DSM V PowerPoint For Clinicians

By: Patrick L. DeChello Ph.D.
, MSW, LCSW, RPH

CLINICIANS
DSM 5 for
Copyright 2013, D & S Associates,
800-950-5559 All rights reserved 2
Introduction
Field of Psychiatry is not an exact science.
Mankind has always tried to understand peoples
actions and reactions.
Explained in the past as possession and witchcraft,
Psychiatry is a new science less than 100 years old.
It grew out of the medical field there are certain
biological differences between men.
There was a need to develop a universal language.
The DSM became the means of communication and
conceptualization of psychiatric illness.
DSM A Brief History
In 1945, Group Psychiatrists working with
soldiers returning from World War 2, found a
group who did not fit into the diagnostic
classification that existed from 1917 to then.
Previously the groups were:
Lunatics, Idiots, Imbeciles, Morons, or
Insane.
History of the DSM
In 1943, the U.S. military published a list of
mental disorders with the title, War
Department Technical Bulletin 203.
The American Psychiatric Association adapted
this document and published it in 1952 as
the Diagnostic and Statistical Manual:
Mental Disorders, or what we now know as
DSM-I.
DSM 5 Clarifies The Definition:
A syndrome characterized by clinically significant
disturbance in an individuals cognition, emotion
regulation or behavior that reflects a dysfunction in
the psychological, biological or developmental
processes underlying mental functioning. They are
associated with underlying stress or disability in
social, occupational, or other important activities.
An expected cultural approved response such as
death of a loved one is not a mental disorder. Social
and political behaviors are not mental disorders.
7 Main Philosophical Changes
No clear difference between a medical illness and a
psychiatric one.
Most normal people have personality defects.
People have illnesses they arent illnesses.
There are many different looks to each disorder.
A social or political deviances are not mental disorders and
are between the individual and society. Ie. Fundamentalists
Childhood personality must be considered.
Cultural variants in symptom definition and symptom
manifestations must be considered.
DSM 5 No more Mood Disorders as a category
Twenty classifications *new or significantly changed
classifications
1. Neurodevelopmental Disorders*
2. Schizophrenia Spectrum* and
Other Psychotic Disorders
3. Bipolar and Related Disorders*
4. Depressive Disorders*
5. Anxiety Disorders
6. Obsessive-Compulsive* and Related Disorders
7. Trauma and Stress Related Disorders*
8. Dissociative Disorders
9. Somatic Symptom Disorders*
10. Feeding and Eating Disorders*
11. Elimination Disorders*
12. Sleep-Wake Disorders*
13. Sexual Dysfunctions
14. Gender Dysphoria*
15. Disruptive, Impulse Control, and
Conduct Disorders*
16. Substance Use* and Addiction Disorders
17. Neurocognitive Disorders*
18. Personality Disorders*
19. Paraphilias*
20. Other Disorders
The multi-axial format of DSM III and DSM IV has
been modified. Axis 1,2,3, and 4 have been
combined & incorporated into the diagnostic
categories.
PTSD no longer an anxiety d/o
New: Suicide and Self-Injury disorders
Cross Cutting
Dimensional Factors
Depression
Anger
Mania
Anxiety
Somatic symptoms
Suicidal
Ideation/attempts
Psychosis
Sleep Problems
Memory
Repetitive Thoughts
and Behaviors
Dissociation
Personality Functioning
Substance Abuse
Inattention
Primary Diagnosis
The first diagnosis listed is the primary.
It should coincide with the presenting
problem.
When the primary reason for the visit is
a mental disorder due to a medical
condition, ICD rules state that the
etiological medical condition be listed
first and it is the primary disorder
Primary Diagnosis
When 2 diagnoses are equally possibly the
main contributing factor such as a client
with alcohol use and schizophrenia, the one
you feel is the main focus of clinical
attention should be listed first.
Disorder listed first is always the primary
When there is a medical dx the ICD
requires it to be primary
We will just write out no diagnosis or
deferred.
If there is no diagnosis, client should be
discharged: no reason to treat them.
Deferrals should be time limited for
many disorders, but are mandated for
Personality Disorders.
Rule out is used when it is either this
diagnosis or that diagnosis. One will
stay one will go. Write it in!
No more V71.09 or 799.9
Provisional Diagnoses
Use when there is a strong presumption that
the full criteria will be met but not enough
info is available to make a firm diagnosis.
Now used in place of the old NOS disorders
No more DSM IV NOS Categories
2 conditions to use Provisional classifications
1. Guidelines for a classification are met, but the specific
disorder remains unclear: Depressive Disorder CNEC, e.g.,
a client presents depressed; but, you dont yet know if it is
a major depression, single episode, recurrent, or
dysthymia. Use this classification until you know..
Provisional Continued
2. Uncertainty regarding nature of the disorder
because client unable to provide accurate information,
limited time, clinician not trained in a diagnostic
category:
Depressive Disorder
Called in to an ER to do an Emergency Evaluation of a
client with a suicide attempt. No time to tell or client not
cooperative.
All other diagnostic uncertainty categories are gone.
Much More Information of Cultural Relevance
Now a CFI Cultural Formation Interview
Each diagnostic category will provide information regarding age, gender,
and culture considerations.
a) The CFI is a set of fourteen questions that clinicians may use to
obtain information during a mental health assessment about the impact of a
patients culture on key aspects of care.
b) Culture refers primarily to the values, orientations, and assumptions
that individuals derive from membership in diverse social groups (e.g.,
ethnic groups, the military, faith communities), which may conform or differ
from medical explanations. culture also refers to aspects of a persons
background that may affect his or her perspective, such as ethnicity, race,
language, or religion.
Each diagnostic category will offer developmental symptom manifestation,
regarding the age of the client, gender specific disorders, and cultural
sensitivity in regard to certain behaviors.
V & Z codes now used instead
of old axis 4
V60 Homelessness
V60.2 Extreme Poverty
V62.5 Conviction w/o Prison.
Z62.898 or V61.29 Child affected by parent
relationship distress.
T Codes For Child Abuse/
Neglect
T74.02 Child neglect confirmed
T76.12 Child neglect suspected
T74.12xa Child Abuse Confirmed
T76.02xa Child Abuse suspected
T76.32xa Child Psychological abuse confirmed
T76.32xd Child Psychological abuse suspected
T74.22xa Child Sexual Abuse Confirmed
T74.22xd Child Sexual Abuse suspected
Suicide and Self Injury*
New Risk Syndromes And Suicide Risk
Assessment Tools- Each disorder criteria will
comment on suicide risk, self-injury, and comorbidity
with other disorders, e.g., depression and alcohol
dependence.
The DSM-5 revisions include two new scales for assessing individuals risk
factors for committing suicide, one for adolescents and one for adults.
The suicide risk tools have been designed to be applied to anyone
receiving an evaluation for a mental disorder, regardless of diagnosis, to
help clinicians identify those at risk for suicide.
V 01 Non-Suicidal Self Injury*
A. In the last year, the individual has
on 5 or more days, intentional self-inflicted damage to the body,
likely to induce bleeding or bruising or pain
not socially sanctioned (e.g., body piercing, tattooing, etc.), but
expectation injury will cause minor or moderate physical harm.
Behavior is not a common one, picking at a scab or nail biting.
