Into the DSM - Antisocial Personality Disorder

When is bad behavior just bad behavior, and when does it cross the line into being clinically significant? Let's take a look at the DSM criteria for antisocial personality disorder. They are:

A. Pervasive pattern of disregard for and violation of the rights of others, occurring since age 15, including three or more of these:

1. Failure to conform to social norms.
2. Deceitfulness.
3. Impulsivity, failure to plan ahead.
4. Irritability and aggressiveness.
5. Reckless disregard for the safety of others.
6. Consistent irresponsibility (work, money).
7. Lack of remorse.

B. At least 18 years older.

C. Conduct disorder onset before age 15.

D. Does not occur exclusively during schizophrenia or bipolar disorder.

So, for the LCSW exam, imagine a question about a high school bully who lies, fights, cuts class, and shrugs off his impact on others. Antisocial? Not yet--not, at least, until he turns 18.

How about a high school bully-turned-Fortune 500-CEO who does the grown-up version of that and delights in humiliating underlings? Now you might be onto something. Take a look at the other choices. Maybe conduct disorder (but the adult CEO has outgrown that). Maybe other cluster B personality disorders BPD (not it), NPD (conceivable). Antisocial personality disorder is probably the best of those answers for the non-vignette sketched out above.

For more about the disorder, try the Mayo Clinic antisocial pages here: https://www.mayoclinic.org/diseases-conditions/antisocial-personality-disorder/symptoms-causes/syc-20353928

Into the DSM - Histrionic Personality Disorder

Let's visit Cluster B personality disorders. You know ones. The dramatic, emotional, erratic group: antisocial, borderline, narcissistic, and, today's spotlight item, histrionic personality disorder.

Personality disorders--as opposed to just personality--involve patterns of beliefs and behaviors that severely impair those diagnosed with them. A full 10-15%  of people meet criteria for a personality disorder. That's a whole lot of people suffering, and often making others suffer, with long-standing, difficult-to-treat conditions.

Those with histrionic personality disorder seek attention more-or-less constantly, exhibiting extremes of feeling and behavior. Focus is often on excessive flirting, attention to looks, and severe reactions when attention isn't given.

Five of the following must be present to make a diagnosis:

• When not receiving attention, feels less valued.
• Inappropriate flirting and seduction.
• Mood lability (quickly changing feelings).
• Attracts attention via physical appearance.
• Vague, detail-lacking style of speech.
• Extreme displays of feeling (aka "drama").
• Easily swayed by others and by fads.
• Rapid attachments with overestimated depth. 

There's a fair amount of overlap with BPD, but it's not the same thing. For the LCSW exam look for flirting, looks-focus, and attention-seeking as signs that a fictional, vignette client is possibly meeting criteria for histrionic PD. 

For more detail, plus a mnemonic (PRAISE.ME) to help remember criteria, take a look at Wikipedia: https://en.wikipedia.org/wiki/Histrionic_personality_disorder

Into the DSM - Schizoaffective Disorder

Schizoaffective disorder readily lends itself to close-call differential diagnosis questions and is a natural favorite for exam writers. A question may boil down to this: Is it schizophrenia or schizoaffective disorder? Well, here are the criteria for schizoaffective disorder:

A. A major mood episode (MDD or manic) concurrent with Criterion A of schizophrenia*
B. Delusions or hallucinations for two or more weeks in the absence of a major mood episode.
C. Symptoms meet criteria for a major mood episode for the majority of the illness.
D. Not attributable to substance or another medical condition.

Subtypes:
Bipolar type (that is, psychotic symptoms alongside--but not exclusively during--a manic episode).
Depressive type (same as a above, but with symptoms of MDD).

Remember that psychotic symptoms can be present within bipolar or depressive illness. They can also be present--with the absence of any major mood episodes--in schizophrenia and other psychotic disorders.

That's a lot to have understood before facing down a question about mood/psychotic symptoms. But now you're that much closer to correctly answering a social work exam question on the topic.

For a lot more about schizoaffective disorder, try this long Wikipedia page: https://en.wikipedia.org/wiki/Schizoaffective_disorder

*Here's Criterion A of schizophrenia, referenced above: Two or more of the following present most of the time for a month or more:

• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms (e.g., blank affect, avolition)

Into the DSM - Narcissistic Personality Disorder

NPD has been thrown around in the news a lot lately. Does that make it any more likely to show up on the social work licensing exam? Hard to say. Exam writers read the news too! Criteria for NPD are:

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.

And that's it. Simple--and difficult--as that. Narcissistic personality disorder is grouped with antisocial personality disorder, borderline personality disorder, and histrionic personality disorder in Cluster B.

