DSM-IV-TR


I wanted to call this post “advice for taking and passing the LMFT exam” but it turns out, having passed last week, that I don’t have much advice to give. The problem is that the ways the exam is hard are not things you can prepare for. I’ll describe that situation, for what it’s worth, then describe the process of taking the test, and give the few pieces of advice I can offer. Take that advice with several grains of salt, though, because when you pass, they don’t tell you your score. I have no idea if I passed with flying colors or barely scraped by. For reasons I’m about to get into, I wouldn’t be surprised either way. I really can’t say if I over-prepared and rocked it or underprepared and got lucky.

The material you have to know is not that hard. With a few exceptions, it’s the same stuff you learned in your grad school program, the same stuff you’ve been drilling in your internship. The test is hard mostly because the writing is terrible. Have you ever read something that has been passed through several languages in a translator program, then back into English? That is how the questions, and especially the answers, read. Most of them. They often barely make sense and some of it is complete nonsense. I doubt they used the translator trick, so it may be that they looked up the most obscure synonym for each word and then garbled up the grammar a bit to top it off. I would be ashamed to be associated with the writing of that exam. I do not consider it an ethical way to make an exam difficult. Unfortunately, that is the situation.

The second reason it is hard is that you have to read and comprehend all of that garble at lightning speed. I read at a slightly above average speed with high comprehension and I had twelve minutes left at the end to review my marked questions. Twelve minutes left at the end of a four hour test.

So that’s my first piece of advice: If you’re a slower than average reader, see what you can do for special accommodations on time, and definitely if English is your second language. I don’t know what’s available in that way, but look into it and take what you can get.

The third reason is that it’s just difficult to sit and concentrate that hard for four hours without stopping. Your body will hurt, if it has that tendency. If you have body or pain issues I would look into what accommodations they have to offer.

—-

The process of taking the test: I took mine in Riverside, so this may vary, and because you have to take the ethics exam right away now, you probably know all of this stuff already. You can skip this and the next paragraphs. PSI, the testing company has a suite in an office building. You walk into their lobby and the staff signs you in, takes your photo, and you wait a bit. The staff is very nice and professional. There is a rack to hang your coat and you can get a locker. (The PSI materials say that you don’t get a locker, but you can.) They let me take my migraine meds in on a tissue, but you can’t take anything else. I wished I’d worn a long sleeve shirt because it was a bit cool for me and I couldn’t take my sweatshirt in. They provide a pencil and scratch paper. You sit in one of fifteen or twenty cubicles with a PC computer, mouse, and keyboard. It’s pretty quiet. They offer you earplugs but I didn’t need them, and I’m pretty sensitive to noise. You run through some instructions and practice questions to get the hang of it. It’s pretty easy. Then you start the test and have four hours to finish 170 questions. That’s less than 90 seconds per question. There are three or four counters at the top of your screen, counting questions, up and down, and time. I can’t remember if the timer counted up or down or both, but I remember it being pretty easy to use. I would occasionally multiply my number of questions answered by 1.5 to make sure I was on track to get through every question. For example, after answering question 40, I could check that I was well under one hour into the exam. You can take breaks whenever you want, but the clock won’t stop. I took two breaks. The first was about a minute, to eat a few bites of a date bar I left in my coat pocket, about an hour and a half into the exam. The second was to pee, at about three hours in. That took five or six minutes, because the bathroom is down the hall and the staff has to escort you. I’m glad I took the breaks. I imagine that seven or eight extra minutes at the end of the exam would not have been very useful after hours of low blood sugar and holding pee.

If you have any time left, you can go back and look at questions you marked. I had time to look at a few and changed one answer. Then you finish. They make you click “yes” on a few versions of “Yes, I understand this will end my test and I can’t go back” before ending, so you can’t end the test accidentally. You walk back out into the lobby, grab your stuff, and get your results. I think if you fail they tell you your score, but I’m not sure. There is also the possibility that the BBS is re-analyzing how the exam is performing and you won’t find out if you passed for another month or so. That happened to me for my ethics exam, and it’s much nicer to know immediately how you did. I was in a bit of a daze after the exam and walked around the roads near the test center for a while before I felt like driving.

