LCSW Prep- Formulation, Diagnosis & Use of the DSM-5

predisposing factors

genetic load, early attachment disruptions, cultural scripts

perpetuating mechanisms

avoidance behaviors, cognitive distortions, systemic barriers, reinforcing family dynamics

precipitating factors

recent losses, traumas, medical illnesses, substance changes

protective factors

personal strengths, spirituality, community resources, insight, treatment motivation

case formulation lens- biological

is there a neurochemical or medical substrate?

case formulation lens- psychological

how do cognitions, emotions, and learning history interact?

case formulation lens- social/systemic

what environmental forces sustain or buffer the distress?

case formulation lens- cultural/spiritual

how does worldview shape symptom meaning and help-seeking?

common exam pitfalls

leap to DSM labels before establishing temporal sequencing, ignoring systemic barriers, overlooking protective elements

risk assessment step 1

detect signals (expressed intent, planning behavior, access to means, major agitation, or sudden withdrawal

risk assessment step 2

weigh vulnerabilities (static-history of attempts, psychosis, TBI; dynamic-current substance use, medication non-adherence, social support, cultural or spiritual prohibitions)

risk assessment step 3

match disposition (safety plan, voluntary hospitalization, involuntary hold, law-enforcement involvement, or adult-protective services report)

pitfall example- believing client denial of suicidal thoughts when collateral reports cutting

re-assess with direct means-based questions, not immediate discharge

pitfall example- calling police before exploring voluntary hospitalization for a non-violent but suicidal client

offer voluntary admission, use involuntary only if refused and risk remains imminent

pitfall example- neglecting to report suspected financial exploitation because “family handles it”

mandated report if suspicion meets statutory threshold

pitfall example- focusing solely on static factors (old attempt) and missing a sharp drop in protective factors (loss of faith community)

update risk level, modify safety plan

DSM-5 Position: early chapters (neurodevelopmental → psychotic)

synaptic pruning, critical-period disruptions → clinician considers genetic syndromes, perinatal insults

DSM-5 Position: mid-manual (mood, anxiety, OCD, trauma)

stress-diathesis models, HPA-axis reactivity) → clinician tracks life events, chronic stress, attachment history

DSM-5 Position: late chapters (neurocognitive, movement, med-induced)

neurodenegeration, iatrogenic factors → check vascular, metabolic, pharmacologic contributors

“other specified” or “unspecified”

capture diagnostic uncertainty while still communicating a service need; when symptom duration is subthreshold or collateral data are pending

differential-diagnosis workflow

1. rule out artifact- is the presentation better explained by intoxication, withdrawal, medication side-effect, or medical illness?

2. assess development- is the behavior normative for the client’s age/cultural stage?

3. identify symptom domain- psychosis, mood, anxiety, somatic, behavioral control, cognition

4. apply DSM gatekeepers- duration thresholds, impairment criteria, and exclusion clauses 

5. layer specifiers- because the manual allows, and often requires, multiple concurrent diagnoses when criteria are independently met

Intellectual Developmental Disorder (IDD)

• global developmental delays in language, motor, and adaptive skills before age 5

• requires both IQ below 70 and deficits in adaptive functioning; rule out severe deprivation or uncorrected sensory loss

• lifelong prognosis

• service implications- level of support specifiers (mild → profound), guide educational planning, guardianship, and social-service eligibility

Communication Disorders (Language, Speech-Sound, Fluency, Social)

• early social reciprocity deficits, restricted interests, sensory anomalies

• differential- hearing impairment, ASD, selective mustism, dialectial variation is not pathology

• prognosis- early speech-language therapy can normalize many cases; pragmatic deficits often persist without social-skills training

ASD

• early social reciprocity deficits, restricted interests, sensory anomalies

• must show both social-communication and restricted/repetitive behavior criteria; no language delay needed under DSM-5

• prognosis- severity specifiers (requiring support → very substantial support) inform insurance coverage and IDEA services

ADHD

• inattention and/or hyperactivity across > 2 settings, onset before 12

• symptom mimicry from anxiety, trauma, sleep apnea, absence seizures; performance vs. capacity disparity due to interests

• often persists into adulthood; combination of behavioral therapy, school accommodation, and medication yields best outcomes