Non-Suicidal Self-Injury
B. The intentional injury is associated with at least 2 of the following:
1. Psychological Precipitant: Interpersonal difficulties or negative feelings
or thoughts, such as depression, anxiety, tension, anger, generalized
distress, or self-criticism, occurring in the period immediately prior to the
self-injurious act.
2. Urge: Prior to engaging in the act, a period of preoccupation with
the intended behavior that is difficult to resist.
3. Preoccupation: Thinking about self injury occurs frequently, even
when it is not acted upon.
4. Contingent Response: The activity is engaged with expectations it will
relieve an interpersonal difficulty, negative feeling, or cognitive state,
or it will induce a positive feeling state, during the act or shortly
afterwards.
Non-Suicidal Self-Injury
C. The behavior or its consequences cause clinically significant distress or
interference in interpersonal, academic, or other important areas of functioning.
D. The behavior does not occur exclusively during states of psychosis,
delirium, or intoxication. In individuals with a developmental disorder, the
behavior is not part of a pattern of repetitive stereotypes. The behavior cannot be
accounted for by another mental or medical disorder (i.e., psychotic disorder,
pervasive developmental disorder, mental retardation, Lesch-Nyhan Syndrome,
stereotyped movement disorder with self-injury, or trichotillomania).
E. The absence of suicidal intent has either been stated by the patient or can be
inferred by repeated engagement in a behavior that the individual knows, or has
learned, is not likely to result in death.
V 02 Suicidal Behavior Disorder*
A. Behaved in a way it would lead to their own death
within the last 24 months.
B. The behavior did not meet criteria for non-suicidal
self-injury.
C. The term suicide attempt can, therefore, apply to
individuals who initiated the behavior and survived
because of the timely interruption by a third party
(sometimes known as an interrupted suicide) or
because the individual changed his or her intent and
decided to seek help (sometimes known as an aborted
suicide).
V 02 Suicidal Behavior Disorder,
Continued
D. The act was not initiated during a confused or
delirious state. However, attempts initiated
during intoxication or while under the
influence of a substance do not preclude this
diagnosis.
E. The act was not undertaken solely for a political or
religious objective.
Neurodevelopmental Disorders
F70 Intellectual Developmental Disorder* 319
F88 Intellectual or Global Developmental Delay 315.8
F80.9 Language Impairment* 315.39
INCLUDES Specific Language Impairment*
F80.89 Social Communication Disorder* 315.39
F80.0 Speech Sound Disorder (Phonological Disorder)315.39
F80.81 Childhood Onset Fluency Disorder (Stuttering)
315.35
F84.0 Autism Spectrum Disorder* 299.9 PG 50
F90.2 Attention Deficit/Hyperactivity Disorder
F90.8 Other Specified ADHD 314.01
Learning Disorder
F81.0 Dyslexia Reading 315.00
F81.2 Dyscalculia Mathematics Disorder*315.1
F81.2 Disorder of Written Expression 315.1
F82 Developmental Coordination Disorder 315.4
F98.4 Stereotypic Movement Disorder* 307.3
F95.2 Tourettes Disorder* 307.23
F95.1 Chronic Motor or Vocal Tic Disorder*307.22
F95.0 Provisional Tic Disorder* 307.21
Substance Induced Tic Disorder note substance
F95.9 Unspecified Tic Disorder 307.20
F95.8 Tic Disorder Due to General Medical Conditions 307.2
F80.89 Social Communications D/O*
Persistent difficulties in pragmatics or the social uses of verbal and
nonverbal communication in naturalistic contexts, which affects the
development of social reciprocity and social relationships that cannot be
explained by low abilities in the domains of word structure, grammar, or
general cognitive ability.
Persistent difficulties in the acquisition and use of spoken language,
written language, and other modalities of language (e.g., sign language)
for narrative, expository, and conversational discourse.
Rule out Autism Spectrum Disorder. Autism spectrum disorder by
definition encompasses pragmatic communication problems, but also
includes restricted, repetitive patterns of behavior, interests, or activities
as part of the autism spectrum. Symptoms must be present in early
childhood.
F84.0 Autism Spectrum Disorder
DSM IV-TR Autism Disorder and Aspergers
Disorder:
1. Deficits in social/emotional reciprocity,
2. Deficits in non-verbal communication behaviors
i.e., body language or eye contact,
3. Deficits in developing and maintaining
relationships to the appropriate
developmental level.
Autism Spectrum Disorder 299.0
4. Repetitive speech, motor movements, or use of objects;
(such as simple motor stereotypes, echolalia, repetitive use of
objects, or idiosyncratic phrases),
5. Excessive adherence to routines, ritualized patterns of verbal
or nonverbal behavior, or excessive resistance to change,
6. Highly restricted, fixated interests that are abnormal
preservative, preoccupation with unusual,
7. Hyper-or hypo-reactivity to sensory input or unusual interest
in sensory aspects of environment; (such as apparent
indifference to pain/heat/cold, adverse response to specific
sounds or textures, excessive smelling or touching of objects,
fascination with lights or spinning objects).
8. Symptoms must be present in early childhood.
Autism Spectrum Severity Levels
Social Communications
3. Requiring very substantial support severe deficits
in verbal & non-verbal communications rarely initiates
speech or minimal response to overtures from others
RESTRICTED/REPETITIVE BEHAVIORS
3.Inflexibility of behaviors, extreme difficulty coping
with change, repetitive behaviors that interfere with
functioning in all spheres
2. Requiring substantial support Marked deficits in
social communication skills and social impairments
even with supports in place Limited interactions or
responses to overtures of others. May speak simple
sentences / odd non-verbal communication.
Restrictive/repetitive behaviors
2. Difficulty coping with change,, inflexibility of
behavior, distress and or difficulty changing focus or
action. Observable Repetitive behaviors
1. Requiring Support-Without supports in place difficulty
difficulties in social communication. Difficulty
initiating social interactions with others.
Unsuccessful in responding to social interactions
from others. Can converse with disconnection to
others
RESTRICTED/REPETITIVE BEHAVIORS
1.Inflexible, difficulty switching between activities.
Problems of organization hamper independence.
F90.2 Attention Deficit/Hyperactivity Disorder
Changes from DSM IV 314.01
1) Change the age of onset from onset of impairing symptoms by age 7
to onset of symptoms by age 12,
2) Change the three subtypes to three current presentations;
3) Add a fourth presentation for restrictive inattentive;
4) Change the examples in the items, without changing the exact
wording of the DSM-IV items, to accommodate a lifespan relevance of
each symptom and to improve clarity.
6) Remove PDD from the exclusion criteria.
7) Modify the pre-amble A1 and A2 to indicate that information must be
obtained from two different informants (parents and teachers for
children and third party/significant other for adults) whenever possible.
ADHD/ADD Presentations*
Combined Presentation: If both Criterion A1 (Inattention) and Criterion A2
(Hyperactivity-Impulsivity) are met for past 6 mos.
Predominantly Inattentive Presentation: If Criterion A1 (Inattention) is met but
Criterion A2 (Hyperactivity-Impulsivity) is not met but 3 or more
symptoms from Criterion A2 present for the past 6 months.
Inattentive Presentation (Restrictive)*: If Criterion A1 (Inattention) is met but no
more than 2 symptoms from Criterion A2 (Hyperactivity-Impulsivity) have
