1. health and fitness
2. disorders

DSM-5 DRILL DOWN
PRESENTER: DIANA PALS, LCPC
DEVELOPED BY: IDAHO-I MHCA
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MAJOR CHANGES OF DSM5
1. Elimination of 5 Axis Diagnosis
1.
2. Inclusion of ICD 10
3.
Addition of V Codes/ T & Z Codes
4.
Consolidation of Aspergers, Autism, PDD
4
MAJOR CHANGES OF DSM5
5. Restructuring SUD into single disorder with varying
severity
1.
6. Integration of emerging genetic & neuroimaging
research
7. Symptom severity assessment
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POSITIVES OF DSM5
1.
Broad Collaboration
2.
Inclusion of Cultural Considerations
3.
More Descriptive Diagnosis
4.
Reorganized to reflect etiology & shared factors
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POSITIVES OF DSM5
5.
Recognition of life span issues related to specific
disorder.
6.
Gender & cultural notes for individual diagnosis.
7.
Removed diagnostic criterion not relevant
across cultural groups.
8.
30% international in each work group
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THREE MAJOR SECTIONS
1.
The Basics
2.
Diagnostic Criteria & Codes
3.
Emerging Measures & Models -
10
INTRODUCTION: CODING &
REPORTING PROCEDURES
• Procedures
• First list focus of treatment or reason for first visit
• Exception: If a mental disorder is caused by a medical condition
then list medical condition first (ICD coding rule).
• Other diagnosis codes are listed in descending order of clinical
importance including V/Z codes
Sample Text
V62.21 Problem Related to Current Military Deployment Status
301.89 Other Specified Personality Disorder (mixed personality features-dependent
and avoidant symptoms)
327.26 Comorbid Sleep-Related Hypoventilation
300.4 Persistent Depressive Disorder (Dysthymia), With anxious distress, In partial
remission, Early onset, With pure dysthymic syndrome, Moderate
V62.89 Victim of Crime (state the crime)
278.00 Overweight or Obesity
WHODAS: 63
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WHODAS
• World Health Organization Disability Assessment Schedule.
• Can be self-administered by the client or proxy administered by the clinician.
Download for free at:
www.psyciatry.org/practice/dsm/dsm5/onlineassessmentmeasures (also in the
back of the DSM 5, p 747)
• Inventories cover the following aspects of functionality:
•
• Cognition
• Mobility
• Self-care
• Getting along or socialization
• Life activities and
• Participation
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GUIDELINES FOR ASSESSEMENT
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Name of client:
DOB:
Pre-natal environment and conditions of delivery
Age of mother during pregnancy
Early infancy development
Age of onset of symptoms
Course of illness development
Description of symptoms
Severity of symptoms
Cultural considerations
School years development
Temperamental status
Genetic issues in the family
History of mental illness in the family
Full Medical history of client and family
Areas of impairment
Level of impairment severity
Substance use /medication use history- assess which came first…the use or the disorder
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SUBSTANCE-RELATED &
ADDICTIVE DISORDERS
Substance Use Disorders
Inhalant-Related Disorders
Substance-Induced Disorders
Opioid-Related Disorders
Substance Intoxication and
Withdrawal
Sedative, Hypnotic, or AnxiolyticRelated Disorders
Substance/medication-Induced
Mental Disorders
Stimulant-Related Disorders
Alcohol-Related Disorders
*Kappa=.40
Tobacco-Related Disorders
Caffeine-Related Disorders
Other (or Unknown) SubstanceRelated Disorders
Cannabis-Related Disorders
Non-Substance-Related Disorders
*Gambling Disorder
Hallucinogen-Related Disorders
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SUBSTANCE-RELATED &
ADDICTIVE DISORDERS
• Substance Use Disorders
• No More Substance Abuse and Substance Dependence
• *Critical* to Read & Follow Recording Procedures and Coding
Notes
• Few changes from the DSM-IV-TR with substance abuse and
dependence criteria combined into one list
• Nearly all substances are defined under the same overarching
criteria
