Treating Co-Occurring Mood & Anxiety Disorders with Substance Use Disorders

Treating Co-Occurring Mood &
Anxiety Disorders with
Substance Use Disorders

Glenn Duncan LPC, LCADC, CCS, ACS

Copyright © 2012, Glenn Duncan Do not reproduce any workshop materials without express written consent.

Evidence Based Treatment Practices
 At the treatment level, interventions that have their own
evidence to support them as EBPs are frequently a part of a
comprehensive and integrated response to persons with co-
occurring disorder.

 These interventions include:
 Psychopharmacological Interventions
 Motivational Interventions
 Cognitive/Behavioral Interventions
 Relaxation/Stress Inoculation Interventions
 Dialectical Behavior Therapy/Mindfulness Interventions

 At the program level, the following models have an evidence base for
producing positive clinical outcomes for persons with Co-occurring
disorders:

 Modified Therapeutic Communities - Individualized treatment, including
lengths of stay tailored to the person's needs, is especially important
due to the complexity of possible problems. In addition, TC clinical and
management activities may need to be modified in terms of disciplinary
sanctions, peer interactions, and degree of confrontation in groups.
They also provide access to mental health and social services for
individuals with co-occurring mental illness and substance abuse

 Integrated Dual Diagnosis Treatment - This treatment approach helps
people recover by offering both mental health and substance abuse
services at the same time and in one setting.

 Assertive Community Treatment – ACT programs integrate behavioral
treatment for more severe mental health disorders such as
schizophrenia. ACT emphasizes more intense outreach, highly
individualized approaches to clients, and smaller caseloads.

 Eye Movement Desensitization and Reprocessing – EMDR is a
comprehensive, integrative psychotherapy approach. During treatment
various procedures and protocols are used to address the entire clinical
picture. One of the procedural elements is "dual stimulation" using
either bilateral eye movements, tones or taps. EMDR has been
recognized as being effective with Post Traumatic Stress Disorder.
Only a licensed mental health professional can be trained in EMDR.

 Cognitive Behavioral Therapy – CBT is designed to modify harmful
beliefs and maladaptive behavior. CBT is the most effective form of
therapy for anxiety and mood disorders. We will address CBT in more
detail later in this presentation.

 Mindfulness – Mindfulness is the capacity to pay attention, non-
judgmentally, to the present moment. It helps individuals accept and
tolerate the powerful emotions they may feel when challenging their
habits or exposing themselves to upsetting situations.

 Dialectical Behavior Therapy (DBT) – Originally devised by Marsha
Linehan at the University of Washington in Seattle for the treatment of
Borderline Personality Disorders, DBT combines standard cognitive-
behavioral techniques for interpersonal effectiveness, emotion
regulation and reality-testing with concepts of distress tolerance,
acceptance, and mindfulness.

 Motivational Interviewing (MI) – Motivational Interviewing is intended
to resolve ambivalence and getting the client moving along the path to
change. The goal of the first part of therapy is to build motivation for
change. The assumption in this part of therapy is that the client is
ambivalent, and in the contemplation or precontemplation stage.

EBTP - Mindfulness
 Mindfulness – Mindfulness is the capacity to pay attention, non-
judgmentally, to the present moment.

 Mindfulness is all about living in the moment, experiencing one's
emotions and senses fully, yet with perspective.

 It helps individuals accept and tolerate the powerful emotions they may
feel when challenging their habits or exposing themselves to upsetting
situations.

 The concept of mindfulness and the meditative exercises used to teach
it are derived from traditional Buddhist practice, and appears
particularly useful in working with clients with either sub-acute anxiety
or anxiety disorders.

EBTP – Defining Mindfulness
 Mindfulness has been defined as bringing one’s complete attention to the
present experience on a moment-to-moment basis.