Seasoned social workers can usually assess the presence of a personality disorder pretty quickly, without knowing which PD they're facing. The quick summary you'll hear all the time in the field: "Cluster B." On the exam you have to be more certain--know these criteria and how to distinguish from the other personality disorders and you'll be able to correctly answer without too much difficulty.

For further reading, try the Mayo Clinic's NPD page: http://www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/basics/definition/con-20025568 and Wikipedia's pages, linked here: https://en.wikipedia.org/wiki/Cluster_B_personality_disorders

Good luck on the exam!

Into the DSM - Schizophrenia

Schizophrenia will doubtless come up for social workers employed in clinic settings. That means it's one of the diagnoses that you may find appear on the social work licensing exam. Here are the criteria:

A. At least two of the following for a significant portion of the time during a one-month period:

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (e.g., flat affect)

B. Level of functioning is markedly below level at onset of symptoms.

C. Disturbance persists at least six months.

D. Schizoaffective, depressive, and bipolar disorder ruled out.

E. Symptoms not attributable to the effects of a substance.

F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, a schizophrenia diagnosis is made only if prominent delusions or hallucinations are present for at least one month.

Specifiers include:

• First episode, currently in acute episode
• First episode, currently in partial remission
• First episode, currently in full remission
• Multiple episodes (acute, partial, or full remission)
• Continuous
• With catatonia

DSM-5 also includes a severity rating for schizophrenia--each symptom can receive its own rating ranging from 0 (not present) to 4 (present and severe).

For further reading, including risk factors and treatment, take a look at http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml

Into the DSM - Autism Spectrum Disorder

New in DSM-5, autism spectrum disorder covers a wide array of symptoms. It's wise to review them ahead of sitting for the social work licensing exam. Here we go...

A. Persistent deficits in social communication and social interaction across multiple contexts, for example:

• Deficits in social-emotional reciprocity (back-and-forth conversation, sharing of interests)
• Deficits in nonverbal communication (eye contact, body language)
• Deficits in developing, maintaining, and understanding relationships (adjusting behavior to context, making friends)

B. Restricted, repetitive patterns of behavior, interests, or activities, including at least two of the following:

• Stereotyped or repetitive motor movements (lining up toys, echolalia, idiosyncratic phrases)
• 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 hyporeactivity to sensory input (indifference to pain/temperature, adverse response to specific sounds...)

C. Symptoms present in early development.

D. Symptoms cause clinically significant impairment.

E. Disturbances not better explained by an intellectual development disorder or global developmental delay.

Specifiers include:

• With or without intellectual impairment
• With or without language impairment
• Associated with a medical or genetic condition or environmental factor
• Associated with another neurodevelopmental, mental, or behavioral disorder
• With catatonia

Since ASD encompasses old (DSM-IV-TR) diagnoses of autistic disorder, Asperger's disorder, and pervasive developmental disorder, severity levels play an important part in the diagnosis. More about those in a future post!

For further reading try NIMH and/or the CDC.

Into the DSM - Panic Disorder

Panic disorder can be summed up in four words: Recurrent unexpected panic attacks. But there's more to it than that. First, what's a panic attack (and what's not a panic attack)? The DSM answers: A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes. During that time, four of the following symptoms occur:

1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or "going crazy."
13. Fear of dying.

With that you know most of what you need to know about the diagnosis, but not all. There's a crucial addition--criterion B: At least one of the attacks has been followed by one month (or more) of one or both of the following:

1. Persistent concern or worry about additional panic attacks or their consequences.
2. A significant maladaptive change in behavior related to the attacks (e.g., avoidance)

Of course, there are the usual "not better explained by" caveats. And that's it.

Risk factors for panic disorder include:

• Family history of panic.
• Major life stress or life changes.
• Trauma.
• Excessive caffeine intake and/or smoking.
• History of childhood physical or sexual abuse.

With the above information digested, consider yourself readied for a panic disorder question on the ASWB exam. For further study try: Panic attacks and panic disorder at MayoClinic.org.

Into the DSM - Bipolar I Disorder

To meet criteria for bipolar I disorder, a manic episode is required--it may be followed by a hypomanic or major depressive episode. (For bipolar II, a hypomanic episode + a current or past major depressive episode are required.) Here are the criteria for a manic episode:

A. Distinct period of abnormally and persistently elevated, expansive, or irritable mood with increased goal-directed activity or energy, lasting at least 1 week.

B. Three or more of the following during the mood disturbance:

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. Increased talkativeness
4. Racing thoughts or flight of ideas
5. Distractibility
6. Increased goal-directed activity or psychomotor agitation
7. Excessive risk-taking

C. Mood disturbance severe enough to cause impairment.

D. Episode is not attributable to effects of a substance or another medical condition.

Hypomanic episodes include many of the same symptoms, but are not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization.