• Criteria for intoxication, withdrawal, substance/medication-induced
disorders, and unspecified substance-induced disorders
• Threshold Criteria= 2 of 11 symptoms
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•
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Impaired Control (Criteria 1-4)
Social Impairment (Criteria 5-7)
Risky Use (Criteria 8-9)
Pharmacological criteria (criteria 10-11)
• *Removed: recurrent legal problems criterion
• *Added: craving or a strong desire or urge to use a substance
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SUBSTANCE-RELATED &
ADDICTIVE DISORDERS
Substance Use Disorders Specifiers &
Severity
Substance Use Disorder
Changes
Remission Specifiers
• No more partial or full
• Early remission=at least 3, but less than
12 months without substance use
disorder criteria (except craving)
• Sustained remission=at least 12 months
without criteria (except craving)
Removed
• Polysubstance
Abuse/Dependence
• Amphetamine
• Cocaine
• Specifier for a physiological
subtype
• On agonist therapy
Severity Ratings
• 2-3 criteria indicate Mild Disorder
• 4-5 criteria indicate Moderate Disorder
• 6 or more indicate Severe Disorder
Added
• Caffeine Withdrawal
• Cannabis Withdrawal
• Tobacco-Related Disorder
• Stimulant-Related Disorder
• On Maintenance therapy
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SUBSTANCE-RELATED &
ADDICTIVE DISORDERS
Gambling Disorder
Gambling Disorder, cont.
• “This change reflects the
increasing and consistent
evidence that some behaviors,
such as gambling, activate the
brain reward system with effects
similar to those of drugs of abuse
and that gambling disorder
symptoms resemble substance
abuse use disorders to a certain
extent.”
• Lowering of the pathological
gambling threshold to 4
symptoms
• Removed: the illegal acts
criterion
• Similar clinical expression, brain
origin, comorbidity, physiology,
and treatment
• Not yet strong or pervasive
research to support the inclusion
of other disorders like:
• Sex addiction
• Relationships
• Codependency
• Cults
• Performance
• Compulsive Spending
• Rage/violence
• Media/entertainment
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PREVALENCE OF AUTISM
SPECTRUM DISORDERS
 1 in 88 children
 1 in 54 boys
 1 in 252 girls
 78% increase from 2002
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PERVASIVE DEVELOPMENTAL
DISORDERS (DSM-IV-TR)
• PDD included
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Autistic Disorder
Rhett’s Disorder
Childhood Disintegrative Disorder
Asperger’s Disorder
Pervasive Developmental Disorder, NOS
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ASPERGER’S DISORDER (DSM-IV-TR)
• Impairment in social interactions (at least 2)
• Restricted repetitive and stereotyped patters of
behavior, interest, and activities (at least one)
• Significant impairment in social, occupational, or
other important areas of functioning
• No clinically significant language delay
• No clinically significant delay in cognitive
development or ADLs
• Not better accounted for by another PDD or
Schizophrenia
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PERVASIVE DEVELOPMENTAL
DISORDER, NOS (DSM-IV-TR)
• Severe and pervasive impairment in reciprocal
social interactions, and
• Impairment in either verbal or nonverbal
communication skills or stereotyped behavior
• Does not meet criteria for a specific PDD,
schizophrenia, schizotypal PD, or Avoidant PD
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WHY THE CHANGE IN DSM-5?
• Improve accuracy of diagnosing
• Describe specific symptoms
• *No significant changes overall
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AUTISM SPECTRUM DISORDER
DSM-5
Criterion Described
Part A
• Persistent deficits in social communications and
social interactions across multiple contexts, as
manifested by the following, currently or by history
Deficits in social-emotional reciprocity
Deficits in nonverbal communicative behaviors used for
social interactions
•
Deficits in developing, maintaining, and understanding
relationships
•
•
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AUTISM SPECTRUM DISORDER
DSM-5 (CONT.)