 It has also been defined as paying attention in a particular way: on
purpose, in the present moment, and nonjudgmentally, and involves a kind
of non-elaborative, nonjudgmental, present-centered awareness in which
each thought, feeling, or sensation that arises in one’s consciousness and is
acknowledged and accepted as it is.

 Bishop, Lau, et. al., offered a two-component model of mindfulness:
n The first component [of mindfulness] involves the self-regulation of
attention so that it is maintained on immediate experience, thereby
allowing for increased recognition of mental events in the present
moment.
n The second component involves adopting a particular orientation
toward one’s experiences in the present moment, an orientation that is
characterized by curiosity, openness, and acceptance.

What is Mindfulness?
 Mindfulness includes the following qualities:

 Non-judgmental awareness
 Alert yet relaxed consciousness
 Compassionate witnessing of experience
 Curiosity

 Mindfulness supports and enhances:

 Development of a witness stance
 Acceptance and tolerance of strong feelings
 Compassion for self and others
 Resilience (the ability to rebound from adversity)
 Relaxation
 Peace of mind

What is Mindfulness – Witness Stance
 What exactly does developing a “witness stance” mean with mindfulness?

 The Witness is the part of your mind that watches - that is aware of thinking.
Since the Witness is beyond the ego, it is not caught up in judging and is thus
content in any situation. Another name for the Witness is the Self, or the
unconditioned mind.

 Witnessing is the observation of thoughts, emotions and images. Make no
attempt to change the thoughts or images in any way. Simply observe and label
them. On their own, they will arise, have a certain duration, and then dissolve.

 This part of your self that is observing and labeling the thinking and images.
This is called the Witness Consciousness, or the energy of Mindfulness - and is
the part of our mind that remains forever untouched by its contents - by the
thoughts and images arising within it.

 A traditional metaphor for this aspect of mind is that it is similar to the deepest
part of an ocean - which remains calm, still & silent, even if at its surface, waves
(of thinking, emotion, or sensation) are raging.

EBTP – Dialectical Behavior Therapy
 Dialectical Behavior Therapy (DBT) – Originally devised by Marsha
Linehan at the University of Washington in Seattle for the treatment of
Borderline Personality Disorders, DBT combines standard cognitive-
behavioral techniques for interpersonal effectiveness, emotion
regulation and reality-testing with concepts of distress tolerance,
acceptance, and mindfulness.

 DBT was developed initially to treat suicidality in adults with borderline
personality disorder; however, it now is being used effectively in
adolescents with similar self-harm behaviors as well as other co-
occurring psychiatric illnesses such as depression and anxiety.

 DBT is an empirically supported technique, meaning that it has been
clinically tested for its effectiveness in adolescents and adults.

 Mindfulness is one of the core concepts behind all elements of DBT. It
is considered a foundation for the other skills taught in DBT, because it
helps individuals accept and tolerate the powerful emotions they may
feel when challenging their habits or exposing themselves to upsetting
situations.

 The concept of mindfulness and the meditative exercises used to teach
it are derived from traditional Buddhist practice, though the version
taught in DBT does not involve any religious or metaphysical concepts.

 Within DBT it is the capacity to pay attention, non-judgmentally, to the
present moment; about living in the moment, experiencing one's
emotions and senses fully, yet with perspective.

"What" skills
Observe - This is used to non-judgmentally observe one’s environment
within or outside oneself. It is helpful in understanding what is going on in
any given situation.

Describe - This is used to express what one has observed with the
observe skill. It is to be used without judgmental statements. This helps
with letting others know what you have observed.

Participate - This is used to become fully involved in the activity that one
is doing. To be able to fully focus on what one is doing.

"How" skills
Non-judgmentally - This is the action of describing the facts, and not
thinking about what’s “good” or “bad”, “fair”, or “unfair.” These are
judgments because this is how you feel about the situation but isn’t a
factual description. Being non-judgmental helps to get your point across in
an effective manner without adding a judgment that someone else might
disagree with.

