Adjustment Disorders DSM-5 Criteria for Adjustment Disorders A.

The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). B. These symptoms or behaviors are clinically significant as evidenced by either of the following: (1) Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation. (2) Significant impairment in social, occupational or other important areas of functioning. C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder. D. The symptoms do not represent normal bereavement. E. Once the stressor (or its consequences) have terminated, the symptoms do not persist for more than an additional 6 months. Adjustment Disorders DSM Criteria A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). B. These symptoms or behaviors are clinically significant as evidenced by either of the following: (1) Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation. (2) Significant impairment in social, occupational or other important areas of functioning. Adjustment Disorders DSM Criteria Specify whether: 309.0 With Depressed Mood 309.24 With Anxiety 309.28 With Mixed Anxiety and Depressed Mood 309.3 Disturbance of Conduct 309.4 With Mixed Disturbance of Emotions and Conduct 309.9 Unspecified Adjustment Disorders Clinical Characteristics Prevalence 2% - 8% of community samples including children, adolescents and the elderly. 12% of general hospital inpatients who are referred for a mental health consultation. 10%-30% of those in mental health outpatient settings Adjustment Disorders Clinical Characteristics Diagnostic Issues Not diagnosed if a more severe mental illness is present. May represent a precursor to a more severe mental illness. Most common diagnostic category used in private practice. Ms. V is a 45 year old woman who has come to therapy because she is having an extramarital affair. She is feeling conflicted about what to do and needs help clarifying her feelings and setting goals for herself. She generally functions well; she attends work daily with good performance, cares for her household responsibilities and spends time with family members and friends. She would like to use her insurance benefits to pay for therapy. Would you assign a DSM diagnosis, and if so, what? Adjustment Disorders Treatment Brief therapies considered most appropriate Empirical support for the use of cognitive therapy Problem-solving for reduction/removal of the stressor Psychoeduction & coping skills for stressors that cannot be changed. Substance Use Disorders Substance Use Disorders Overview Previous DSMs included Substance Abuse, Substance Dependence classifications. DSM-5 Classifications Use Disorder Intoxication Withdrawal Unspecified _________-Related Disorder Substance Use Disorders: Criteria A. A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period: 1. The substance is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 3. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or

recover from its effects. Substance Use Disorders: Criteria 4. Craving, or a strong desire to use the substance. 5. Continued substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; suspensions, or expulsions from school; neglect of children or household). 6. 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 about consequences of intoxication, physical fights). Substance Use Disorders: Criteria 7. Important social, occupational, or recreational activities are given up or reduced because of substance use. 8. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) 9. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption) ***Does not apply to caffeine*** Substance Use Disorders: Criteria 10. Tolerance, as defined by either of the following: (a) A need for markedly increased amounts of the substance to achieve intoxication or desired effect. (b) A markedly diminished effect with continued use of the same amount of the substance. 11. Withdrawal, as manifested by either of the following: (a) The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for withdrawal from the specific substances) (b) The same (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. Substance Use Disorders: Specifiers Specify if: In early remission: After full criteria for substance use disorder were previously met, none of the criteria for substance use disorder have been met for at least 3 months, but less than 12 months (with the exception that Criterion A4, Craving, or a strong desire or urge to use alcohol may be met). In sustained remission- No criteria for substance use disorder have been met at any time for a period of 12 months or longer, with the exception of Craving. In a controlled environment- This additional specifier is used if the individual is in an environment where access to a substance is restricted. Substance Use Disorders: Specifiers Specify if: Mild: Presence of 2-3 symptoms Moderate: Presence of 4-5 symptoms Severe: Presence of 6 or more symptoms Substance Use Disorders: Coding Cocaine Use Disorder, Mild, In early remission 305.60 Tobacco Use Disorder, Severe ??? Substance Intoxication A. Recent ingestion or use of a substance. B. Clinically significant problematic behavioral or psychological changes that develop during, or shortly after, use of the substance. Substance Intoxication C. One / two or more (check specific substance) of the following