——

To prepare for the exam, I bought the Therapist Development Center’s MFT Clinical Exam package and did their 65 hour (versus 110 hour) track. I can’t say how it compares to Grossman or AATBS because I’ve never seen those packages. I can say that I used a Grossman practice-test package to study for the ethics exam and passed, but I’m pretty sure that I spent too much time studying that way. I basically tried to reverse-engineer the test using the practice tests plus the legal statutes and CAMFT Code of Ethics, which took a long time—a little over 70 hours of dedicated studying. The TDC package helped me avoid rabbit holes and working too long. TDC’s 65-hour track took me 68 hours to complete, plus I did an extra eight hours of study on the DSM-5, having been trained exclusively on the DSM-IV-TR. I made two outlines of the DSM-5, one of timeline information, like how long you need symptoms for each diagnosis, and one for age limit information. (I put those up here and here.) I also spent about four hours reading (and rereading) the CAMFT Code of Ethics, California statutes, and legal/ethics articles from CAMFT’s Therapist magazine archives.

Again, I have no idea how I would have done without studying that way, but I went in feeling as well-prepared as I could have. I barely studied the last couple days before the test because I felt like I knew the material. I remember thinking, “If I don’t pass, I’m not sure what I will do for the next four months, because I already know this stuff.”

So I can recommend the Therapist Development Center material. The extra DSM study didn’t help me that I remember on the exam—the TDC coverage would have been enough. I could probably say the same for the Code of Ethics and statutes reading. I don’t recall the test getting very nit-picky about any of that stuff. That’s not how they made the exam difficult, though I would have preferred it that way. Even if it was extra studying, I feel good about having done it. We MFTs should know that stuff cold.

That was likely the last multi-hour multiple choice exam I’ll ever have to take. I’m fine with that. Now it’s time to focus on setting up my private practice!

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

The structure of Panic and Agoraphobia Disorders diagnostic criteria in the DSM-IV-TR is similar to that of Mood Disorders; there are the “ingredients” of Panic Attack (which I have quoted below from p. 432 of the DSM-IV-TR) and Agoraphobia (quoted from p. 433), and then the Disorders are like recipes, including or excluding the ingredients in different ways. The Disorders are Panic Disorder Without Agoraphobia (quoted from p. 440), Panic Disorder With Agoraphobia (quoted from p. 441), and Agoraphobia Without History of Panic Disorder (quoted from p. 443).

Please remember that you cannot ethically or accurately diagnose yourself or anyone you know, even if you are a mental health professional. I am posting these criteria for general interest, not diagnosis:
Criteria for Panic Attack

Note: A Panic Attack is not a codable disorder. Code the specific diagnosis in which the Panic Attack occurs (e.g., 300.21 Panic Disorder With Agoraphobia [p. 441]).

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

(1)    palpitations, pounding heart, or accelerated heart rate

(2)    sweating

(3)    trembling or shaking

(4)    sensations of shortness of breath or smothering

(5)    feeling of choking

(6)    chest pain or discomfort

(7)    nausea or abdominal distress

(8)    feeling dizzy, unsteady, lightheaded, or faint

(9)    derealization (feelings of unreality) or depersonalization (being detached from oneself)

(10)  fear of losing control or going crazy

(11)  fear of dying

(12)  paresthesias (numbness or tingling sensations)

(13)  chills or hot flushes

Criteria for Agoraphobia

Note: Agoraphobia is not a codable disorder. Code the specific diagnosis in which the Panic Attack occurs (e.g., 300.21 Panic Disorder With Agoraphobia [p. 441] or 300.22 Agoraphobia Without History of Panic Disorder [p. 441]).

A.      Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpe3cted or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crows or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.

Note: consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few specific situations, or social Phobia if the avoidance is limited to social situations.

B.      The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.

C.      The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as social Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).

Diagnostic criteria for 300.01 Panic Disorder Without Agoraphobia

A.      Both (1) and (2):

(1)    recurrent unexpected Panic Attacks (see p. 432)

(2)    at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

(a)    persistent concern about having additional attacks

(b)   worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)

(c)    a significant change in behavior related to the attacks

B.      The absence of Agoraphobia (see p. 433)

C.      The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D.      The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety disorder (e.g., in response to being away from home or close relatives).

Diagnostic criteria for 300.21 Panic Disorder With Agoraphobia

A.       Both (1) and (2):

(1)    recurrent unexpected Panic Attacks (see p. 432)

(2)    at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

(a)   persistent concern about having additional attacks

(b)   worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)

(c)     a significant change in behavior related to the attacks

B.       The presence of Agoraphobia (see p. 433)

C.     The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D.      The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety disorder (e.g., in response to being away from home or close relatives).

