DSM 5 What AALs and GALs

Need to Know

Norma Villanueva, LCSW, DCSW

Modern View Clinical & Forensic Servicesn.villa@modernviewonline.com

Multiaxial to Single Axis• Perhaps the most significant change in the DSM-5 was the return to a single-

axis diagnosis First, the separation of personality disorders to Axis II under DSM-IV gave these disorders undeserved status and the misguided belief that they were largely untreatable (Good, 2012; Krueger & Eaton, 2010). Clients who met the criteria for an Axis II diagnosis may now find it easier to navigate mental health treatment.

• Medical conditions are no longer listed on a separate axis (Axis III in DSM-IV). Thus, they will likely take a more significant role in mental health diagnosis.

• Psychosocial and environmental stressors, will be listed alongside mental disorders and physical health issues. In fact, DSM-5 has increased the number of “V codes” (Z codes in ICD-10), which are considered nondisordered conditions that sometimes are the focus of treatment and often are reflective of a host of psychosocial and environmental issues.

• As for the GAF score, previously on Axis V of DSM-IV, the APA intended to replace this historically unreliable tool with a different scaling assessment altogether.

Systematic Changes

CHILDRENFAMLIESCOMMUNITY

Case Example

• What the child wants . . .

• What the child needs . . .

Case – First Phase

Full Adversary hearingMH Factors Parent Child – Outcry Family Dynamics nuclear extended

Dynamics – Hints & Initial View

• The FIRST view of POSSIBLE mental health factors and family Dynamics is:

• Removal Affidavit

• Determination for FBSS

Case – First Phase

Full Adversary hearing

MH Factors Parent Child – Outcry Family Dynamics nuclear extended

Service Plan Filed (45 days)

Services: How determined Therapy vs Eval Causal Factors vs Behavior

Case – First Phase

Full Adversary hearing

MH Factors Parent Child – Outcry Family Dynamics nuclear extended

Service Plan Filed (45 days)

Services: How determined Therapy vs Eval Causal Factors vs Behavior

Status Hearing (60 days)

Diagnosis School Adjustment Outcry

Comparative Example

Children Parents

Transparency

TherapyStyle

Visitation

Re-victimization

Triggers

Case – Second Phase

First Permanency Hearing (180 days)Diagnosis Driven Therapy Risk Targeted Parent Child

Risk• 78.3% Perpetrator is parent

• Child Vulnerability• Home & Social Environment• Caregiver Capability• Quality of Care• Maltreatment Pattern• Response to CPS• Protective Capacities

• 25.5% Turnover rate – case workers

2013 TDFPS-CPS Data Book

Case – Second Phase

First Permanency Hearing (180 days)

Diagnosis Driven Therapy Risk Targeted Parent Child

Second Permanency Hearing (300 days)

Progress: How determined Behaviors Symptoms Notes

Case – Second Phase

First Permanency Hearing (180 days)

Diagnosis Driven Therapy Risk Targeted Parent Child

Second Permanency Hearing (300 days)

Progress: How determined Behaviors Symptoms Notes

Trial/Final Order

Resolution of Risk Factors Adult Child Systemic-Family

Case Example

Diagnosis• Criterion for Clinical Significance

• WHO & DSM 5 Task force: distinguish between disability and mental disorder.

• Separate normal from pathological symptoms

• Function: “the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning”

Nonaxial Format

• Axis I, II & III: Primary Diagnosis, and others in order of significance

• Axis IV replaced by V codes Z codes• Only if focus of treatment

• Axis V replaced by self report measures if utilized

Work Toward Accurate Diagnosis

Level of Functioning in Major Roles

Self

Repo

rt D

espa

ir &

Sx

Seve

rity

Presenting Symptoms

Assess level of

functioning

Self report distress &

Impairment

DSM 5

Biological Basis

Function

ICD-10

Diagnosis

• Thorough Psychosocial History• Mental Status Exam

• History: Presenting Problem, specific symptoms, complaints• Identify duration and severity of symptoms• Functioning in major roles, ADL’s

• Mental Health History• Relevant medical history• Family History: MH, stressors• Social History: school/work, social/community• Diagnosis + specifiers

Trauma & Stressor Related Disorders

• New category1

• Includes Adjustment disorders2

• New criteria3

Trauma & Stressor related Disorders• PTSD: Changed definition of traumatic event

Eliminated criterion of how person responds to trauma• Exposure to actual or threatened a)death, b) serious injury, c)

sexual violation, in 1 or more of the following ways• Directly experiencing• Witnessing, in person, as they occur to others• Learning event occurred to a close family member or friend;

actual or threatened death must have been violent or accidental

• Experiencing repeated or extreme exposure to aversive details of traumatic events (not electronic media, tv, movies unless work related)

Trauma & Stress Related Disorder: Clusters and Subtypes

4 Symptom Clusters• Intrusion• Avoidance• Negative alterations in cognition and mood• Marked alterations in arousal and reactivity

Different SubtypesEliminating Acute versus chronicAddition of Preschool subtypeAddition of Dissociative Subtype

Trauma & Stress Related Disorder: Diagnostic CriteriaA. StressorB. 1 or more intrusion symptomsC. 1 or more avoidance of stimuli D. Negative alterations in cognition and mood (2 new)E. Marked altercations in arousal and reactivity

2 or more

Persistent, distorted blame of self or others about the cause or consequences of the traumatic event(s)

Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame)

PTSD in Preschool Children

The first developmental subtype of a diagnosisCriterion Deleted: reaction to event, inability to recall, foreshortened futureIntrusion Sxs: Intrusive thoughts + neutral reactionAvoidance Sxs: cognition & mood alterations 1 symptom in avoidance or cognitive/mood Diminished interest = constricted play Detachment – behaviorally social withdrawalIncreased Arousal: addition of extreme temper tantrums.

Neurodevelopmental Disorders

• IQ no longer criteria• <70 understood1

• Asperger’s in Autism spectrum2

• Variation in personality factors, IQ, and Sx severity

3

Neurodevelopmental cont.

Diagnostic criteria: must assess cognitive capacity & adaptive functioning – determines Severity. Domains reduced from 3 to 2 • Social/communication deficits• Fixed Interests/repetitive behaviors• Merged Communication & Social interaction• Require 2 versus 3 behavioral markers• Onset: early childhood• Categorize by need for support• Removed language delay criterion

ADHD

• Age of onset: prior to 12 + symptoms1

• 4 Subtypes2

• Requires 2 different informants3

ADHD cont. • Subtypes: Combined,

Primarily Inattentive, Inattentive, Predominantly hyperactive/impulsive

• Criterion items are applied across the lifespan• Cross-Situational requirement strengthened to several

symptoms in each setting • Adult Symptom threshold reflects

significant impairment

Specific Learning Disorders

• Reading, Writing, Math & Written expression combined

1

• R/O other disorders2

• Specific topic characteristics3

Specific Learning Disorders cont.Specific Criteria for each: Can be combined• Reading: accuracy, rate, comprehension

Writing: accuracy of spelling, grammar & punctuation, legible handwriting, clarity of written expression Math: memorizing facts, accurate calculations, effective math reasoning. Written Expression: spelling, grammar, punctuation, clarity, organization

Disruptive, Impulse-Control & Conduct Disorders

• Problems in emotional & behavioral self control symptoms

1

• Antisocial personality has dual listing2

• ADHD often comorbid with this diagnostic group.3