been present for the past 6 months.
Predominantly Hyperactive/Impulsive Presentation: If Criterion A2 (Hyperactivity-
Impulsivity) is met and Criterion A1 (Inattention) is not met for the past 6
months.
Coding note: For individuals (especially adolescents and adults) who currently have
symptoms with impairment that no longer meet full criteria, In Partial Remission
should be specified.
ADD/ADHD
A1. Inattention: Six (or more) of the following symptoms have persisted
for at least 6 months:
a. fails to give close attention to details or makes careless mistakes
b. difficulty sustaining attention in tasks or play activities
c. does not seem to listen when spoken to directly
d. does not follow through on instructions and fails to finish work, chores,
e. difficulty organizing tasks and activities poor time management;
f. avoids, to engage in tasks that require sustained mental effort
g. loses things necessary for tasks or activities (e.g., school materials,
h. easily distracted by extraneous stimuli
i. Is often forgetful in daily activities
A2. Hyperactivity and Impulsivity: Six (or more) of the
following symptoms have persisted for at least 6 months
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected
c. runs about or climbs in situations where it is inappropriate.
d. Often unable to play or engage in leisure activities quietly.
e. Is often on the go, acting as if driven by a motor
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, or
activities; may start using other peoples things without asking permission,
Schizophrenia Spectrum & Other Psychotic Disorders
F 21 Schizotypal Personality Disorder
F22 Delusional Disorder
F23 Brief Psychotic Disorder
F.. Substance-Induced Psychotic Disorder coding is drug specific pg110
F 04 Psychotic Disorder Associated with Another Medical Condition
F06.1 Catatonic Disorder Associated with Another Medical Condition
F20.89 Schizophreniform Disorder
F25 Schizoaffective Disorder
F20.9 Schizophrenia
F29 Unspecified Schizophrenia Spectrum Disorder
LISTED FROM LEAST TO MOST SEVERE
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Psychotic Dimensions
Hallucinations
Delusions
Disorganized speech
Abnormal psychomotor
behavior
Negative symptoms
Impaired cognition
Depression
Mania
Suicide
F06 Attenuated Psychosis Syndrome* Section 3
Prodromal Stage of Psychosis: At least a
month. A condition with recent onset of
modest, psychotic-like symptoms
hallucinations and delusions and clinically
relevant distress and disability. These
patients also are at significantly increased
risk of conversion to a full-blown psychotic
disorder. (35%)
In DSM 4 thought to be 60%
F 21 Schizotypal Personality Disorder*
Merges traits of the Schizoid PD
Confused identity or interpersonal functioning e.g.
lack of empathy ot intimacy*
Difficulty in maintaining relationships*
Eccentricity oddity psychoticism
Odd thoughts, beliefs and experiences
Withdrawal prefers to be alone*
Detachment Restricted affect-lack of response to usual
situations, withdrawal*
Negative Affectivity- Suspiciousness of others Ill-intent
Rarely, if ever, seeks treatment for the condition*
No correlation to drug use or suicidal behaviors*
* schizoid criteria
F20.9 Schizophrenia-295.9 no types-6 mos+
F20.81 Schizophreniform 295.4 1 mos or up
to 6months
A. Two (or more) of the following. At least one of these should
include 1, 2, or 3.
(1) delusions
(2) hallucinations
(3) disorganized speech
(4) grossly abnormal psychomotor behavior, including catatonia
(5) negative symptoms, e.g., diminished emotional expression
No longer an age of onset can occur at any age
Rule out Bipolar, Depression and Schizo-Affective
Anxiety Disorders
F93.0 Separation Anxiety Disorder* 309.21
F94.0 Selective Mutism 312.23
F41.0 Panic Disorder 300.01
F40.00 Agoraphobia 300.22
F40.2x Specific Phobia .18 animals, .29 environment .23 injection/blood,
.48 situations heights, travel
F40.10 Social Anxiety Disorder
F41.1 Generalized Anxiety Disorder 300.02
F 06.4 Resulting from a General Medical Conditions 293.84
F10.x depending on drug Substance-Induced
Bipolar and Related Disorders
F31.1 Bipolar I Disorder
F31.81 Bipolar II Disorder 296.89
F34.0 Cyclothymic Disorder 301.13
F06.3 General Medical Conditions
Substance-Induced
F31.9 Unspecified Bipolar Disorder 296.80
Highest correlate with suicide, Disorders
mainly unchanged
Trauma- and Stressor-Related Disorders
F94.1 Reactive Attachment Disorder
F94.2 Disinhibited Social Engagement Disorder* had been a
specifier in RAD in DSM IV; it is now separate.
F43.0 Acute Stress Disorder
F43.10 Posttraumatic Stress Disorder
F43.2x Adjustment Disorders*
F43.8 Other Specified Trauma Disorders
F43.9 Unspecified Trauma Disorder
Child has experienced 1 or the
following Pathogenic Realms
These can create a RAD or Disinhibited Soc. Eng. D/O:
1. Deprivation childs needs for affection or support/neglect lack of
providing for the childs basic needs/ comfort. Inept parenting
2. Failure to provide for physical or psych safety
3. Repeated changes of primary caregiver, no stable
relationships, i.e. , foster care
4. Rearing in unusual settings that limit opportunities
to form selective attachments (e.g., institutions
with high child-to-caregiver ratios).
Pathogenic Care Realms are the root of each of the
following: *
1. F94.1 Reactive Attachment Disorder 313.89
2. F94.2 Disinhibited Social Engagement Disorder 313.89
3. PTSD in Children
4. Separation Anxiety Disorder
5. Disruptive Mood Dysregulation Disorder
6. Dissociative Disorders in Children
7. Oppositional Defiant Disorder
8. Conduct Disorder (especially the G06.1 Specifier the
sociopathic child)
9. Antisocial Personality disorder
Each one of the above will require you to indicate that they are due to
one or more of the Pathogenic Care Realms.
F43.10 Post Traumatic Stress Disorder
309.81 (No longer under Anxiety Disorders)
Criteria applies to children above 6 through adulthood
A. Exposure to actual or threatened death, serious injury, or
sexual violation, in one or more of the following ways:
1.) Directly experiencing the traumatic event(s);
2.) Witnessing, in person, the traumatic event(s) as they occurred to others;
3.) Learning that the traumatic event(s) occurred to a close family member or
close friend; cases of actual or threatened death must have been violent or
accidental;
4.) Experiencing repeated or extreme exposure to aversive details of the
traumatic event(s) (e.g., first responders collecting human remains;
police officers repeatedly exposed tto details of child abuse); not due to
exposure through electronic media, television, movies, or pictures, unless
this exposure is work-related.
PTSD, Continued
B. Presence of one or more of the following intrusion symptoms:
1.) Spontaneous or cued recurrent, involuntary, and intrusive distressing
memories of the traumatic event(s) (Note: In children, repetitive play
may occur in which themes or aspects of the traumatic event(s) are
expressed.)
2.) Recurrent distressing dreams in which the content or affect of the
dream is related to the event(s) (Note: In children, there may be
frightening dreams without recognizable content. )
3.) Dissociative reactions (e.g., flashbacks) in which the individual feels
or acts as if the traumatic event(s) are recurring (such reactions may
occur on a continuum, with the most extreme expression being a
complete loss of awareness of present surroundings. (Note: In children,
trauma-specific re-enactment may occur in play.)
PTSD Continued
4.) Intense or prolonged psychological distress at exposure to
internal or external cues that symbolize or resemble an
aspect of the traumatic event(s)
5.) Marked physiological reactions to reminders of the traumatic
event(s)
PSTD Continued
C. Persistent avoidance of stimuli associated with