Diagnostic criteria for 300.22 Agoraphobia Without History of Panic Disorder

A.      The presence of Agoraphobia (see p. 433) related to fear of developing panic-like symptoms (e.g., dizziness or diarrhea).

B.      Criteria have never been met for Panic Disorder

C.      The disturbance is not due to the direct physiological effects of a substance (e.g.,  a drug of abuse, a medication) or a general medical condition.

D.      If an associated general medical condition is present, the fear described in Criterion A is clearly in excess of that usually associated with the condition.

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

The DSM-IV-TR devotes 84 pages to how to diagnose Mood Disorders. It’s a complex business, and something diagnosticians can take extremely seriously. The criteria for the actual disorders (Depressive Disorders and Bipolar Disorders) are like recipes. The ingredients for those recipes are Mood Episodes (Depressive, Manic, Mixed, or Hypomanic) and “specifiers.” The following are the criteria for the specifiers, which are about severity, accompanying symptoms, and timing aspects. The Criteria for Severity/Psychotic/Remission Specifiers for the Mood Episodes are quoted from the DSM-IV-TR:

Major Depressive Episodes, p. 413

Manic Episodes, p. 415

Mixed Episodes, p. 416

Hypomanic Episodes, p. 417

And the criteria for other Mood Disorder specifiers:

Chronic Specifier, p. 417

Catatonic Features Specifier is from p. 418

Melancholic Features Specifier is from p. 420

Atypical Features Specifier is from p. 422

Postpartum Onset Specifier is from p. 423

Criteria for Longitudinal Course Specifier is from p. 425

Seasonal Pattern Specifier is from p. 427

Rapid-Cycling Specifier is from p. 428

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Major Depressive Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Major Depressive Episode. In Partial Remission and In Full Remission can be applied to the most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode.

.x1–Mild: Few, if any, symptoms in excess of those required to make the diagnosis and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others.

.x2–Moderate: Symptoms between “mild” and “severe.”

.x3–Severe Without Psychotic Features: Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Major Depressive Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Major Depressive Episode lasting less than 2 months following the end of the Major Depressive Episode. (If the Major Depressive Episode was superimposed on Dysthymic Disorder, the diagnosis of Dysthymic Disorder alone is given once the full criteria for a Major Depressive Episode are no longer met.)

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

 

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Manic Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Manic Episode. In Partial Remission and In Full Remission can be applied to the most recent Manic Episode in Bipolar I Disorder only if it is the most recent type of mood episode.

.x1–Mild: Minimum symptoms criteria are met for a Manic Episode

.x2–Moderate: Extreme increase in activity or impairment in judgement.

.x3–Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic themes  of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Manic Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Manic Episode lasting less than 2 months following the end of the Manic Episode.

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Mixed Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Mixed Episode. In Partial Remission and In Full Remission can be applied to a Mixed Episode  in Bipolar I Disorder only if it is the most recent type of mood episode.

.x1–Mild: No more than minimum symptom criteria are met for both a Manic Episode and a Major Depressive Episode.

.x2–Moderate: Symptoms or functional impairment between “mild” and “severe.”

.x3–Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic or depressive themes.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic or depressive themes. of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Mixed Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Mixed Episode lasting less than 2 months following the end of the Mixed Episode.

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

Criteria for Chronic Specifier

Specify if:

Chronic (can be applied to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode)

Full criteria for a Major Depressive Episode have been met continuously for at least the past 2 years.

Criteria for Catatonic Features Specifier

Specify if:

With Catatonic Features (can be applied to the current or most recent Major Depressive Episode, Manic Episode, or Mixed Episode in Major Depressive Disorder, Bipolar Disorder, or Bipolar II Disorder)

The clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli)

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movements as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Criteria for Melancholic Features Specifier

Specify if:

With Melancholic Features (can be applied to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode)

A. Either of the following, occurring during the most severe period of the current episode:

(1) loss of pleasure in all, or almost all, activities

(2) lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)

B. Three (or more) of the following:

(1) distinct quality of depressed mood (i.e., the depressed mood is experienced as distinctly different from the kind of feeling experienced after the death of a loved one)

(2) depression regularly worse in the morning

(3) early morning awakening (at least 2 hours before usual time of awakening)

(4) marked psychomotor retardation or agitation

(5) significant anorexia or weight loss

(6) excessive or inappropriate guilt

Criteria for Atypical Features Specifier

Specify if:

With Atypical Features (can be applied when these features predominate during the most recent 2 weeks of a current Major Depressive Episode in Major Depressive Disorder or in Bipolar I or Bipolar II Disorder when a current Major Depressive Episode is the most recent type of mood episode, or when these features predominate during the most recent 2 years of Dysthymic Disorder; if the Major Depressive Episode is not current, it applies if the feature predominates during any 2-week period)

A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events)

B. Two (or more) of the following features:

(1) significant weight gain or increase in appetite

(2) hypersomnia

(3) leaden paralysis (i.e., heavy, leaden feelings in arms or legs)

(4) long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment

C. Criteria are not met for With Melancholic Features or With Catatonic Features during the same episode.

Criteria for Postpartum Onset Specifier

Specify if:

With Postpartum Onset (can be applied to the current or most recent Major Depressive, Manic, or Mixed Episode in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder)

Onset of episode within 4 weeks postpartum

Criteria for Longitudinal Course Specifiers

Specify if (can be applied to Recurrent Major Depressive Disorder or Bipolar I or II Disorder):

With Full Interepisode Recovery: if full remission is attained between the two most recent Mood Episodes

Without Full Interepisode Recovery: if full remission is not attained between the two most recent Mood Episodes

Criteria for Seasonal Pattern Specifier

Specify if:

With Seasonal Pattern (can be applied to the pattern of Major Depressive Episodes in Bipolar I disorder, Bipolar II Disorder, or Major Depressive Disorder, Recurrent)

A.      There has been a regular temporal relationship between the onset of Major Depressive Episodes in Bipolar I or Bipolar II Disorder or Major Depressive Disorder, Recurrent, and a particular time of the year (e.g., regular appearance of the Major Depressive Episode in the fall or winter).

Note: Do not include cases in which there is an obvious effect of seasonal related psychosocial stressors (e.g., regularly unemployed every winter).

B.      Full remissions (or a change from depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring).

C.      In the last 2 years, two Major Depressive Episodes have occurred that demonstrate the temporal seasonal relationships defined in Criteria A and B, and no nonseasonal Major Depressive Episodes have occurred during that same period.

D.      Seasonal Major Depressive Episodes (as described above) substantially outnumber the nonseasonal Major Depressive episodes that may have occurred over the individual’s lifetime.

Criteria for Rapid-Cycling Specifier

Specify if:

With Rapid Cycling (can be applied to Bipolar I Disorder or Bipolar II Disorder)

At least four episodes of a mood disturbance in the previous 12 months that meet criteria for a Major Depressive, Manic, Mixed, or Hypomanic Episode.

Note: Episodes are demarcated either by partial or full remission for at least 2 months or a switch to an episode of opposite polarity (e.g., Major Depressive Episode to Manic Episode).

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

I usually post a prevalence-rate map from Wikipedia along with diagnostic criteria. For Bipolar Disorder, though, Wikipedia currently has a map of “age-standardised disability-adjusted life year (DALY) rates.” (Yellow countries have something like two-thirds the DALY rates from Bipolar Disorder of the red countries.)

Bipolar_disorder_world_map_-_DALY_-_WHO2002

DALY is basically trying to measure how costly an affliction is, as opposed to just how many people experience it. Perhaps this is why it looks so much worse in poorer countries than rich ones, quite the opposite of how Major Depressive Disorder prevalence map looks. I’d still like to look at prevalence. Can anyone point me to a good prevalence map?

As you will see, there are a bunch of versions of Bipolar Disorder. The basic ingredients of them are called Mood Episodes (which I have here): Depressive, Manic, Mixed, and Hypomanic Episodes. There are also a whole bunch of “specifiers,” which are used to describe severity, extra features, and timing (which I will link to at some point). The criteria quoted in this post are basically recipes of Episodes and specifiers.

Here are the diagnostic criteria, directly quoted from the DSM-IV-TR, for Bipolar I Disorders (pp. 388-392), Bipolar II Disorder (p. 397),  and Cyclothymic Disorder (p. 400). There is a final Bipolar Disorder Not Otherwise Specified available to diagnosticians who suspect a Bipolar Disorder in a client that doesn’t fit any of the diagnostic criteria. I can’t post criteria for BD NOS, though, because there aren’t any.

Diagnostic criteria for 296.0x Bipolar I Disorder, Single Manic Episode

A. Presence of only one Manic Episode (see p. 362) and no past Major Depressive Episodes.

Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms.