Specifiers for bipolar I disorder include:

• With anxious distress
• With mixed features
• With rapid cycling
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern

Risk factors include:

• Having a first-degree relative (e.g., parent or sibling) with the disorder.
• Substance abuse
• High stress
• Major life changes (e.g., death of loved one)

For further study: Bipolar I Disorder at MayoClinic.org

Into the DSM-5 - Schizoaffective Disorder

If you've encountered schizoaffective disorder in your work  with clients, questions about the diagnosis on the licensing exam shouldn't give you much trouble. For everyone else, here's a quick primer. The essential formula to remember with schizoaffective disorder is psychotic symptoms + mood symptoms which are independent of the psychotic symptoms. Common rule-outs: schizophrenia, bipolar disorder, MDD with psychotic features.

There are two essential criteria:

• Major mood episode concurrent with symptoms of schizophrenia
• Delusions or hallucinations in the absence of mood symptoms at some point

 Specifiers include:

• Bipolar type
• Depressive type
• With catatonia

Risk factors: Having a blood relative with schizophrenia, schizoaffective disorder, or bipolar disorder; stress; drug use.

For further study: Schizoaffective disorder at MayoClinic.com

DSM-5 Arrives

It's been quiet here, but you may still have heard the rumbling of an approaching giant: DSM-5. The new, purple edition of the APA's Diagnostic and Statistical Manual of Mental Disorders has been in circulation for a couple of years, but until now, you may have been able to avoid it. If you're preparing for the LCSW exam (or any other social work licensing exam), avoiding it is--as of July 1st, 2015--no longer an option. But don't fear. While the DSM-5 may have big impact on some clients by, for example, widening autism or narrowing bipolar disorder, for your exam prepping purposes, the switch isn't a huge deal. The little changes are minor enough to probably escape the interest of ASWB exam item writers. The big changes are in small enough number to be manageable. While this blog may examine some of the more likely-to-show-up-on-the-exam changes in future posts, to take a big gulp of DSM-5 change info, try the links below. Happy reading, happy studying.

For review: DSM-5 changes (APA); DSM-5 changes (Psych Central); DSM-5 (Wikipedia)

Knowing Which DSM to Study

Are you confused about the new DSM as it relates to the social work licensing exam? Let's get that settled and off your anxiety plate. DSM-5 is out and in use. It's purple, it's big, it's controversial. And, as of this post (August, '14), it's not yet appearing on the test. Not anywhere. It will soon and not-so-soon, depending upon where you're sitting for the exam.  Here are your guidelines, straight from the horses' mouths:

From the ASWB which administers most exams--just not California:

No content related to DSM-5 will appear on the exams until July 2015. [Everywhere but California.] 

That's most people--49 states plus Canada. If you're taking the exam between now and July, '14, study DSM-IV-TR. People in sunny CA have to put down their surfboards and get their DSM-5 knowledge together sooner. From the California BBS:

Exam administrations December 1, 2014 and after: DSM-5 [California only.]

Two different exam administrators, two different times to expect to see DSM-5 questions on the exam. Since everyone's eventually going to be using DSM-5 diagnoses, the California people may have an advantage in that they don't have to dig into two different DSMs. But it's not hard to imagine a big, everywhere-but-California sigh of relief at getting to push that particular information loading down the road some.

Wherever you are, whichever DSM you're learning, good luck!

Into the DSM-IV - Generalized Anxiety Disorder

Generalized Anxiety Disorder is diagnosed when a person suffers from excessive anxiety and worry that takes place for more than half the days in a 6 month time period. Furthermore, the anxiety causes impairment in social, occupational or other areas of functioning. Criteria for this diagnosis includes at least three of the following:

• Restlessness or feeling keyed up or on edge


• Easily fatigued


• Difficulty concentrating


• Irritability


• Muscle tension


• Sleep disturbance

Risk Factors

• Having a comorbid DSM-IV disorder. Generalized anxiety disorder is often diagnosed in those who have another anxiety disorder, a mood disorder or substance-related disorder


• Having a family member who suffers with Generalized Anxiety Disorder


• Being female (it is twice as common in women)


• Having a history of frequent losses or severe childhood fears


• Having a poor psychological disposition (irrational thinking, negative thinking, overgeneralizing)


• Being neurotic or excessively conscientious


• Experiencing a number of overly stressful life events

Protective Factors

• Healthy childhood development


• Appropriate parental attachments


• Strong social supports


• Knowledge and use of stress management techniques


• Optimism and self-confidence


• Psychotherapy: behavioral approaches involving coping skills, relaxation and medication

Into the DSM-IV - Anorexia Nervosa

Anorexia Nervosa is an eating disorder characterized by the following symptomatic clues:

• An inability to maintain a healthy or minimum body weight
• A distorted body image
• An intense fear of gaining weight or becoming overweight
• An excessive emphasis on weight
• The denial of the seriousness of their condition
• In females an additional characteristic is the cessation of the menstrual cycle.