Part B
• Restricted, repetitive patterns of behavior, interests,
or activities, as manifested by at least two of the
following, currently or by history
• Stereotyped or repetitive motor movements, use of objects,
or speech
• Insistence on sameness, inflexible adherence to routines, or
ritualized patterns of verbal or nonverbal behavior
• Highly restricted, fixated interests that are abnormal in
intensity or focus
• Hyper-or hypo-reactivity to sensory input or unusual interest
in sensory aspects of the environment (*new criteria)
**Both Part A & B must be present to diagnose
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AUTISM SPECTRUM DISORDER
DSM-5 (CONT.)
Part C
• Symptoms must be present in the early developmental
period (but may not become fully manifest until social
demands exceed limited capabilities, or may be
masked by learned strategies in later life).
Part D
• Symptoms cause clinically significant impairment in
social, occupational, or other important areas of current
functioning
Part E
• These disturbances are not better explained by
intellectual disability or global developmental delay.
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AUTISM SPECTRUM DISORDER
SPECIFIERS/MODIFIERS
• With or without accompanying intellectual
impairment
• With or without accompanying language
impairment
• Associated with a known medical or genetic
condition or environmental factor
• Associated with another neurodevelopmental,
mental, or behavioral disorder
• With catatonia
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AUTISM SPECTRUM DISORDER
LEVEL OF SEVERITY
• Level 1: Requiring Support
• Level 2: Requiring Substantial Support
• Level 3: Requiring Very Substantial Support
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FOCUS IS NOW ON HISTORY & OTHER
ASSOCIATED FACTORS
History & Associated Factors now considered in the
diagnosis of Autism Spectrum Disorder include:
Age of perceived onset
Pattern of onset
Culture-related issues
Gender-related issues
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AUTISM SPECTRUM DISORDER
DIFFERENTIAL DIAGNOSIS
Rhett’s Syndrome
Selective mutism
Language disorders
Intellectual Disabilities without Autism Spectrum
Disorder
• Stereotypical movement disorder
• Attention-deficit/hyperactivity disorder
• Schizophrenia
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MAJOR CHANGES IN THE DSM-5
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Spectrum of Disorders
Focus on two key areas instead of three
More focus on history
Addition of Specifiers and Modifiers
Social Communication Disorder (SCD)
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IMPLICATIONS OF THE CHANGE
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Elimination of Asperger’s Disorder and PDD, NOS
Better history screening
Comorbid diagnoses
Hopefully better services
Intellectual Disability
New Testing Measures
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CONCERNS ABOUT THE NEW CRITERIA
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Spectrum vs. Individual Diagnosis
Too Stringent
Social Communication Disorder
Educational Needs
Third Party Payers
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TREATMENT FOR AUTISM
• Team Approach
• Medical Care-pediatrician, neurologist, psychiatrist,
gastroenterologist
• Early intervention/behavioral approaches
• Speech Therapy
• Occupational Therapy
• Physical Therapy
• Nutritionist
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TYPES OF EARLY INTERVENTIONS FOR
AUTISM SPECTRUM DISORDER
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Applied Behavioral Analysis
Pivotal Response Treatment
Verbal Behavior
Early Start Denver Model
Floortime
Relationship Development Intervention
TEACCH
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WHERE TO FIND SERVICES FOR
AUTISM SPECTRUM DISORDER
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Screenings
Local testing
Children’s Hospitals
Local Universities
Community Mental Health Centers
Private Practitioners Specializing in ASD
Autismspeaks.org—Tool kits
Support Groups
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DSM-5 LAYOUT FOR MOOD DISORDERS
• Divided into 2 sections designed to assist in
diagnosing problems with mood.
• 1. Criteria and description of all disorders, including
diagnostic features, associated features, and differential
diagnostic issues
• 2. Definitions of Specifiers that provide greater description of
the current or most recent mood episode.
• Recognition is important: bipolar disorder is often missed;
average time for non-MD to correctly diagnose is 8.9 years;
for an MD it is 6.5 years (Ghaemi, as cited in Quinn, 2008).
• TIPS: Always check for a mood disorder in any new client
and NEVER assume mood disorder is client’s only diagnosis.
