advancing social work practice with clients: understanding the dsm 5
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Advancing Social Work Practice with Clients: Understanding the DSM 5. Columbia University School of Social Work Conference December 6, 2013. For Personality Vulnerabilities. Alternative DSM-5 Model. - PowerPoint PPT PresentationTRANSCRIPT
Advancing Social Work Practice with Clients: Understanding the DSM 5
Columbia University School of Social Work Conference
December 6, 2013
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ALTERNATIVE DSM-5 MODELFor Personality Vulnerabilities
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Changes From DSM-IV-TR To the DSM-5
1. The criteria for personality disorders in Section II of DSM-5 have not changed from those in DSM-IV.
2. 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
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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?
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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.
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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?”
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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?”
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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?”
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Reformulation of Personality Disorders in the DSM-5
1. 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.
2. 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.
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Proposed DSM-5 SystemA 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
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Proposed DSM-5 System Guide to Implementation
Proposes the following components as most central in comprising a personality functioning continuum:
SELF: Identity and Self-direction INTERPERSONAL:Empathy and IntimacySource: DSM-5 Table I Elements of Personality Functioning. http://dsm.psychiatryonline.org/content.aspx?bookid=556§ionid=41101793
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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.
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Level of Personality Functioning Scale
RATING SCALE
Clinician indicates the level that most closely characterizes the patient’s functioning in the self and interpersonal domains.
• LEVEL: 0 Little or No Impairment
• LEVEL: 1 Some Impairment• LEVEL: 2 Moderate
Impairment• LEVEL: 3 Severe Impairment• LEVEL: 4 Extreme Impairment
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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., 1. Negative Affectivity2. Detachment: (vs. Extraversion)3. Antagonism (vs. Agreeableness)
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Also Provides Opportunity to Assess 25 Subsets of Trait Domains DSM-5 Trait Facets
• Emotional Lability• Anxiousness• Perseveration• Anhedonia• Depressivity• Restricted Affectivity• Grandiosity
• Attention Seeking• Eccentricity• Cognitive and
perceptual dysregulation
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For example
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ALTERNATIVE MODELGeneral Criteria for Personality Disorder
The essential features of a personality disorder are:A. Moderate or greater impairment in
functioning. B. One or more pathological personality traits.
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Essence of Criteria C-G:
Relatively inflexible and pervasive across situations
Relatively stable across time, Not better explained by another mental
disorderNot better understood as normal
development
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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 IntimacyPD-TS: One or more pathological personality trait domains OR specific trait facets within domains, considering ALL of the trait domains
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THE CASE OF RORYDSM-5 Alternate Model
Borderline Personality Disorder
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Illustrative borderline patient rated at level 3 of functioning
Rory Long SELF INTERPERSONAL Evaluation Date 12.06.2013
Level Identity Self-Direction Empathy Intimacy
3Patient
Rory Long functions at
Level 3
Therapist: A.L. Sloan,
LCSW
Mr. Long’s sense of autonomy and agency appear significantly compromised, He often experiences a lack of identity and emptiness. His boundary definitions are poor or rigid: he often over identifies with others, and then over emphasizes independence from them, or vacillates between these two extremes.
Mr. Long’s self-esteem is fragile and he is easily influenced by events. His self-image lacks coherence. His self appraisal is characterized by “black and white thinking”. He vacillates between self-loathing and self-aggrandizing. His emotions rapidly shift between extremes.
Mr. Long has difficulty establishing and/or achieving his personal goals.
Mr. Long’s internal standards for behavior are unclear or contradictory. He appears to experience life as meaningless or dangerous.
-Mr. Long demonstrates a significantly compromised ability to reflect upon and understand his own mental processes.
Mr. Long is significantly limited is his ability to consider and understand the thoughts, feelings and behavior of other people;. He is able to discern certain specific aspects of others’ experience, particularly vulnerabilities and suffering.
Mr. Long is generally unable to consider alternative perspectives; he appears highly threatened by differences of opinion or alternative viewpoints.
Client is often confused and almost always unaware of the impact of his actions on others; he is often bewildered about peoples’ thoughts and actions. He frequently misattributes destructive motivations to others.
Mr. Long expresses the desire to form relationships in his community and personal life but his capacity for positive and enduring connection appears to be significantly impaired.
-Mr. Long’s relationships are based on a strong belief in the absolute need for the intimate other(s), and/or expectations of abandonment or abuse. His feelings about intimate involvement with others consistently alternates between fear/rejection and desperate desire for connection.
Demonstrates little mutuality: others are conceptualized primarily in terms of how they affect the self (negatively or positively). Often perceives slights from others.
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Bearing Witness to the Texture of Distress
DSM-5
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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.
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Other Conditions That May Be a Focus of Clinical Attention
E.g., 1. Relational Problems3. Educational and Occupational Problems4. 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
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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.
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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.
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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 manifold burdens.
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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.
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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.
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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.”
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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.”
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Documenting the Texture of Distress Example)
• Spouse or Partner Abuse, Psychological, Confirmed Subsequent 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”.
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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.
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