B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify if:

Mixed: if symptoms meet criteria for Mixed Episode (see p. 365)

If the full criteria are currently met for a Manic, Mixed, or Major Depressive Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Manic, Mixed, or Major Depressive Episodespecify the current clinical status of the Bipolar I Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Diagnostic criteria for 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic

A. Currently (or most recently) in a Hypomanic Episode (see p. 368).

B. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.4x Bipolar I Disorder, Most Recent Episode Manic

A. Currently (or most recently) in a Manic Episode (see p. 362)

B. There has previously been at least one Major Depressive Episode (see p. 356), Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Manic Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Manic Episodespecify the current clinical status of the Bipolar I Disorder and/or features of the most recent Manic Episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.6x Bipolar I Disorder, Most Recent Episode Mixed

A. Currently (or most recently) in a Mixed Episode (see p. 365).

B. There has previously been at least one Major Depressive Episode (see p. 365), Manic Episode, (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Mixed Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Mixed Episodespecify the current clinical status of the Bipolar I Disorder and/or features of the most recent Mixed Episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.5x Bipolar I Disorder, Most Recent Episode Depressed

A. Currently (or most recently) in a Major depressive Episode (see p. 365).

B. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Major Depressive Episodespecify the current clinical status of the Bipolar I Disorder and/or features of the most recent Major Depressive Episode:

In Partial Remission, In Full Remission (see p. 414)

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.7 Bipolar I Disorder, Most Recent Episode Unspecified

 A. Criteria, except for duration, are currently (or most recently) met for a Manic (see p. 362), a Hypomanic (see p. 368), a Mixed (see p. 365), or a Major Depressive Episode (see p. 356).

B. There has previously been at least on Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abus, a medication) or a general medical condition (e.g., hypothyroidism).

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 424)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.89 Bipolar II Disorder

A. Presence (or history) of one or more Major Depressive Episodes (seep. 356).

B. Presence (or history) of at least one Hypomanic Episode (see p. 368).

C. There has never been a Manic Episode (see p. 362) or a Mixed Episode (see p. 365).

D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify current or most recent episode:

Hypomanic:  if currently (or most recently) in a Hypomanic Episode (see p. 362)

Depressed:  if currently (or most recently) in a Major Depressive Episode (see p. 356)

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)     Note: Fifth-digit codes specified on p. 413 cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Hypomanic or Major Depressive Episodespecify the current clinical status of the Bipolar II Disorder and/or features of the most recent Major Depressive Episode (only if it is the most recent type of mood episode):

In Partial Remission, In Full Remission (see p. 414)     Note: Fifth-digit codes specified on p. 413 cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 301.13 Cyclothymic Disorder

A. For at least 2 years, the presence of numerous periods with hypomanic symptoms (see p. 368) and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode.     Note: In children and adolescents, the duration must be at least 1 year.

B. During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.

C. No Major Depressive Episode (p. 356), Manic Episode (p. 362), or Mixed Episode (see p. 365) has been present during the first 2 years of the disturbance.

Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may be superimposed Manic or Mixed Episodes (in which case both Bipolar I Disorder and Cyclothymic Disorders may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II Disorder and Cyclothymic Disorder may be diagnosed).

D. The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

Major Depressive Disorder is one of the most common diagnoses given in the mental health field, almost 15 million adults at a time in the US, according to NIHM. The DSM-IV-TR says that it occurs equally throughout ethnicities, education and income strata, and for married and unmarried people. It does not occur equally by gender, however, with something like three times as many women as men carrying the diagnosis. It’s also not spread equally by nationality. Here’s a Wikipedia map of the distribution. The red countries have twice as much Major Depressive Disorder:

800px-Unipolar_depressive_disorders_world_map_-_DALY_-_WHO2004

Here are the diagnostic criteria for Major Depressive Disorder, first Single Episode then Recurrent, word for word quoted from the DSM-IV-TR, pages 375 and 376. Note that most of the diagnostic action happens in the criteria for Major Depressive Episode, not Major Depressive Disorder. Also, it is interesting (and frustrating, in my case) that most prescribers and a great many diagnosticians use Major Depressive Episode’s criteria A and B, but disregard criteria C, D and E. That is, the symptom lists are considered important but the disqualification by environmental and historical factors are not.

Diagnostic criteria for 296.2x Major Depressive Disorder, Single Episode

A.      Presence of a single Major Depressive Episode (see p. 356)

B.      The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophreniform disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C.      There has never been a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368). Note:   This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects  of a general medical condition.

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a  Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Diagnostic criteria for 296.3x Major Depressive Disorder, Recurrent

A.      Presence of two or more Major Depressive Episodes (see p. 356)

Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.

