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

Dissociative Identity Disorder (DID)

• primary disrupted function- coherent sense of self >2 distinct identities

• typical trigger pattern- chronic childhood trauma, especially before age 6

• hallmark clinical clue- gaps in everyday recall plus “voice” dialogue or sudden shifts in handwriting, posture, affect

• first line clinical tasks- stabilization (safety, grounding) before trauma processing; educate on parts

Dissociate Amnesia (with/without fatigue)

• primary disrupted function- autobiographical memory (usually traumatic)

• typical trigger pattern- single catastrophic event or prolonged abuse

• hallmark clinical clue- localized or selective amnesia; may discover self far from home if fugue

• first-line clinical tasks- rule out neurologic causes; gently restore narrative without forced recall

Depersonalization/Derealization Disorder

• primary disrupted function- sense of self or external reality feels unreal

• typical trigger pattern- severe stress, panic, substance use; adolescence onset common

• hallmark clinical clue- “I’m watching my life like a movie”, yet intact reality testing

• first-line clinical tasks- grounding, mindfulness, treat comorbid anxiety; avoid benzodiazepines (worsen detachment)

3 clinical questions that clarify excessiveness (somatic symptom context)

• how much time per day is devoted to bodily monitoring or care-seeking?

• does the worry persist despite adequate medical reassurance?

• is functioning (work, social, physical) limited more by anxiety than by the symptom’s pathophysiology?

Anorexia Nervosa (restricting/binge-purge)

• persistent energy-intake restriction + intense fear of gaining weight + distorted body image

• body weight pattern- underweight

• distinguishing marker- ego-syntonic pride in control; amenorrhea no longer required

• mid-adolescence; 10:1 female:male

• diagnosed on behavior and cognition regardless of BMI

Bulimia Nervosa

• recurrent binge eating with compensatory behavior (vomiting, laxatives, exercise); >1x a week for 3 months

• normal or slightly overweight

• binges feel out of control; shame and secrecy

• late adolescence; female predominance narrowing

Binge-Eating Disorder

• recurrent binge episodes without compensatory behaviors, marked distress

Avoidant/Restrictive Food Intake Disorder (ARFID)

• nutritional/weight failure from sensory aversion, fear of aversive consequence, or low interest- no body image disturbance

• under or normal weight; growth faltering in children

• picky eating becomes medical/socially impairing

• childhood onset; boys slightly more than girls

Pica

• persistent non-nutritive consumption (chalk, soil) > 1 month

• beyond culturally normative practice

• preschoolers, pregnant women, IDD

Rumination Disorder

• repeated regurgitation/re-chewing >1 month

• occurs effortlessly, not nausea-based

• infancy but seen in adults with IDD

Enuresis

• >5 years developmentally

• frequency of 2x week for 3 months or clinically significant distress

• nocturnal subtype most common; diurnal suggests daytime urge or social anxiety

• rule out UTI, diabetes, sleep apnea, seizure; consider ADHD if daytime accidents

Encopresis

• >4 years developmentally

• 1x a month for 3 months

• with constipation/overflow (retentive) vs without constipation (non-retentive)

• abdominal pain, large stool mass on exam = retentive; maltreatment screening for smearing

Insomnia Disorders

• core problem is sleep initiation/maintenance

• takes >30 minutes to fall asleep or wakes >3x a night, 3 nights a week for 3 months

• clear for hyperthyroidism, substance use, restless legs

• strategy: stimulus control, sleep restriction (CBT-I)

Hypersomnolence Disorder

• excessive sleepiness despite >7 hours of sleep

• unrefreshing 9-hour sleeps + involuntary naps

• clear for OSA, depression, narcolepsy

• strategy: sleep hygiene; schedule strategic naps; rule out breathing disorder

Narcolepsy

• REM boundary intrusions

• irrepressible daytime sleep attacks + cataplexy, sleep paralysis

• rule out idiopathic hypersomnia, seizure disorder

• strategy: lifestyle anchors; referral for modafinil, pitolisant

Circadian Rhythm Sleep-Wake Disorders

• misaligned biological clock

• delayed sleep phase: can’t sleep until 3 am; shift work disorder; rotating nights