the traumatic event(s), as evidenced by avoidance
one or more of the following:
1. Distressing memories, thoughts, or feelings about
or closely associated with the traumatic event(s),
2. External reminders (i.e., people, places,
conversations, activities, objects, situations) that
arouse distressing memories, thoughts, or feelings
about, or that are closely associated with, the
traumatic event(s).
D. Negative changes in cognitions and mood associated
with the traumatic event(s), beginning or worsening after
the traumatic event(s) occurred), as evidenced by two or
more of the following:
1. inability remember an important aspect of traumatic event(s)
2. persistent and exaggerated negative beliefs or expectations
about oneself, others, or the world (e.g., I am bad, No one can
be trusted, "The world is completely dangerous").
3. persistent, distorted blame of self or others about the cause or
consequences of the traumatic event(s)
4. persistent negative emotional state (e.g., fear, horror, anger,
guilt, or shame)
5. markedly diminished interest or participation in significant
activities
6. feelings of detachment or estrangement from others
7. persistent inability to experience positive emotions (e.g.,
unable to have loving feelings, psychic numbing)
E. Marked alterations in arousal and reactivity
associated with the traumatic event(s),
beginning or worsening after the traumatic
event(s) occurred, as evidenced by two or more
of the following:
1. Irritable or aggressive behavior
2. Reckless or self-destructive behavior
3. Hyper vigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance (e.g., difficulty falling or
staying asleep or restless sleep)
F. Duration of the disturbance (Criteria B, C, D,
and E) is more than 1 month.
PTSD Continued
G. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
H. The disturbance is not attributed to the direct physiological
effects of a substance (e.g., medication, drugs, or alcohol) or
another medical condition (e.g. traumatic brain injury).
Specify if:
With Delayed Expression: if the diagnostic threshold is not
exceeded until at least 6 months after the event
PTSD in Children Continued
B. Presence of one or more intrusion symptoms :
1. Spontaneous or cued recurrent, involuntary, and
intrusive distressing memories of the trauma
2. Recurrent or distressing dreams
3. Dissociative reactions may occur on a continuum with
the most extreme expression being a complete loss of
awareness of present surroundings trauma-specific re-
enactment may occur in play.
4. Intense or prolonged psychological distress at
exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s)
5. Marked physiological reactions to reminders of the
traumatic event(s)
One item from criterion C or D below:
C. Persistent avoidance of stimuli associated with the
traumatic event,, as evidenced by avoidance of:
1.) Activities, places, or physical reminders that arouse
recollections of the traumatic event,
2.) People, conversations, or interpersonal situations
that arouse recollections of the traumatic event.
D. Negative alterations in cognitions and mood associated with
the traumatic event, as evidenced by one or more of the
following:
1.) Markedly diminished interest or participation in
significant activities, including constriction of play,
2.) Socially withdrawn behavior,
3.) Persistent reduction in expression of positive
emotions.
Depressive Disorders
F34.8 Disruptive Mood Dysregulation*Disorder
F32. Major Depressive Disorder Single episode
mild F32.0 moderate F32.1 Severe F32.2 Psychotic F32.3
partial remission F32.4, full remission F32.5, unspecified F32.26
Major Depressive Disorder, Recurrent
mild F33.3 moderate F33.1 Severe F33.2 Psychotic F33.3
partial remission F33.41, full remission F33.42, unspecified F33.9
F34.1 Dysthymic Disorder*3004
F10. Substance Induced- depends on substance pg 176
625.4 Premenstrual Dysphoric disorder (N94.3)
Depressive Disorders
Controversial removal of the bereavement exclusion in
Major Depressive Episode. No waiting period!
F34.8 Mood Dysregulation
Disorder(296.99)
Prior to age 18.
Frequency: The temper outbursts average, three or more times/ week.
Mood between temper outbursts:
1. Nearly every day, most of the day, the mood between temper outbursts
is persistently irritable or angry.
2. The irritable or angry mood is observable by others
Duration: Criteria have been present for 12 or more months. Throughout
that time, the person has not had 3 or more consecutive months when
they were without the symptoms of Criteria.
Criterion A or C is present in at least two settings (at home, at school,
Often associated with the 5 pathogenic realms.
Disruptive Mood Dysregulation Disorder
B. Frequency: The temper outbursts average, three or more
times/ week.
C. Mood between temper outbursts:
1. Nearly every day, most of the day, the mood between temper
outbursts is persistently irritable or angry.
2. The irritable or angry mood is observable by others
D. Duration: Criteria A-C have been present for 12 or more
months. Throughout that time, the person has not had 3 or more
consecutive months without the symptoms of Criteria A-C.
E. Criterion A or C is present in at least two settings ( home,
school,
Often associated with the pathogenic realms.
Major Depression - #1 or #2 plus 5 or more
1. depressed mood by report feels sad, empty, hopeless
2. Anhedonia by report or observation
3. Significant weight loss or gain without trying, increase
appetite
4. insomnia or hypersomnia
5. Psychomotor retardation/agitation nearly every day
6. Fatique or loss of energy nearly every day
7. Sense of worthlessness or inappropriate guilt
8. Poor ability to concentrate or indecisiveness
9. Thoughts of death,suicidal ideation, suicide plan or attempt
Depressive Disorders continued
Due to a medical condition depends on illness (primary)
F06.31 With depressive features full criteria for Maj. Depression not met
F06.32 with major depressive like episode criteria met for Major Depression
F06.34 with mixed features for mania/hypomania as well
Other specified Depressive disorder F32.8 3 types
1. recurrent brief dep. Depression and at least 4 other symptoms for 2-13
days/month for year not due to menses
2. Short duration depressive episode 4-13 days depressed affect and at
least 4 of 8 other symptoms no past hx of depression
3. Depressive episode with insufficient symptoms Depressed affect with
at least 1 of the other 8 symptoms of depression for at least 2 weeks
625.4 Premenstrual Dysphoric
disorder (N94.3)
Now included in the main depressive diagnoses section. No
longer in the disorders requiring clinical consideration.
For the majority of the menstrual cycles 1 week before 5
symptoms
Mood Lability Irritability Anger Depressed mood Anxiety
Tension Feeling keyed up.
1 of these : Decreased intest in usual activities or poor
concentration, lethargy, anhedonia, feel overwhelmed,
insomnia/hypersomnia breast tenderness, joint/muscle pain
bloating or weight gain.
F43 Adjustment Disorders 309.xx
F43.22 With Anxiety 309.24
F43.21 With Depression 309.0
F43.24 With disturbance of conduct 309.3
F43.23 With mixed anxiety and depressed mood 309.4
F43.25 With disturbance of emotions and conduct
309.4
F43.8 Adjustment Disorder with Complex Bereavement
F43.20 Unspecified 309.9
F43.8 Adjustment Disorder Complex Bereavement
pg 289
Twelve months of symptoms are required before the diagnosis may be
made.
Intense yearning for the loved one
Intense sorrow and emotional pain
Preoccupation with the deceased or the circumstances of the death
Feels life is empty
Difficulty planning for the future
Anger related to the loss
Suicide intent
Hopelessness on the value of life
Detachment from support systems
Found primarily in survivors of suicide, homicide, and loss of
child
Mourning shows substantial cultural variation; the bereavement
reaction must be out of proportion or inconsistent with cultural,
religious, or age-appropriate norms.
Dissociative Disorders
F48.1 Depersonalization-Derealization Disorder
F44.10 Dissociative Amnesia
F44.81 Dissociative Identity Disorder
Often result from the 3 pathogenic realms
F44.10 Dissociative Amnesia
An inability to recall important autobiographical
information, usually of a traumatic or stressful
nature, that is inconsistent with ordinary forgetting.
(Note: there are two primary forms of Dissociative
Amnesia:
(1) Localized or Selective Amnesia for a specific
event or events, and
(2) Generalized Amnesia for identity and life
history.)
F44.81 Dissociative Identity Disorder
Identity characterized by two or more distinct personality states
or an experience of possession.
Poor recall of everyday events, important personal information,
and/or traumatic events
The symptoms cause clinically significant distress.
Not a normal part of a broadly accepted cultural or religious
practice. (Note: In children, the symptoms are not attributable
to imaginary playmates or other fantasy play.
Often the result of repeated physical or sexual child
abuse
F45.1 Somatic Symptom Disorders