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WHAT IS A MOOD EPISODE?
• Mood episodes are building blocks of (most) mood
disorders.
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Quality of mood (high or low)
Required time
Required symptoms
Degree of disability
Exclusions not result of GMC or substance use
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CLASSIC TRIAD OF MANIC EPISODE
Heightened self-esteem
Increased motor activity
Pressured Speech
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BUILDING BLOCKS OF MOOD
DISORDERS: MANIC EPISODE
• Must meet five (5) criteria
• Mood that is abnormally elevated and expansive (sometimes irritable)
• Heightened mood has existed for a minimum of one week.
• Must meet 3 of the following criteria:
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1. increased self esteem
2. decreased sleep
3. Pressured speech
4. racing thoughts
5. increase in physical activity
6. goal agitation
7. risk taking behavior
• Has resulted in significant social, personal, and/or occupational
impairment
• Does not violate exclusions of GMC & substance induced
• At least one lifetime manic episode is required for the diagnosis of
Bipolar I.
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BUILDING BLOCKS OF MOOD
DISORDERS: HYPOMANIC EPISODE
• “Watered down” version of a manic episode
• Quality of mood that is euphoric, but without the driven quality
present in a manic episode
• Mood must be qualitatively different from normal nondepressed mood
• Disturbance in mood is observable by others
• Is NOT severe enough to cause marked impairment
• Client must have symptoms for a period of four (4) days
• Same number of symptoms from the same list required for manic
episode: At least three (3) symptoms must be present during
previous four (4) days. If mood is irritable than four (4) symptoms are
required.
Hypomanic episodes are common in Bipolar I Disorder, but are not
required for a diagnosis of Bipolar I Disorder.
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BUILDING BLOCKS OF MOOD
DISORDERS: MAJOR DEPRESSIVE EPISODE
• One of the most common problems for why people
seek help.
• Must meet following criteria:
• Depressed mood or loss of interest or pleasure
• Existed most of the day, nearly every day, for at least 2
weeks.
• Accompanied by at least five (5) symptoms, where one (1)
symptom must be depressed mood or loss of pleasure
• Death wishes/suicidal ideation
• Mood disturbance cannot be due to a GMC or use of
substances
• Major Depressive episodes are common in Bipolar I Disorder,
but are not required for a diagnosis of Bipolar I Disorder.
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BIPOLAR I DISORDER
CODING & RECORDING ISSUES
• Big changes to coding & recording from the DSM-IV TR.
• If you suspect a Bipolar I diagnosis, then you need
to determine the following related to the current or
most current episode
• (a) severity, (b) if psychotic features are present, and (c)
remission status
• Note: Current severity and psychotic features are only
indicated if full criteria are met for a manic or major
depressive episode.
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BIPOLAR I DISORDER: DIAGNOSTIC
CODING
Bipolar I disorder, Current or most recent episode
manic
Choose one of the following for coding purposes:
• Mild, 296.41 (F31.11)
• Moderate, 296.42 (F31.12)
• Severe, 296.43 (F31.13)
• With psychotic features, 296.44 (F31.2)
• In partial remission, 296.45 (F31.73)
• In full remission, 296.46 (F31.74)
• Unspecified, 296.40 (F31.9)
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BIPOLAR I DISORDER: DIAGNOSTIC
CODING
Bipolar I disorder, Current or most recent episode
depressed
Client’s current or most recent episode is depressed and
criteria have been met for at least one manic episode
Choose one of the following for coding purposes:
• Mild, 296.41 (F31.31)
• Moderate, 296.52 (F31.32)
• Severe, 296.53 (F31.4)
• With psychotic features, 296.54 (F31.5)
• In partial remission, 296.55 (F31.75)
• In full remission, 296.56 (F31.76)
• Unspecified, 296.50 (F31.9)
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BIPOLAR I DISORDER: DIAGNOSTIC
CODING
Bipolar I disorder, current or most recent episode
hypomanic
Client’s current or most recent episode is hypomanic and
criteria have been met for at least one manic episode
Choose one of the following for coding purposes:
• Severity and psychotic specifiers do not apply, always
code 296.40 (F31.0).