signs or symptoms developing during, or shortly after, substance use. Please see specific substances for particular criteria D. The signs and symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. ***Does not apply to tobacco*** http://www.youtube.com/watch?v=6HvKlkS_C7o&feature=endscreen Substance Withdrawal A. Cessation of (or reduction in) prolonged substance use. B. Symptoms develop a few within a few hours to a few days after the cessation of (or reduction in) substance use. C. The signs or symptoms in Criteria B cause clinically significant distress or impairment in social, occupational or other important areas of functioning. Substance Withdrawal D. The signs and symptoms are not due to another medical condition and are not better accounted for by another mental disorder, including intoxication or withdrawal from another substance. Specify if: With perceptual disturbances: This specifier applies in the rare instance when hallucinations (usually visual or tactile) occur with intact reality testing, or auditory, visual or tactile illusions occur in the absence of delirium. ***Does not apply to hallucinogens or inhalants*** Unspecified (Specific Substance)Related Disorder The category applies to presentations in which symptoms characteristic of a substance related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any specific substance related disorder or any of the disorders in the substance-related diagnostic class. Categories of Substances Alcohol Stimulants Caffeine Cannabis Cocaine Hallucinogens Each class of drugs has own profile of intoxication and withdrawal syndromes Inhalants Tobacco Opioids Phencyclidine Sedatives/ hypnotics Easy to get hooked, hard to stop How easy is it to get hooked? How hard is it to stop? Assessment Issues Clients insight into the problem, desire for change and the point in the illness course in which help is being sought, can all influence assessment. Clients may not be initially forthcoming about substance use and instead focus on affective issues. Often people will under report what they are actually doing- Multiply it by 2 or 3. Assessment Questions How much______ do you use. Good to have some knowledge of drug terminology . Don t be afraid to ask!!! Bundle?? Dime Bag?? 40?? Whens the last time you used______ How often do you use ______ When you were using the most, how much ______ were you using How do you use it (snort, IV, smoke)? Assessment Questions How old were you when you first started? How did you start, who introduced you? Have you needed to use more over time? Did you ever (loose children, job, have legal consequences) as a result of your use? Have you ever tried to stop?Whats your longest clean time in the community? Assessment Questions How did you stop? Did you ever go to a program to help you stop? Do you go to AA, NA or other support group now? Do you have clean (non using) friends? Any diagnosis of Hep B,C or HIV? Assessment Observations Nodding (Opiate use) Observe clients hands and arms- look for puncture

marks needle marks, hyperpigmented lines track marks. Long sleeves in warm weather, insistence on covering certain body parts. Complaints of oral thrush. Comorbidities 2/3s of individuals with substance use disorders meet criteria for another non-substance use disorder in their lifetime. Individuals with 3 or more psychiatric disorders have a risk of substance use disorder 14 x greater than individuals with less than 3 disorders. Comorbidities 50% of individual with severe mental illness will develop a substance use disorder in their lifetime. Only 25% of people get treatment for substance use and mental illness. Treatment Motivational Interviewing (Prochaska and DiClemente) Focused on assessing clients stage of change and encouraging them to move on to the next one. Pre contemplation Stage Not thinking about changing behavior in the next 6 months. Contemplation Intention to change in the next 6 months. Treatment Motivational Interviewing (Prochaska and DiClemente) Preparation Intention to change in the next 30 days with active steps. Action Active change, but for less than 6 months. Maintenance Active change for 6 months or more. Treatment CBT Relapse prevention- Differentiates between lapse and relapse. Goals are to: Prevent a lapse in sobriety Maintain goals related to abstinence or harm reduction. Treatment CBT Interventions: Teach clients to recognize triggers for use: Internal Triggers External Triggers Teach clients to recognize and be aware of consequences: Short term consequences Long term consequences Treatment CBT Interventions Teach clients to develop coping skills for triggers Reframe maladaptive thoughts that lead to use- Im a failure One hit wont hurt. I deserve this. Developing Assertiveness Skills Rehearsal Maintaining Balance- Time management, stress management, developing clean social outlets. Develop coping cards or other cues to remind clients to use their skills and stick to goals. Treatment Medical Detoxification Maintenance Treatment Methadone Maintenance for Opioid Dependence Harm reduction intervention Can also be abused, particularly when mixed with Benzodiazepines Administered in a clinic setting where daily dose is give. Take home dose is a privilege. Not in my back yard- meth maintenance http://www.youtube.com/watch?v=2AJGnY-wo2I Treatment AA and NA- The Fellowship 12 step program- must work through each step to maintain sobriety. Very spiritually based, however has good outcomes for people who do not report a spiritual connection. Meetings conducted by members. Sponsor assigned Good source of social support Other treatment issues: Children removed from their parents care. Can be significant motivator or trigger. Increased risk of abuse for children. Doctor shopping and prescription drug abuse / dependence. Xanax Mandated Treatment Challenging to engage at times Co-occurring treatment- often difficult to find. May not get adequate care on one side. Glossary Dyskinesia- involuntary movements Tonic clonic seizures- formerly known as a grand mal seizure. It is a seizure that affects the entire brain. Nystagmus- fast, uncontrollable movement of the eyesdancing eyes. Lacrimation- Abnormal or excessive secretion of tears. Rhinorrhea- Runny nose Piloerection- good bumps Heroine Nod standing up http://www.youtube.com/watch?v=IcoUuK2pVqs Dope fiend lean http://www.youtube.com/watch? v=6HvKlkS_C7o&feature=endscreen Not in my back yard- meth maintenance http://www.youtube.com/watch?v=2AJGnYwo2I