM-IV’s reactive attachment disorder (RAD) subtypes
are now two distinct disorders: RAD and disinhibited
social engagement disorder (DSED)
â–  Rationale: These appear to be two distinct conditions that are characterized
by different attachment behaviors. RAD is more similar to ADHD and
disruptive behavior disorders and reflects poorly formed or absent
attachments to others. DSED is more similar to depression and other
internalizing disorders but occurs in children with both insecure and more
secure attachments.
Copyright © 2013. American Psychiatric Association.
Posttraumatic Stress Disorder
â–  Criterion A is more explicit with regard to how an individual experienced
“traumatic” events.
1. directly experiences the traumatic event
2. witnesses the traumatic event in person
3. learns that the traumatic event occurred to a close family member or
close friend or
4. experiences first-hand repeated or extreme exposure to aversive details
of the traumatic event
Posttraumatic Stress Disorder
â–  The stressor criterion (Criterion A) is more explicit (e.g.,
elimination of “non-violent death of a loved one” as a
trigger) and subjective reaction (Criterion A2) is
eliminated
â–  Rationale: Direct and indirect exposure to trauma are still reflected in the
criteria, but a review of the literature indicated more restrictive wording was
needed. Criterion A2 is not well-supported by the data and rarely endorsed by
military and other professionals who otherwise would meet full criteria for
PTSD.
Copyright © 2013. American Psychiatric Association.
Posttraumatic Stress Disorder
■ Separate criteria set for “PTSD for Children 6 Years and Under”
â–  Directly under the PTSD criteria box
â–  Same code number
Specify:
â–  With dissociative symptoms
â–  With delayed expression

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