• In partial remission: 296.45 (F31.73)
• In full remission: 296.46 (F31.74)
• Unspecified, 296.40 (F31.9)
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BIPOLAR I DISORDER: DIAGNOSTIC
CODING
Bipolar I disorder, current or most recent episode
unspecified
Client’s current or most recent episode is unspecified
and criteria have been met for at least one manic
episode
• Choose the following for coding purposes:
Severity, psychotic, and remission specifiers do not
apply, always code 296.7 (F31.9)
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MAKING THE BIPOLAR I DISORDER
DIAGNOSIS
For Bipolar I Disorder, the symptoms must not be better accounted
for by schizoaffective disorder, schizophrenia, schizophreniform,
delusional disorder, or other psychotic disorder exclusions.
The clinician has the option to add other specifiers that are not
associated with a code (applies only to the current or most recent
episode, except with rapid cycling).
•
With anxious distress
• With mixed features
• With rapid cycling (applies to course of disorder rather than to most recent
episode)
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia (coding note: Use additional code 293.89 (F06.1)
• With peripartum onset
• With seasonal pattern (applies only to current or most recent depressive
episode
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BIPOLAR I DIAGNOSIS, CONTINUED
• In recording the Bipolar I diagnosis, start with the
name of disorder, type of current or most recent
episode, severity/psychotic features/remission
specifiers, as many specifiers without codes that
apply.
• Some examples of diagnoses:
• 296.52 (F31.32) Bipolar I disorder, current episode depressed,
moderate, with atypical features
• 296.44 (F31.2) Bipolar I disorder, most recent episode manic,
with psychotic features, with anxious distress, with rapid
cycling.
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BIPOLAR II DISORDER:
DIAGNOSTIC CODING
• Criteria have been met for at least one hypomanic
episode and at least one major depressive episode;
no history of manic episode.
• Choose the following for coding purposes:
• Only one diagnostic code. 296.89 (F31.81)
• Current severity, psychotic features (depressive episode
only), course, and other specifiers cannot be coded, but
can be expressed in writing.
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MAKING THE BIPOLAR II DIAGNOSIS
• Specify the following in writing if relevant to client’s symptoms:
• Most recent episode is hypomanic or depressed
• Any of these characteristics match the most recent episode?
• With anxious distress
• With mixed features
• With rapid cycling (applies to course of disorder rather than to most
recent episode)
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia (coding note: Use additional code 293.89 (F06.1)
• With peripartum onset
• With seasonal pattern (applies only to current or most recent
depressive episode)
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BIPOLAR II DIAGNOSIS, CONTINUED
• Additional specifiers:
• If full criteria for mood episode are not currently met
• In partial remission
• In full remission
• If full criteria for mood episode are currently met
• mild, moderate, severe
• Writing out the Bipolar II diagnosis should have the following
pattern:
• Name of disorder, current or most recent episode, additional
specifiers, course specifiers, severity specifiers.
• Example:
• 296.89 (F31.81) Bipolar II disorder, current episode depressed, with
seasonal pattern, moderate
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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
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CYCLOTHYMIC 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)
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KEY DIAGNOSTIC PRINCIPLES (QUINN, 2008)
• Most critical task: is the depression unipolar or bipolar?
• Always rule out medical disorders or substance abuse
that may cause secondary depression or mania
• Diagnostic assessment should search strategically for
periods of hypomania in client’s history
• Hypomania can “look like” normal happiness, but if it happens
repeatedly without sleep, and the client has more energy but
with less sleep, or these times are preceded/followed by rapid
bouts of depression, think hypomania.
• Assess multiple criteria
• Symptoms are important, but also look at course of symptoms,
family history, and client response to medication.
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THE BIPOLARITY INDEX (SACHS, 2004; WEGMANN, 2011)
• Assesses the client on 6 dimensions: episode characteristics
(hypomania or mania), age of onset, illness course, and other
features, response to medications, and family history.