300.82
A. Somatic symptoms: One or more somatic symptoms that are
distressing and/or result in significant disruption in daily life.
B. Excessive thoughts, feelings, and behaviors related to these
somatic symptoms or associated health concerns: At least one of
the following must be present.
(1) Disproportionate and persistent thoughts about the seriousness of
one's symptoms.
(2) Persistently high level of anxiety about health or symptoms
(3) Excessive time and energy devoted to these symptoms or health
concerns
C. Chronicity: Although any one symptom may not be continuously
present, the state of being symptomatic is persistent (typically >6
months).
F45.21 Illness Anxiety Disorder 300.7
A. Somatic symptoms are not present or, if present, are only minimal.
B. Preoccupation with having or acquiring a serious illness.
C. High level of anxiety about health and a low threshold for becoming
alarmed about their health.
D. The individual performs excessive health-related behaviors (e.g.,
repeatedly checking one's body for signs of illness), or exhibits
maladaptive avoidance (e.g., avoiding doctors' appointments and
hospitals).
E. Chronic (at least 6 months).
Subtypes
Care-seeking subtype: Elevated rates of medical utilization.
Care-avoidant subtype: Rarely seek medical care because seeing a
physician and undergoing laboratory tests and diagnostic procedures
heightens anxiety to intolerable levels.
Feeding and Eating Disorders
307.52 Pica F50.8 adult F98.3 children
F98.91 Rumination Disorder*
F50.8 Avoidant/Restrictive Food Intake D/O*
F50.01 Anorexia Nervosa
F50.2 Bulimia Nervosa
F50.08 Binge Eating Disorder*
Feeding and Eating Disorders
F50.08 New Binge Eating Disorder* Recurrent
episodes of binge eating. An episode of binge eating is
characterized by both of the following:
1.) Eating, in a discrete period of time (e.g., within any 2-
hour period), an amount of food that is definitely larger
than most people would eat in a similar period of time
under similar circumstances,
2.) A sense of lack of control over eating during the
episode (for example, a feeling that one cannot stop
eating or control what or how much one is eating).
F 64 Gender Dysphoric Disorder*
F64.1 Gender Dysphoria in Children
F64.2 Gender Dysphoria in Adolescents
and Adults
F64.3 Unspecified Gender Dysphoria
Removed from DSM 4 Sexual and
Gender Identity Disorders
Gender Dysphoria (in Children)**
A. A marked incongruence between ones experienced/expressed gender
and assigned gender, of at least 6 months duration, as manifested by
at least 6
*
of the following indicators:
1.) Strong desire to be of the other gender or an insistence that he or
she is the other gender,
2.) In boys, a strong preference for cross-dressing or simulating female
attire; in girls, a strong preference for wearing only typical
masculine clothing and a strong resistance to the wearing of
typical feminine clothing.
3.) Strong preference for cross-gender roles in make-believe or fantasy
play.
Gender Dysphoria (in Children) Continued
4. Strong preference for the toys, games, or activities typical of the
other gender,
5. Strong preference for playmates of the other gender,
6. In boys, a strong rejection of typically masculine toys, games,
and activities and a strong avoidance of rough-and-tumble play; in
girls, a strong rejection of typically feminine toys, games, and
activities,
7. Strong dislike of ones sexual anatomy,
8. Strong desire for the primary and/or secondary sex
characteristics that match ones experienced gender,
B. The condition is associated with clinically significant distress or
impairment in social, occupational, or other important areas of
functioning, or with a significantly increased risk of suffering, such
as distress or disability.**
Gender Dysphoria (in Adolescents or Adults)**
A. A marked incongruence between ones experienced/expressed gender
and assigned gender, of at least 6 months duration, as manifested by
two
*
or more of the following indicators:
1.) Marked incongruence between ones experienced expressed gender
and primary and/or secondary sex characteristics,
2.) Strong desire to be rid of ones primary and/or secondary sex
characteristics because of a marked incongruence with ones
experienced/expressed gender (or, in young adolescents, a desire to
prevent the development of the anticipated secondary sex
characteristics),
3.) Strong desire for the primary and/or secondary sex characteristics of
the other gender,
4.) Strong desire to be of the other gender (or some alternative gender
different from ones assigned gender),
5. a strong desire to be treated as the other gender (or some
alternative gender different from ones assigned gender)
6. a strong conviction that one has the typical feelings and
reactions of the other gender (or some alternative gender
different from ones assigned gender)
B. The condition is associated with clinically significant distress
or impairment in social, occupational, or other important areas
of functioning, or with a significantly increased risk of suffering,
such as distress or disability**
Specifier**
Post-transition, i.e., the individual has transitioned to full-time
living in the desired gender (with or without legalization of
gender change) and has undergone (or is undergoing) at least
one cross-sex medical procedure or treatment regimen, namely,
regular cross-sex hormone treatment or gender reassignment
surgery confirming the desired gender (e.g., penectomy,
vaginoplasty in a natal male, mastectomy, phalloplasty in a
natal female). Copyright 2012, D & S Associates,
Conduct Disorder F91.1 children .2 adolescent
Now incorporates Pyromania & Kleptomania
Repetitive, persistent patterned behaviors where the rights of others or
societal norms or rules are violated, as in 3 of the following 15, including
Aggression to people and animals
1. Often bullies, threatens, or intimidates others,
2. Often initiates physical fights,
3. Has used a weapon that can cause serious physical harm to others (e.g.,
a bat, brick, broken bottle, knife, gun),
4. Has been physically cruel to people,
5. Has been physically cruel to animals,
6. Has stolen while confronting a victim (e.g., mugging, extortion, robbery),
7. Has forced someone into sexual activity.
Destruction of Property
8. Deliberately engaged in fire setting with the intention of causing serious
damage
9. Deliberately destroyed others property (not by fire)
Deceitfulness or theft
10. Has broken into someone elses house, building, or car
11. Often lies to obtain goods or favors or to avoid obligations (i.e., cons
others)
12. Has stolen items of nontrivial value without confronting a victim (e.g.,
shoplifting, but without breaking and entering; forgery)
Conduct Disorder/Antisocial
Serious violations of rules
13. Often stays out at night despite parental prohibitions, beginning before
age 13 years . (In adults, often violates rules of family life, e.g.,
neglects basic needs of a child.)
14. Has run away from home overnight at least twice while living in
parental or parental surrogate home, or once without returning for a
lengthy period. (In adults, often violates major societal norms, e.g.,
rulings of the court or conditions of parole/probation or rules of a
public agency or residential setting.)
15. Often truant from school, beginning before age 13 years. (In adults or
adolescents not in school, often violates rules of the workplace, e.g.,
chronic work absenteeism without acceptable reason.)
Conduct Disorder Children or (adults
if antisocial criteria not met)
Antisocial Personality Classic F63.1
A. Disregard for the rights of others 3 of the following 7:
1. Repeatedly performing acts that are grounds for arrest.
2. Deceitfulness lying, using aliases, conning for profit or pleasure
3. Impulsivity or failure to plan ahead.
4. Irritability/ aggressiveness physical fights or assaults.
5. Reckless disregard for the safety of self or others
6. Consistent irresponsibility failure to sustain work or pay obligations
7. Lack of remorse indifferent as to hurting, mistreating or stealing
B. Must be at least 18
C. Evidence of onset before 15
D . Not during the course of bipolar or schizophrenia disorders.
Antisocial New Version
1.Identity Egocentric Self esteem
from power/pleasure seeking
2. Self-direction-Illegal acts Personal
Gratification no internal standards
3.Empathy- lacks concern for others
4. Intimacy-exploits others unable
to form mutual intimate relations.
Must be 18+ years old
All of the above plus ---->
6+ of the following
1.Manipulates
2.Callousness-no concern for others
3.Deceitful dishonest, fraudulent
4.Hostility often angry/aggression
5. Risk Taking w/o regard for
consequences disregards danger
6. Impulsivity-acts w/o planning or
concern for consequences
7. Irresponsibility-failure to honor
obligations or commitments
Substance Use and Addictive Disorders
Newly reorganized by drug type not diagnosis like DSM 4
4 Groups: Substance use, intoxication, withdrawal, induced
Ten classes of drugs:
Alcohol; caffeine; cannabis; hallucinogens/PCP(separate);
inhalants; tobacco; opioids; sedatives-hypnotics-anxiolytics;
stimulants/amphetamines type/cocaine or other stimulants.
Gambling Addiction is included.
Hypersexuality disorder (Sex Addiction) in Paraphillias section
Poly-Substance Dependent Disorder is eliminated.
Substance Use
A. A pattern of substance use leading to clinically significant impairment
or distress, as manifested by 2 (or more) of the following, occurring
within a 12-month period:
1. Use more than intended or for a longer time than intended
2. Persistent desire or unsuccessful efforts to cut down or control
3. A great deal of time is spent in activities necessary to obtain subs.
4. Recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home,
5. Continued substance use, despite having persistent or recurrent social
or interpersonal problems caused or exacerbated by the effects of the
substance (e.g., arguments with spouse).
Substance Use, Continued
6. Important social, occupational, or recreational activities are given up
or reduced because of substance use,
7. Recurrent use in physically hazardous situations (driving),
8. Continued using despite having physical & psychological effects,
9. Tolerance need for more to get same effect or diminished effect
with same amount,
10. Withdrawal or use of drugs to prevent withdrawal
11. Craving or a strong desire to have the drug.
#s 1,2,8,9,10 Indicate Severe Subs Use with Physiological Dependence.
#s 4,5,6.7 Indicate Substance Use Moderate w/o physiological
dependence.
Gambling Disorder 4 of following
1. Needs to gamble with increasing amounts of money gamble with increasing amounts of money
in order to achieve the desired excitement
2. Restless or irritable when attempting to cut down or
stop gambling
3. Repeated unsuccessful efforts to control, cut back,
or stop gambling
4. Often preoccupied with gambling
5. Gambles often when feeling dysphoric.
6. After losing money gambling, often returns another
day to get even (chasing ones losses)
Gambling Disorder 4 of following cont
7. Lies to conceal the extent of gambling
8. Jeopardized or lost a significant relationship, job, or
educational or career opportunity because of it
9. Relies on others to provide money to relieve
desperate financial situations caused by gambling
B. The gambling behavior is not better accounted for by
a Manic Episode.
Course Specifiers.
- Episodic- Chronic- In Remission
Episodic ie. only gambles during baseball season
Severity Scale:
The Severity of each Substance Use Disorder is
based on:
- 0 or 1 criterion: No diagnosis
- 2-3 criteria: Mild Substance Use Disorder
- 4-5 criteria: Moderate Substance Use
Disorder
- 6 or more criteria: Severe Substance Use
Disorder
Recommended for Further Study in
Section III of the DSM 5
Caffeine Use Disorder
Internet Use Disorder
Neuro-behavioral Disorder Associated
with Prenatal Alcohol Exposure
Paraphilic Disorders
F65.2 Exhibitionistic Disorder 302.4
F65.0 Fetishistic Disorder 302.81
F65.81 Frotteuristic Disorder 302.89
F65.4 Pedophilic Disorder 302.2
F65.51 Sexual Masochism Disorder 302.83
F65.52 Sexual Sadism Disorder 302.84
F65.1 Transvestic Disorder 302.3
F65.3 Voyeuristic Disorder 302.82
F65.4 Pedophilic Disorder
A. 6+ months, an equal or greater sexual arousal from prepubescent or
early pubescent children (generally 13 and younger) than from physically
mature persons, as manifested by fantasies, urges, or behaviors.
B. The individual has acted on these sexual urges, or the sexual urges or
fantasies.
C. The individual must be at least 16 years of age and at least 5 years
older than the children in Criterion A.
Do not include a late adolescent involved in an ongoing sexual relationship with a
12 or 13 year old.
Specify type: Exclusive only children or non-exclusive - or incest type only
Classic TypeSexually Attracted to Prepubescent Children
Hebephilic TypeSexually Attracted to Early Pubescent Children
Pedohebephilic TypeSexually Attracted to Both
Specify type: Sexually Attracted to Males, Females or Both
Hypersexual Disorder
A. Over a period of at least 6 months, recurrent and intense sexual
fantasies, sexual urges, and sexual behavior in association with four or
more of the following five criteria:
1.) Excessive time is consumed by sexual fantasies and urges, and by
planning for and engaging in sexual behavior
2.) Repetitively engaging in these sexual fantasies, urges, and behavior
in response to dysphoric mood states (e.g., anxiety, depression, boredom,
irritability)
3.) Repetitively engaging in sexual fantasies, urges, and behavior in
response to stressful life events
(4) Repetitive but unsuccessful efforts to control or reduce
(5) Repetitively engaging in sexual behavior while disregarding the risk
for physical or emotional harm to self or others.
Specifiers
Specify if:
Masturbation
Pornography
Sexual Behavior with Consenting Adults
Cybersex
Telephone Sex
Adult Entertainment Venues/Clubs
Other:
Obsessive-Compulsive and
Related Disorder
F 00 Obsessive-Compulsive Disorder
F 01 Body Dysmorphic Disorder*
F 02 Hoarding Disorder
*F 03 Hair-Pulling Disorder*
F 04 Skin Picking Disorder*
F 05 Substance Induced OCD
F 07 OCD Due to General Medical Conditions
F 08 OCD NEC
F 00 Obsessive-Compulsive Disorder
A. Presence of obsessions, compulsions, or both
B. Are time consuming 1 hour+/day and cause distress
*Indicate if OCD beliefs are currently characterized by:
Good or fair insight: The individual recognizes that OCD beliefs
are definitely or probably not true, or that they may or may not be
true,
Poor insight: The individual thinks OCD beliefs are probably true,
Absent insight: The individual is completely convinced OCD beliefs
are true.
Specify if: Tic-related OCD: The individual has a lifetime history of
a chronic tic disorder
F02 Hoarding Disorder*
A. Persistent difficulty discarding or parting with possessions,
regardless of their actual value.
B. Anxiety due to a perceived need to save the items and
distress associated with discarding them.
C. Clinically significant distress or impairment maintaining a
safe environment for self and others.
D. Not due to another mental illness/medical condition/drug
Specify if:
With Excessive Acquisition: excessive collecting, buying, or
stealing items not needed or there is no available space.
Personality Disorder Points
2 separate sections on Personality old is kept currently for
continuity and the new suggested method is in keeping with the
latest science.
Section 2 keeps the traditional diagnoses and clusters.
Section 3 does away with many personalities and keeps 5 which
are considered the most pathological. You may use either the old
or the new version.
New approach addresses many of the short comings of the old
method where the typical client in the old method meets the
requirements for one disorder, also meets the requirement for 2
or more personality disorders.
DSM 5 ALTERNATIVE DIANOSTIC APPROACH
Six specific Personality Disorder types
Antisocial,
Avoidant,
Borderline,
Narcissistic,
Obsessive-compulsive,
Schizotypal
Personality Disorder Due to a Medical Condition F07.0
These are the the recommended personlities.
Impairments in Personality functioning and
pathological traits.
Where did they go in the new method?
Paranoid was eliminated
Schizoid was merged with Schizotypal
Schizotypal was merged with Schizophrenia Spectrum
Histrionic was eliminated
Antisocial(Dysocial) & Conduct DO merged and put in the
Disruptive, Impulse Control, and Conduct Disorders
Borderline, Narcissistic, Avoidant Personality still there
Dependent was eliminated
D & S 2012 102
LEVELS OF PERSONALITY FUNCTIONING DSM 5
Self and Interpersonal Functioning Dimensional Definition
The levels of personality functioning are based on the severity of
disturbances in self and interpersonal functioning.
Self: Identity: Experience of oneself as unique, clear boundaries
between self and others; stability of self-esteem accuracy of self-
appraisal; capacity for, and ability to regulate, a range of emotional
experience
Self-direction: Pursuit of coherent & meaningful short-term and life
goals; utilization of constructive and prosocial internal standards of
behavior; ability to self-reflect productively
Interpersonal:
Empathy: Comprehension and appreciation of others experiences
and motivations; tolerance of differing perspectives; understanding of
the effects of own behavior on others
Intimacy: Depth and duration of positive connections with others;
desire and capacity for closeness; mutuality of regard reflected in
interpersonal behavior
Standard Approach to the Assessment of Personality Pathology
1.Pathological Personality Traits
a. Negative Affectivity: labile moods,
anxiousness, separation insecurity,
perseveration, hostile, submissive, suspicious,
dysphoric, emotional dysregulation
b. Detachment: emotional constriction,
anhedonia, social withdrawal, intimacy
avoidance
2. Pathological Personality Traits
c. Antagonism: manipulative, deceitful, attention
seeking, grandiose, callous