B.      The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizzophreniform disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C.      There has never been a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368). Note:   This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects  of a general medical condition.

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a  Major Depressive Episodespecify the current clinical status of the Major Depressive Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

These “Mood Episodes” are the building blocks for the DSM‘s major “Mood Disorders”: Major Depressive Disorder, Bipolar I Disorder, and Bipolar II Disorder. That is, the experiences described below are necessary but not necessarily sufficient to get you one of the big Mood Disorder diagnoses. Please do not use this post to diagnose yourself or anyone else you know. (Read my disclaimer here.)

These are word-for-word from the DSM-IV-TR, page 356 for Major Depressive Episode, page 362 for Manic Episode, page 365 for Mixed Episode, and page 368 for Hypomanic Episode.

Criteria for a Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

(1)    depressed mood most of the day, nearly every day, as indicated by either subsjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

(2)    markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3)    significant weight loss when not dieting or weight gain (e.g., a  change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4)    insomnia or hypersomnia nearly every day

(5)    psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6)    fatigue or loss of energy nearly every day

(7)    feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

(8)    diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

(9)    recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B.      The symptoms do not meet criteria for a  Mixed Episode (see p. 365).

C.      The symptoms are not due to the direct distress or impairment in social, occupational, or other important areas of functioning

D.      The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abus, a medication) or a general medical condition (e.g., hypothyroidism).

E.       The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Criteria for a Manic Episode

A.      A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration of hospitalization is necessary).

B.      During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

(1)    inflated self-esteem or grandiosity

(2)    decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3)    more talkative than usual or pressure to keep talking

(4)    flight of ideas or subjective experience that thoughts are racing

(5)    distractibility (i.e., attention to easily drawn to unimportant or irrelevant external stimuli)

(6)    increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7)    excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C.      The symptoms do not meet criteria for a Mixed Episode (see p. 365)

D.      The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

E.       The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Criteria for Mixed Episode

A.      The criteria are met both for a Manic Episode (see p. 362) and for a Major Depressive Episode (see p. 365) (except for duration) nearly every day during at least a 1-week period.

B.      The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others., or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

C.      The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Criteria for Hypomanic Episode

A.      A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.

B.      During the period of mood disturbance, three (or more) of the following symptoms have persisted (four of the mood is only irritable) and have been present to a significant degree:

(1)    inflated self-esteem or grandiosity

(2)    decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3)    more talkative than usual or pressure to keep talking

(4)    flight of ideas or subjective experience that thoughts are racing

(5)    distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

(6)    increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7)    excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C.      The episode is associated with an  unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

D.      The disturbance in mood and the change in functioning are observable by others.

E.       The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

F.       The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

The Diagnostic and Statistical Manual of Mental Disorders is a giant catalog of behaviors and other complaints that cause people to suffer psychologically. If a person claims or admits to having a constellation of problems which fits one of the categories in the DSM, they can be diagnosed with that Mental Disorder. Most people who make these diagnoses as part of their living take this process very seriously, distinguishing between subtypes of ADHD in a client with the same seriousness as a doctor distinguishing between subtypes of breast cancer in a patient. This book has the answers. It is like the Bible for mental health diagnosticians.

Every decade or so, we get a new version of our Bible. Here are the six versions we’ve had since 1958.

DSMs

We are about to get a new version this spring. This change-over is both exciting and awkward in a way that I don’t imagine new versions of other Bibles can be. When a new version of the Christian Bible come out, I imagine that the impact is mostly academic, and the new version may or may not catch on. With a new DSM, there is no choice for diagnosticians or their clients. In 1973, you could diagnose someone with Homosexuality Disorder. In 1975, you could not. The debate was over.

More often than disappearing, new disorders become available. Asperger’s Disorder, for example, appeared in version IV, in 1994. At other times the categories change in big ways, such as the much-talked-about removal of Asperger’s Disorder in the upcoming version V in favor of a more inclusive “Autism Spectrum.”

The awkwardness of this process is especially salient to me, just starting my internship as a family therapist. Since I live in California, I must do my 3,000 client-contact hours for licensure at a community clinic, which means I have to diagnose each of my clients with a qualifying Mental Disorder. To that end, I have been boning up on my diagnostic criteria in the DSM-IV-TRI have to be really good at this to get the resources flowing for my clients. At the same time, I am aware that in a matter of weeks I will be learning not only new criteria and new Mental Disorders, but a whole new diagnostic process spelled out in the DSM-V.

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