• Clients are scored depending on where they “fall” related to
each dimension. For example: A client who has experienced
an episode characteristic of full blown manic symptoms would
be assigned 20 points. If he or she had an age of onset of
between 20-30, another 15 points would be scored, and so
forth.
• Most bipolar I patients score about 60, according to Sachs
(2004).
• Still needs to be fine-tuned, but can provide some quantitative
sense of the likelihood and magnitude of bipolar disorder.
• Note that even if a client has not had a manic episode, some
characteristics are highly predictive of bipolar disorder (e.g.,
early onset of depression, brief depressive episodes).
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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
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•
•
•
•
• Lithium
• Anticonvulsants (Depakote, Tegretol, Lamictal)
• Atypical Antipsychotics (Risperdal, Seroquel)
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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).
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CHARACTERISTICS OF ANXIETY
DISORDERS
• Physiological symptoms include:
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•
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•
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Muscle tension
Heart palpitations
Sweating
Dizziness
Shortness of breath
• Emotional symptoms include:
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Restlessness
Sense of impending doom
Fear of dying
Fear of embarrassment or humiliation
Fear of something terrible happening
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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).
• 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).
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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.
• Assigning Panic Attack as a specifier that may be
applied to a wide array of DSM-5 diagnoses.
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DIFFERENTIAL DIAGNOSIS OF ANXIETY
DISORDERS & DEPRESSIVE DISORDERS
• Challenging due to the high comorbidity (up to
50%) of Anxiety Disorders with Depressive Disorders
• Depressive Disorders are sometimes viewed as
“anxious-misery” 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 (APA,
2013).
66
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.
• 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).
67
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%)
• 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).
68
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.
• Selective Mutism usually has an age of onset of under 5
years and is often first noticed in school settings (APA,
2013).
69
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).
• 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 were first identified as such in the
DSM-III-R, carry a lifetime prevalence rate of 9.4% to
12.5% (Marques et al., 2011).
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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.
• The median age of onset for a diagnosis of Specific
Phobia is 13 years (APA, 2013).
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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)
• 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.
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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).
• It is one of the most common mental disorders with a
lifetime prevalence rate of slightly greater than 10%.
• The majority of diagnoses are made during childhood or
early adolescence (Kerns, et al., 2013; Marques et al.,
2013).
• SAD is often seen in conjunction with Major Depressive
Disorders, other Anxiety Disorders, and Substance Use
Disorders (APA, 2013).
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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.
• New: A Performance only specifier has been added
for SAD in the DSM-5 and includes a minimum
duration of 6 months.
• Children, adolescents, and adults now share the
same criteria for duration, and the criterion for adult
insight has been dropped (Mohr & Schneider, 2013).
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SAD
• The Performance only specifier is given if anxiety is
specific to speaking or performing in public.
• 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.
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PANIC DISORDER
• Panic Disorder is defined as recurrent, unexpected
panic attacks and was initially classified in the DSMIII.
• There is a median age of onset ranging from 20 to
24 years with a small percentage of individuals first
diagnosed in childhood.
• Panic Disorder is not usually first seen in individuals
over the age of 45.
• There is an annual U.S. prevalence rate of 2.1% to
2.8%; this is one of the highest prevalence ratings in
the world (Marques, et al., 2011).
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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.
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).
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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).
• Illness Anxiety Disorder, formerly known as hypochondriasis,
often shares features with an/or is comorbid with Panic
Disorder (Starcevic, 2013).
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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.
• An example of panic attack used as a specifier is Social
Anxiety Disorder, with Panic Attack (APA, 2013).
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PANIC ATTACK SPECIFIER
• 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 DSM5.
• Panic Attacks have an 11.2% annual prevalence
rate in the general U.S. population (APA, 2013).
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AGORAPHOBIA
• 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).
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AGORAPHOBIA: ESSENTIAL FEATURES
• 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).
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GENERAL ANXIETY DISORDER (GAD)
• GAD has been in existence since the DSM III
• 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.
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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.
• 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.