d. Disinhibition or Compulsivity: perfectionism,
controlling, impulsive, risk taking, distancing, emotionally
inaccesible
e. Psychoticism: unusual beliefs, eccentric,
cognitive dysregulation
3. Overall Measure of Severity
a. Very little - 0
b. Mild - 1
c. Moderate - 2
d. Extreme - 3
Copyright 2008D & S Associates 106
SELF INTERPERSONAL
Level Identity Self-Direction Empathy Intimacy
0
-Ongoing
awareness of a
unique self;
maintains role-
appropriate
boundaries.
-Consistent and
self-regulated
positive self-
esteem, with
accurate self-
appraisal.
-Capable of
experiencing,
tolerating and
regulating a full
range of
emotions.
-Sets and aspires
to reasonable goals
based on a realistic
assessment of
personal capacities.
-Utilizes appropriate
standards of
behavior, attaining
fulfillment in
multiple realms.
-Can reflect on, and
make constructive
meaning of, internal
experience.
-Capable of
accurately
understanding others
experiences and
motivations in most
situations.
-Comprehends and
appreciates others
perspectives, even if
disagreeing.
-Is aware of the effect
of own actions on
others.
-Maintains multiple
satisfying and
enduring
relationships in
personal and
community life.
-Desires and
engages in a
number of caring,
close and
reciprocal
relationships.
-Strives for
cooperation and
mutual benefit and
flexibly responds
to a range of
others ideas,
emotions and
behaviors.
1
-Relatively intact sense of
self, with some decrease
in clarity of boundaries
when strong emotions and
mental distress are
experienced.
-Self-esteem diminished
at times, with overly
critical or somewhat
distorted self-appraisal.
-
Strong emotions may be
distressing, associated
with a restriction in range
of emotional experience.
-Excessively goal-
directed, somewhat goal-
inhibited, or conflicted
about goals.
-May have an unrealistic
or socially inappropriate
set of personal standards,
limiting some aspects of
fulfillment.
-Able to reflect upon
internal experiences, but
may overemphasize a
single (e.g., intellectual,
emotional) type of self-
knowledge.
-Somewhat compromised
in ability to appreciate and
understand others
experiences; may tend to
see others as having
unreasonable
expectations or a wish for
control.
-Although capable of
considering and
understanding different
perspectives, resists doing
so.-Inconsistent in
awareness of effect of
own behavior on others.
-Able to establish
enduring relationships in
personal and community
life, with some limitations
on degree of depth and
satisfaction.
-Capacity and desire to
form intimate and
reciprocal relationships,
but may be inhibited in
meaningful expression
and sometimes
constrained if intense
emotions or conflicts
arise.
-Cooperation may be
inhibited by unrealistic
standards; somewhat
limited in ability to respect
or respond to others
ideas, emotions and
behaviors.
SELF INTERPERSONAL
2
-
Excessive dependence on
others for identity
definition, with
compromised boundary
delineation.
-Vulnerable self-esteem
controlled by exaggerated
concern about external
evaluation, with a wish for
approval. Sense of
incompleteness or
inferiority, with
compensatory inflated, or
deflated, self-appraisal.
-Emotional regulation
depends on positive
external appraisal.
Threats to self-esteem
may engender strong
emotions such as rage or
shame.
-
Goals are more often a
means of gaining external
approval than self-
generated, and thus may
lack coherence and/or
stability.
-Personal standards may
be unreasonably high
(e.g., a need to be special
or please others) or low
(e.g., not consonant with
prevailing social values).
Fulfillment is
compromised by a sense
of lack of authenticity.
-Impaired capacity to
reflect upon internal
experience.
-Hyper-attuned to the
experience of others, but
only with respect to
perceived relevance to
self.
-Excessively self-
referential; significantly
compromised ability to
appreciate and
understand others
experiences and to
consider alternative
perspectives.
-Generally unaware of or
unconcerned about effect
of own behavior on
others, or unrealistic
appraisal of own effect.
-
Capacity and desire to
form relationships in
personal and community
life, but connections may
be largely superficial.
-Intimate relationships are
largely based on meeting
self-regulatory and self-
esteem needs, with an
unrealistic expectation of
being perfectly
understood by others.
-Tends not to view
relationships in reciprocal
terms, and cooperates
predominantly for
personal gain.
SELF INTERPERSONAL
3
-A weak sense of
autonomy/agency;
experience of a lack of
identity, or emptiness.
Boundary definition is poor
or rigid: may be over
identification with others,
overemphasis on
independence from others,
or vacillation between
these.
-Fragile self-esteem is
easily influenced by events,
and self-image lacks
coherence. Self-appraisal is
un-nuanced: self-loathing,
self-aggrandizing, or an
illogical, unrealistic
combination.
-Emotions may be rapidly
shifting or a chronic,
unwavering feeling of
despair.
-Difficulty establishing and/or
achieving personal goals.
-Internal standards for
behavior are unclear or
contradictory. Life is
experienced as meaningless
or dangerous.
-Significantly compromised
ability to reflect upon and
understand own mental
processes.
-Ability to consider and
understand the thoughts,
feelings and behavior of
other people is
significantly limited; may
discern very specific
aspects of others
experience, particularly
vulnerabilities and
suffering.
-Generally unable to
consider alternative
perspectives; highly
threatened by differences
of opinion or alternative
viewpoints.
-Confusion or
unawareness of impact of
own actions on others;
often bewildered about
peoples thoughts and
actions, with destructive
motivations frequently
misattributed to others.
-Some desire to form
relationships in community
and personal life is present,
but capacity for positive and
enduring connection is
significantly impaired.
-Relationships are based on a
strong belief in the absolute
need for the intimate other(s),
and/or expectations of
abandonment or
abuse. Feelings about
intimate involvement with
others alternate between
fear/rejection and desperate
desire for connection.
-Little mutuality: others are
conceptualized primarily in
terms of how they affect the
self (negatively or positively);
cooperative efforts are often
disrupted due to the
perception of slights from
others.
SELF INTERPERSONAL
4
-Experience of a unique
self and sense of
agency/autonomy are
virtually absent, or are
organized around
perceived external
persecution. Boundaries
with others are confused
or lacking.
-Weak or distorted self-
image easily threatened
by interactions with
others; significant
distortions and confusion
around self-appraisal.
-Emotions not congruent
with context or internal
experience. Hatred and
aggression may be
dominant affects,
although they may be
disavowed and attributed
to others.
-Poor differentiation of
thoughts from actions, so
goal-setting ability is
severely compromised,
with unrealistic or
incoherent goals.
-Internal standards for
behavior are virtually
lacking. Genuine
fulfillment is virtually
inconceivable.
-Profound inability to
constructively reflect upon
own experience. Personal
motivations may be
unrecognized and/or
experienced as external
to self.
-Pronounced inability to
consider and understand
others experience and
motivation.
-Attention to others'
perspectives virtually
absent (attention is
hypervigilant, focused on
need-fulfillment and harm
avoidance).
-Social interactions can
be confusing and
disorienting.
-Desire for affiliation is
limited because of
profound disinterest or
expectation of
harm. Engagement with
others is detached,
disorganized or
consistently negative.
-Relationships are
conceptualized almost
exclusively in terms of
their ability to provide
comfort or inflict pain and
suffering.
-Social/interpersonal
behavior is not reciprocal;
rather, it seeks fulfillment
of basic needs or escape
from pain.
SELF INTERPERSON
AL
Borderline Personality Disorder
1 a. Self-functioning:
Identity poorly developed and unstable, self-critical, feelings of
emptiness, dissociates under stress
Self-direction instability in goals, aspirations, values, career goals
1 b. Interpersonal functioning:
Empathy: limited ability to recognize the feelings or needs of others,
hypersensitivity to perceived rejection or criticism from others
Intimacy: intense, unstable, conflicted in relationships, views
relationships with extreme idealization or devaluation, mistrusting,
needy, suspicious of abandonment
Borderline
2. Pathological Personality Traits:
Negative affectivity emotional lability,
anxiousness, separation insecurity,
dysphoria
Disinhibition impulsivity, risk taking
Antagonism hostility
3. Severity Levels of 2 or 3 consistent
across time and circumstances
doctord@prodigy.net
800-950-5559
D & S Associates, P.O. Box 178,
Middlefield, CT 06455
www.dandsassociates.net
2012 American Psychiatric Association. All Rights Reserved. See Terms & Conditions of Use for more information.
Cultural Formulation Interview