Specific Learning Disorder (SLD)

• persistent academic skill deficits despite intervention (dyslexia, dyscalculia, dysgraphia)

• intelligence-achievement gap no longer required, but academic skills must fall well below age norms

• supports via IEP/504 plans; early phonics-based remediation improves trajectory

Motor Disorders (Developmental Coordinaton Disorder, Stereotypic Movement, Tic Disorders)

• clumsiness, delayed motor milestones, hand-flapping, simple/complex tics

• rule out cerebral palsy, tourette vs. transient tics, methamphetamine-induced movements

• OT, CBIT for tics; prognosis varies- Tourette peaks 9-14yrs then often declines

Brief Psychotic Disorder

• 1 day <1 month

• mood symptoms incidental or absent

• sudden onset, full return to baseline

• golden hours for psychoeducation, relapse prevention

Schizophreniform Disorder

• >1 month < 6 months

• mood incongruent or absent

• meets criterion A schizophrenia but premature to confirm chronicity

• initiate antipsychotic plus prodome monitoring

Schizophrenia

• >6 months, at least 1 month active

• mood episodes brief relative to psychosis

• decline in functioning; negative symptoms prominent (avolition, flat affect, asociality, anhedonia)

• coordinate specialty care within first 2-5 yrs (“critical period”)

Schizoaffective Disorder

• >1 month psychosis + > 2 weeks psychosis without mood sx

• mood symptoms present most of illness

• requires either depressive or bipolar type specifier

• combined antipsychotic and mood-stabilizer/antidepressant

Delusional Disorder

• >1 month

• mood episodes brief

• non-bizarre delusions, relatively intact functioning

• low-dose antipsychotic, CBT for belief modification

Substance/Medication-Induced Psychotic Disorder

• variable (during or soon after exposure)

• N/A for mood-episode relationship

• evidence of substance temporal link; resolves after abstinence

• withdrawal management, relapse prevention

Catatonia (specifier or due to medical)

• >3 catatonic signs

• may occur in mood, psychotic, medical, or developmental conditions

• stupor, mutism, posturing negativism, echolalia

• lorazepam challenge, possible ECT

Coordinated Speciality Care (CSC) models

engaging clients within 18 months of 1st episode with:

• family psychoeducation and partnerships

• supported employment/education

• cognitive-behavioral therapy for psychosis (CBTp)

• metabolic monitoring

Bipolar I Disorder

• major depressive episodes

• >1 manic lifetime episode (depression not required but typical)

• minimum duration- >7 days (hospital)

• marked impact on functioning, often psychotic

• onset in late adolescence-early 20s

Bipolar II Disorder

• major depressive episodes

• >1 hypomanic + >1 major depressive lifetime episodes

• minimum duration- >4 days (hypomania) 

• hypomania non-impairing; depression disabling on functioning

• onset in mid-20s, slight female preponderance

Cyclothymic Disorder

• >2 years (1 yr in youth) of sub-threshold hypomanic & depressive symptoms for lifetime episodes

• minimum duration- symptom-free periods less than 2 months

• fluctuating distress, relational strain on functional impact

• onset in adolescence onward

Substance/Medication-Induced Disorder (Bipolar context)

• mood disturbance during or soon after intox/withdrawal for lifetime episodes

• variable for duration

• linked to substance for functional impact

• any age for onset

Other Specified/Unspecified Disorder (Bipolar context)

• fails strict criteria but clinically significant for lifetime episodes

• variable for duration

• variable for functional impact

• various onset

rapid cycling (bipolar context)

>4 mood episodes in 12 months

Mood stabilizers (Bipolar context)

Lithium (suicide-protective), valproate, carbamazepine- track labs and teratogenic counseling

Atypical Antipsychotics (Bipolar context)

Quatiapine, lurasidone, cariprazine, particularly for mixed or depressive poles

Major Depressive Disorder (MDD)

• temporal pattern- >2 weeks, episodic; >5/9 symptoms include mood or anhedonia

• neurovegetative shifts (sleep, appetite), psychomotor change, guilt, suicidality

• no prior mania/hypomania; exclude bereavement only if criteria not me

• interventions- CBT or IPT; SSRI/SNRI; combined for mod-severe

Persistent Depressive Disorder (Dysthymia)