• rule out insomnia or hypersomnia without clock misalignment

• strategy: light therapy, melatonin timing, work-schedule advocacy

Gender Dysphoria in children

• >6 of 8 indicators for >6 months (ex. strong desire to be other gender, cross-gender roles in play, dislike of one’s sexual anatomy)

• insistence on other-gender pronouns, distress with urination posture

• social transition (name, pronouns, clothing) can markedly reduce distress even before puberty blockers)

Gender Dysphoria in adolescents and adults

• 2 of 6 indicators for >6 months (incongruence between experienced gender and sex characteristics, desire for hormone/surgical affirmation)

• depression or anxiety tied to secondary-sex trait development, binder use, body-focused avoidance

• must distinguish from body dysmorphic disorder (focus is on gendered anatomy, not imagined defect)

ODD

• angry-irritable mood, argumentative/defiant behavior, or vindictiveness toward authority

• >6 months at least 4 symptoms; with >1 non-sibling

• preschool onset common; severity tied to settings (home-only vs. multiple)

• interventions: parent management training; emotion-coaching skills

IED

• recurrent impulsive aggression- verbal or physical- grossly out of proportion

• >2 weekly outbursts for 3 months or >3 serious outbursts in 12 months

• onset after 6; diagnosis requires baseline periods of calm

• interventions: CBT for anger, SSRI or mood stabilizer adjunct

Conduct Disorder

• repetitive violation of rights- aggression, property destruction, theft, serious rule breaches

• 3+ behaviors in past year, 1+ in past 6 months

• child-onset (<10 yrs) predicts worse prognosis than adolescent-onset

• interventions: multisystemic therapy, functional family therapy; treat comorbid ADHD/SUD

Delirium

• acute, potentially reversible, always a medical emergency

• can take hours to days, fluctuates over 24 hours

• attention and awareness is affected first, then memory

• clues: disorganized thinking, reversed sleep-wake, sundowning

• priorities: identify medical cause; frequent reorientation; low-dose antipsychotic if severe agitation

Cluster A (odd-eccentric personality disorders)

• Paranoid, Schizoid, Schizotypal

• signatures: social detachment, perceptual oddity, mistrust

• pitfalls: mislabeling cultural guardedness as paranoia; overlooking prodomal psychosis in schizotypal

Cluster B (dramatic-erratic personality disorders)

• Antisocial, Borderline (frequently co-occurs with PTSD and substance-use disorders), Histrionic, Narcissistic

• signatures: emotional intensity, impulsivity, unstable or grandiose self-image

• pitfalls: stigmatizing “manipulation”; failing to set boundaries; missing ADHD or bipolar overlap

Cluster C (anxious-fearful personality disorders)

• Avoidant, Dependent, Obsessive-Compulsive

• signatures: fear-driven inhibition, need for reassurance/control

• pitfalls: mistaking social anxiety for avoidant PD; confusing OCPD perfectionism with OCT rituals

Personality Disorders diagnosis requirements

impairment in two or more domains:

• cognition (self/other appraisal)

• affectivity (range/intensity)

• interpersonal functioning

• impulse control

Paraphilic Disorders

requires either clinically significant personal distress or behaviors that entail risk of harm to self or non-consenting others, lasting at least 6 months

• Criterion A: recurrent, intense sexual arousal for a specific focus 

• Criterion B: the fantasies, urges, or behaviors cause distress/impairment or have been acted on with a non-consenting person

• If A is met with B, no DSM code

Voyeuristic Disorder

• observing unsuspecting nude/sexual activity

• non-consensual

• age of onset: >15, peaks 15-25

• tasks: risk assessment, CBT-RP, legal education

Exhibitionistic Disorder

• exposing genitals to stranger

• non-consensual

• age of onset: adolescence

• tasks: mandated report if minors targeted; covert sensitization

Frotteuristic Disorder

• touching/rubbing non-consenting person

• onset: mid-adolescence

• tasks: public-space safety plan; impulse-control CBT

coding path- Other Specified 

signals that the clinician knows why full criteria are unmet and states it in the note

coding path- Unspecified

reserved for situations with insufficient information (ex. emergency departments, language barriers) where a working code allows billing but avoids premature pigeonholing