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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%).
• It is important for clinicians to tease out substances used
to self-medicate anxious symptoms with anxiety resultant
from substance usage or withdrawal.
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ANXIETY DISORDER DUE TO ANOTHER
MEDICAL CONDITION
• 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.
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ANXIETY DISORDER DUE TO ANOTHER
MEDICAL CONDITION
• 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.
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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).
• Additionally, Anxiety Disorders are the most
common disorders in youth (Sood, Mendez, &
Kendall, 2012) and have a median age of onset of
11 years.
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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 Cognitive-Behavioral Therapy (CBT), Behavior
Therapy (BT), and relaxation training (AADA, 2013).
• 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).
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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
• Unspecified Depressive Disorder
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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:
• 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.
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ISSUES WITH DMDD
•
•
•
•
•
More common in males
No empirically supported treatments yet.
Need more research
Avoid bipolar medications
Consider CBT treatments used for depression in
children:
• Coping skills for thoughts, feelings, and behavior
• Parent training
• Parent support group
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MAJOR DEPRESSIVE EPISODE
• Essential features: Either depressed mood OR loss of
interest or pleasure plus four other depressive
symptoms
• Duration: At least two weeks
• 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.”
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GRIEF VS. A MAJOR DEPRESSIVE
EPISODE IN DSM-5
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.
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DIAGNOSING MAJOR DEPRESSIVE
DISORDER
• Essential Features:
• Meets criteria for a Major Depressive Episode
• No history of a Manic or Hypomanic Episode
• Coding Steps:
• 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
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DIAGNOSING MAJOR DEPRESSIVE
DISORDER, CONTINUED
• 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
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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).
• 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.
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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, moodcongruent or mood-incongruent psychotic features, and
peripartum onset
• 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.
•
•
•
•
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102
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
• 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.
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PMDD UPDATE
• What’s 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 individual’s quality of life
Impact on psychosocial functioning
Treatments:
• Diet
• SSRI’s
• CBT
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FINAL THOUGHTS
• 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).
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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.
• And, there was NO significant co-morbidity.
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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.
Very controversial topic!
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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.
Personality Disorders with the least research behind them:
• 1. Paranoid Personality Disorder
• 2. Histrionic Personality Disorder
• 3. Schizoid Personality Disorder
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PERSONALITY DISORDERS IN DSM-5
• No significant co-morbidity was found between the
disorders…so 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.
Personality Disorders was tacked on to the end of the
manual.
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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
4. Impulse control issues
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10 PERSONALITY DISORDERS
Paranoid Personality Disorder
Cluster A
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Cluster B
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality Disorder
Cluster C
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DEFINITION OF PERSONALITY
DISORDER
“A personality disorder is an enduring
pattern of inner experience and
behavior that deviates markedly from
the expectations of the individual’s
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).
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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
• OCPD: Work and productivity in some cultures vary
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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
• Does the system go far enough?
116
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).
• Criterion B includes Pathological Personality Traits
• 5 Broad Traits: negative affectivity, detachment, antagonism,
disinhibition, and psychotic features (and 25 trait facets).
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PERSONALITY DISORDERS: DSM-5,
CONTINUED
• 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 individual’s developmental stage
or sociocultural environment.
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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:
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
•
•
•
•
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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:
1. Anxiousness; 2. Withdrawal; 3. Anhedonia; 4. Intimacy Avoidance
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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
Shared treatment response
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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.
Externalizing: disorders with prominent impulsive
disruptive conduct, substance use symptoms.
Characterized by anti-social 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
• 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
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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).
• Identified 8 areas professionals can focus their
passions in research
125
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).
• Advance “counseling science” to contribute to the
field. We need more empirical data and counselors
can be a huge contributor to that research base.
126
WHAT SHOULD COUNSELORS DO?
• 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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128
FINAL THOUGHTS?
129
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/onlineassessmen
tmeasures they are also in the back of the DSM 5
• ACA Webinar
• Idaho Mental Health Counselors Webinar
• You Tube –free 4 hour seminar
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