• >2 years, youth >1, symptom-free less than 2 months

• “double depression” when superimposed MDE

• low grade, insidious onset; often trait-like pessimism, low self-esteem

• intervention- CBT for chronic depression; SSRI/SNRI; augmentation

Disruptive Mood Dysregulation Disorder (DMDD)

• onset < 10 years; dx between 6-18

• >3 outbursts/week, baseline irritable mood

• severe temper outbursts disproportionate to context

• cannot co-diagnose with ODD, intermittent-explosive, or bipolar

• interventions- parent management training, school interventions, SSRI if persistent

Separation Anxiety

• anticipated or actual distance from attachment figures

• minimum symptom span- 4 weeks in youth, 6 months as adult

• key clues- school refusal, nightmares of harm to caregiver; adult form often miscoded as GAD

Selective Mutism

• social settings requiring speech

• minimum symptom span- 1 month beyond first school month

• key clues- speaks freely at home; high social-anxiety overlap

Specific Phobia

• single object or situation

• for at least 6 months

• key clues- immediate panic on exposure; insight intact; limited to trigger

Social Anxiety

• scrutiny or performance

• for at least 6 months

• key clues- fear of humiliation; blushing/tremor; performance-only specifier if limited to public speaking

• rehearses images of humiliation

Panic Disorder

• unexpected panic for at least 1 month fear/avoidance of more attacks

• N/A for duration of attack; 1 month anticipatory

• key clues- nocturnal attacks, ER visits, rule out cardiopulmonary disease

• revolves around catastrophic misinterpretation of bodily sensations

Agoraphobia

• at least 2 situations where escape seems hard

• duration at least 6 months

• key clues- frequent secondary to panic; housebound or needs companion

Generalized Anxiety Disorder (GAD)

• multiple life domains, “free floating” worry

• for at least 6 months, most days

• key clues- muscle tension, restlessness, sleep difficulty; worry hard to control

• features what if scenarios 

OCD

• obsessions (ego-dystonic, intrusive thoughts) and/or compulsions (rituals) recognized as excessive

• childhood onset in 25%; peaks in early adulthood and chronic if untreated

• time-consuming >1 hour a day rituals; compulsion relief → transient anxiety drop

Body Dysmorphic Disorder (BDD)

• preoccupation with perceived defect in appearance; repetitive checking, camouflaging

• onset in adolescence; often post-puberty

• check to see if concern is about weight (rules out eating disorders); shame-driven social avoidance

Hoarding Disorder

• difficulty discarding possessions regardless of value; clutter impairs living areas

• peaks at middle age; often preceded by “saving” childhood behaviors

• no pleasure in accumulation (vs. collecting); distress if forced to discard

Trichotillomania

• recurrent hair-pulling causing hair loss; tension before, relief after

• peaks in puberty; ratio is 10:1 female to male

• occurs during sedentary activities; distinguish from alopecia, OCD (no intrusive fear)

Excoriation (Skin-Picking) Disorder

• repetitive skin picking → lesions; attempts to stop

• onset in adolescence; high comorbidity with OCD, BDD

• not attributable to meth use or dermatologic illness

PTSD

• qualifying stressor- actual/threatened death, serious injury, or sexual violence; direct, witnessed, or vicarious (professional)

• symptoms start at least 1 month after event

• core symptoms- intrusion, avoidance, negative modd/cognition, hyperarousal

Acute Stress Disorder

• same qualifying stressors at PTSD

• 3 days-1 month post trauma

• >9 dissociative intrusive, avoidance, arousal symptoms

• early intervention window; predictive of PTSD

Adjustment Disorders

• any identifiable stressor not life-threatning (job loss, divorce)

• onset <3 months; resolve <6 months once stressor ends

• distress out of proportion and functional impairment

• specify with anxiety, depressed mood, mixed, disturbance of conduct 

RAD

• extreme insufficient caregiving → inhibited attachment

• evident <5 years; onset >9 months

• minimal comfort seeking, emotion blunting

• rule out autism; requires history of neglect

Disinhibited Social Engagement Disorder (DSED)

• same caregiving neglect

• same age anchors as RAD

• indiscriminate sociability, no stranger awareness

• persists into adolescence even if caregiving improves