One-mindfully - This is used to focus on one thing. One-mindfully is
helpful in keeping your mind from straying into emotion mind by a lack of
focus.

Effectively - This is simply doing what works. It is a very broad-ranged
skill and can be applied to any other skill to aid in being successful with
said skill.

Distress tolerance

Many current approaches to mental health treatment focus on changing
a person’s thoughts, feelings and/or belief systems regarding distressing
events and circumstances.

They have paid little attention to accepting, finding meaning for, and
tolerating distress.

Dialectical behavior therapy emphasizes learning to bear pain skillfully.

The goal is to become capable of calmly recognizing negative situations
and their impact, rather than becoming overwhelmed or hiding from them.

Distress tolerance

Distract with ACCEPTS - This is a skill used to distract oneself temporarily
from unpleasant emotions.
n Activities - Use positive activities that you enjoy.
n Contribute - Help out others or your community.
n Comparisons - Compare yourself either to people that are less
fortunate or to how you used to be when you were in a worse state.
n Emotions (other) - cause yourself to feel something different by
provoking your sense of humor or happiness with corresponding
activities.
n Push away - Put your situation on the back-burner for a while. Put
something else temporarily first in your mind.
n Thoughts (other) - Force your mind to think about something else.
n Sensations (other) – Do something that has an intense feeling other
than what you are feeling, like a cold shower or eating a spicy food.

Distress tolerance

Self-soothe - This is a skill in which one behaves in a comforting,
nurturing, kind, and gentle way to oneself. You use it by doing something
that is soothing to you. It is used in moments of distress or agitation.

IMPROVE the moment - This skill is used in moments of distress to help
one relax. Imagery, Meaning, Prayer, Relaxation, One thing in the
moment, Vacation (brief) - Take a break from it all for a short period of
time, and Encouragement

Pros and cons - Think about the positive and negative things about not
tolerating distress.

Distress tolerance

Radical acceptance - Let go of fighting reality. Accept your situation for
what it is.

Turning the mind - Turn your mind toward an acceptance stance. It
should be used with radical acceptance.

Willingness vs. willfulness - Be willing and open to do what is effective.
Let go of a willful stance which goes against acceptance. Keep your eye on
the goal in front of you.

Emotional Regulation

Dialectical behavior therapy skills for emotion regulation include:
1. Identify and label emotions
2. Identify obstacles to changing emotions
3. Reduce vulnerability to emotion mind
4. Increase positive emotional events
5. Increase mindfulness to current emotions
6. Take opposite action than that emotion that the situation evoked
7. Apply distress tolerance techniques

Other skills of emotional regulation include understanding the story of
the emotion, addressing ineffective health habits, mastering one skill at a
time, problem solving when emotions are justified and learning to observe
and experience your emotion and let it go.

Interpersonal Effectiveness

Interpersonal response patterns taught in DBT skills training are very similar to
those taught in many assertiveness and interpersonal problem-solving classes. They
include effective strategies for asking for what one needs, saying no, and coping
with interpersonal conflict.

Interpersonal effectiveness focuses on situations where the objective is to change
something (e.g., requesting that someone do something) or to resist changes
someone else is trying to make (e.g., saying no).

The skills taught are intended to maximize the chances that a person’s goals in a
specific situation will be met, while at the same time not damaging either the
relationship or the person’s self-respect.

Skills including helping people get what they want when asking; aiding clients in
maintaining his or her relationships, whether they are with friends, coworkers,
family, romantic partners, etc.; and aiding oneself in maintaining their own self
respect.

EBTP – Motivational Interviewing

1. Assess Motivation, which consists of the following:
- Importance – the extent to which one wants, desires, or wills
change.
- Readiness – what is the priority level of the presenting problem(s).
- Confidence – self-efficacy, or the perceived ability to make a change.

2. Ask open ended questions to the client in response to their answers during
the assessment period.
- (e.g., “What are some other ways marijuana has interfered with
other areas that are important to you?” versus “Is marijuana a
problem for you?”)