GUIDE TO INTERVIEWER:

THE FOLLOWING QUESTIONS AIM TO
CLARIFY KEY ASPECTS OF THE
PRESENTING CLINICAL PROBLEM FROM
THE PATIENTS POINT OF VIEW,
INCLUDING ITS MEANING, POTENTIAL
SOURCES OF HELP, AND
EXPECTATIONS FOR SERVICES.

INSTRUCTIONS TO THE INTERVIEWER ARE IN ITALICS, BOLD, AND CAPITALIZED.

INTRODUCTION FOR THE PATIENT: I would like to understand the problems that bring you
here so that I can help you more effectively. I want to know about your experience and ideas. I
will ask some questions about what is going on and how you are dealing with it. There are no
right or wrong answers. I just want to know your views and those of other important people in
your life.

CULTURAL DEFINITION OF THE PROBLEM

ELICIT THE PATIENTS VIEW OF CORE
PROBLEMS AND KEY CONCERNS.
1. What problems or concerns bring you to the clinic? (IF PATIENT ONLY MENTIONS
SYMPTOMS, PROBE: Anything else?)

FOCUS ON THE ASPECTS OF THE
PROBLEM THAT MATTER MOST TO THE
PATIENT.
2. What troubles you most about your problem?

ASK FOR THE PATIENTS OWN WAY OF
UNDERSTANDING THE PROBLEM.
3. People often understand their problems in their own way, which may be similar or different
from how doctors explain the problem. How would you describe your problem to someone
else?

THIS CAN BE A CULTURAL LABEL, A
TERM IN A DIFFERENT LANGUAGE OR
AN INFORMAL EXPRESSION.
3a. Sometimes people use particular words or phrases to talk about their problems. Is
there a specific term or expression that describes your problem?
Yes No
3b. IF YES: What is it?

USE THE TERM, EXPRESSION, OR BRIEF
DESCRIPTION TO IDENTIFY THE
PROBLEM IN SUBSEQUENT QUESTIONS.

CULTURAL PERCEPTIONS OF CAUSE, CONTEXT AND SUPPORT

THIS QUESTION INDICATES THE
MEANING OF THE CONDITION FOR THE
PATIENT, WHICH MAY BE RELEVANT
FOR CLINICAL CARE.
CAUSES

4. Why do you think this is happening to you? What do you think are the particular causes of
your [PROBLEM]?

PROMPT FURTHER IF REQUIRED: Some people may explain their problem as the
result of bad things that happen in their life, problems with others, a physical illness, a
spiritual reason, or by some other cause.

IDENTIFY STRESSORS THAT COULD BE
ADDRESSED DURING TREATMENT.
STRESSORS AND SUPPORTS

5. What, if anything, makes your [PROBLEM] worse, or makes it harder to cope with?

CLARIFY IDEAS ABOUT NEGATIVE
EFFECTS OF THE SOCIAL NETWORK ON
THE PATIENTS PROBLEM.
5a. IF DOES NOT MENTION FAMILY/SOCIAL NETWORK: What have your family,
friends, and other people in your life done that may have made your [PROBLEM]
worse?

LISTEN FOR COPING STRATEGIES,
RESOURCES, SOCIAL SUPPORTS AND
RESILIENCE.
6. What, if anything, makes your [PROBLEM] better, or helps you cope with it more easily?

CLARIFY HOW THE PATIENTS FAMILY
AND SOCIAL NETWORKS HELP TO COPE
WITH THE PROBLEM.
6a. IF DOES NOT MENTION FAMILY/SOCIAL NETWORK: What have your family,
friends, and other people in your life done that may have made your [PROBLEM]
better?

ASK THE PATIENT TO REFLECT ON
ELEMENTS OF HIS/HER CULTURAL
IDENTITY THAT ARE IMPORTANT LIFE
PROBLEMS.
ROLE OF CULTURAL IDENTITY

7. Is there anything about your background, for example your culture, race, ethnicity, religion
or geographical origin that is causing problems for you in your current life situation?

Yes No
2012 American Psychiatric Association. All Rights Reserved. See Terms & Conditions of Use for more information.
7a. IF YES: In what way?

ASK THE PATIENT TO REFLECT ON
ELEMENTS OF HIS/HER CULTURAL
IDENTITY THAT CONSTITUTE
IMPORTANT SUPPORTS.
8. On the other hand, is there anything about your background that helps you to cope with
your current life situation?
Yes No
8a. IF YES: In what way?

CULTURAL FACTORS AFFECTING SELF COPING AND PAST HELP SEEKING

CLARIFY SELF-COPING FOR THE
PROBLEM.
9. Sometimes people consider various ways of making themselves feel better. What have you
done on your own to cope with your [PROBLEM]?

LISTEN FOR MENTAL HEALTH
TREATMENT, MEDICAL CARE, SUPPORT
GROUPS, WORK-BASED COUNSELING,
FOLK HEALING, RELIGIOUS OR
SPIRITUAL COUNSELING, OR OTHER
ALTERNATIVE HEALING.
10. Often, people also look for help from other individuals, groups, or institutions to help them
feel better. In the past, what kind of treatment or help from other sources have you sought
for your [PROBLEM]?

CLARIFY THE PATIENTS EXPERIENCE
AND REGARD FOR PREVIOUS
TREATMENT.
IF SOUGHT OUTSIDE HELP

10a. What type of help or treatment was most useful? Why?/How?

10b. What type of help or treatment was not useful? Why?/How?

CLARIFY THE ROLE OF SOCIAL
BARRIERS TO HELP-SEEKING, ACCESS
TO CARE, AND PROBLEMS ENGAGING IN
PREVIOUS TREATMENT.
11. Has anything prevented you from getting the help you need-- for example, cost or lack of
insurance coverage, getting time off work or family responsibilities, concern about stigma
or discrimination, or lack of services that understand your language or culture?

Yes No
11a. IF YES: What got in the way?

CURRENT HELP-SEEKING

ELICIT POSSIBLE CONCERNS ABOUT
THE CLINICIAN-PATIENT RELATIONSHIP,
INCLUDING PERCEIVED RACISM OR
CULTURAL DIFFERENCES THAT MAY
UNDERMINE COMMUNICATION,
GOODWILL, OR CARE DELIVERY.
CLINICIAN-PATIENT RELATIONSHIP

12. Now lets talk about the help you would be getting here. Is there anything about my own
background that might make it difficult for me to understand or help you with your
[PROBLEM]?
Yes No
12a. In what way?/Why not?

ADDRESS POSSIBLE BARRIERS TO
CARE OR CONCERNS ABOUT THE
CLINICIAN-PATIENT RELATIONSHIP
RAISED PREVIOUSLY.
13. How can I and others at our clinic be most helpful for you?

CLARIFY PATIENTS CURRENT
PERCEIVED NEEDS AND EXPECTATIONS
OF MENTAL HEALTH SERVICES (E.G.,
PSYCHOTHERAPY, SPECIFIC ADVICE,
MEDICATION, REFERRAL, OR
ASSISTANCE WITH DISABILITY
BENEFITS).
PREFERENCES

14. What kind of help would you like from us now, as specialists in mental health?

HERE THE CLINICIAN SUMMARIZES THE MAIN POINTS AND MAKES A TRANSITION TO THE REST OF THE INTERVIEW.

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By: Patrick L. DeChello Ph.D.

, MSW, LCSW, RPH

C. Persistent avoidance of stimuli associated with

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