Anorexa Nervosa can be further classified as a Restricting type, which involves volutary starvation, Binge/Purging (including the use of laxatives or vomit induction). The onset of Anorexa Nervosa typically occurs in adolescence and affects about 1% of the female population.

Risk Factors

• Having a history of dieting (diets do not cause, instead all eating disorders originate through dieting attempts
• Being female (95% of diagnoses are in females)
• Having a parent in the family system who is overly concerned with weight issues
• Being a prepubscent or adolescent female (due to the incongruence of actual and ideal female body types portrayed in cultural situations)
• Biological predispostion.
• Psychological characteristics: distorted thinking, low self-esteem, stress, anxiety, perfectionism, and fear of rejection
• A history of trauma, sexual or physcial abuse
• Socio-cultural factors such as media or peer influences.

Protective Factors

• Psychological characteristics: high self-esteem, internal locus of control, high self-efficacy, mature defense mechanisms and coping strategies
• Personality characteristics: easy temperment, ability to make and maintain friendships, optimism
• Secure attachment to a parent
• Good parental adjustment. Parents with healthy attitudes towards weight and food can pass these along to children
• Socio-cultural factors: low levels of stress, high levels of support, minimal exposure to media images.

Into the DSM-IV – OCD

Obsessive-Compulsive Disorder is an anxiety related disorder that is marked by recurrent obsessions and compulsions that persist for more than one hour daily. Moreover, these obsessions and compulsions cause significant amounts of distress or impairment in daily functioning.

Obsessions consist of the repetition of distressing thoughts, impulses, ideas or images.

Compulsions are repetitive behaviors or mental acts that are intended to quell the anxiety of the obsession.

Risk factors

• Having a history of eating disorders in first degree relatives
• Having another mental disorder (OCD is comorbid in over 50% of cases)
• Being biologically pre-disposed to the condition
• Having a reduced rate of serotonin (persons who suffer with OCD have difficulty entering REM sleep)

Theoretical risk factors

• Psychodynamics – the person is stuck in the anal stage of development seeking rigidity and over control
• Learning theory – the person plays out classical and operant conditioning and negative reinforcement
• Family Systems – OCD develops to serve as a function of the family.

Protective Factors

• The development of better diagnostic categories to capture a better understanding of the disorder in adolescence
• Better education of family members in order to better recognize and monitor OCD inclinations.

Into the DSM-IV – Major Depression

As of 1996, Major Depression was diagnosed in roughly 17% of the total population, with a majority of that population being women (21%). Major Depression is the single largest disease that affects the US population in terms of economic scale.

To be diagnosed with Major Depression the symptoms must not have been the result of substance use, a general medical disorder or bereavement in the previous two months.

Furthermore, the client must have exhibited four of the following symptoms for at least two solid weeks:

1) Depressed mood for most of the day (irritability in adolescents and males)
2) Loss of interest or pleasure in all activities
3) Gains or losses in weight or increased/decreased appetite
4) An interruption in sleep patterns (sleeping more or less)
5) Fatigue
6) Others view the person as speeding up or slowing down
7) Feelings of worthlessness or inappropriate guilt
8) Inability to concentrate
9) Experiencing repeated thoughts about death

Risk factors for Depression

Gender – More females are diagnosed with depression than males
Age – Major Depression occurs in 1 in 6 adults over the age of 59
Health – Poorer general health increases risks, as well as a medical illness
Substance Abuse – increases risks (cannot be comorbid with Major Depression)
Genetics – There is some research that posits a genetic component to Major Depression
Comorbidity – Major Depression is often comorbid with anxiety, dysthymia or other disorders
History – Recurrence of depression is likely over the life-span
Abuse – Women who experience abuse are more likely to exhibit Major Depressive features
Economics – Lower socio-economic classes have higher rates of depression
Support – Isolation, divorce, widowed, separated and single individuals have greater risks
Stress – Major life events contribute to risks of major depression

Protective Factors for Depression

Social – Extended education, employment, financial stability, close relationships, marriage (for men), and adequate social support can protect against depressive symptoms
Medication – Can help resolve chemical imbalances in some individuals (must be weighed against side-effects and often work better in conjunction with psychotherapy)
Exercise – This is especially important for older adults, but has some protective factors for others as well.

Treatment Possibilities

Three forms of therapy have been researched and have proven effective for the treatment of Major Depression. Cognitive, Behavioral and Interpersonal therapeutic paradigms have provided the best outcomes for clients who suffer from Major Depression. Furthermore, a fourth paradigm that combines Cognitive and Behavioral treatments is effective. Finally, there is some research that states that therapy in conjunction with medication provides for the most effective and longest lasting results in the treatment of Major Depression.