3. Respond Reflectively (examples):
- “It sounds like you are saying …”
- “The way you see your drinking is …”
- “From your point of view, the good part about using marijuana is …”
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MI - Stages of Readiness for Change
 Precontemplation – The client is not ready to change and
identification with the “problem” is marked with positive
associations. Goal is to get client to form some ambivalence
regarding problem.

 Contemplation – Ambivalence exists with the client regarding
problem (the association with the identified problem are now
good and bad). Goal is to move the client into preparation
stage.

 Preparation – Client has substantially resolved ambivalence and
prepares to commit to a change in the problem behavior. Goal
is to move the client into the action stage.

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MI - Stages of Readiness for Change
 Action – The client has committed to specific actions intended to bring
about change, but needs help in maintaining this level of change. Goal is
to provide client with help in this area and work client towards next stage.

 Maintenance – The client enters the point of being able to sustain the
changes accomplished previously. Replacing problem behaviors with new,
healthy life-style.

 Termination – Person exits the cycle of change without fear of relapsing to
previous behavior. Much debate over whether certain problems can be
terminated. (Termination needs the following: a new self image; no
temptation in any situation; solid self-efficacy; and a healthier lifestyle)

 Relapse/Recycling – Relapse to one of the first three stages of change.
Expectable setbacks and hopefully learn from relapse before committing to
a new cycle of action. Multidimensional assessment to explore relapse
reasons.

23

Principles of Motivational Interviewing
 The strategies of Motivational Interviewing are more persuasive than
coercive, more supportive than argumentative.

 The counselor seeks to create a positive atmosphere that is conducive
to change.

 The overall goal is to increase the client’s intrinsic motivation, so that
change arises from within, rather than being imposed from without.

There are 5 general principles underlying motivational interviewing:
8. Express empathy
9. Develop discrepancy
10. Avoid Argumentation
11. Roll with resistance
12. Support self-efficacy 24

Principle – Express Empathy
 Empathy is NOT an ability to identify with a person’s
experiences.

 Empathy is a learnable skill for understanding another’s
meaning through reflective listening, whether or not you’ve had
similar experiences yourself. This is done without judging,
criticizing or blaming … but with acceptance.

 Empathic listening requires sharp attention to each new client
statement, and a continual generation of hypotheses as to the
underlying meaning.

 Your interpretation as to the meaning is reflected back to the
client, often adding to the content that was overtly stated.

25

Principle – Develop Discrepancy
 Create and amplify, in the client’s mind, a discrepancy between
present behavior and broader goals.

 Motivation for change is created when people perceive a
discrepancy between their present behavior and important
personal goals.

 ME Therapist wants to develop discrepancy, make use of it,
increase it, and amplify it until the discrepancy overrides
attachment to the present behavior.

 This change needs to occur within the client (not external
forces), the client should present the arguments for change.

26

Principle – Avoid Argumentation
 A key principle to MET is to avoid arguments and head-to-head
confrontations.

 One place that arguments are very likely to emerge is in regard
to the applicability of a diagnostic label. Some counselors place
great importance on a client’s willingness to “admit” to a label
such as “alcoholic”.

 AA the emphasis is more on self-recognition. “We do not like to
pronounce any individual as alcoholic, but you can quickly
diagnose yourself.” (Bill W.)

 Resistance is a signal for the therapist to change strategies.

27

Principle - Roll with Resistance
 Reluctance and ambivalence are not opposed, but are
acknowledged by the therapist to be natural and
understandable.

 The therapist does not impose new views or goals. Rather, the
client is invited to consider new information and is offered new
perspectives.

 Rolling with resistance includes involving the client actively in
the process of problem solving. The client is a valuable
resource in finding the solution to their problems.

28

Principle – Support Self-Efficacy
 Self-efficacy is a person’s belief in his/her ability to carry out
and succeed with a specific task.

 General goal of MET is to increase the client’s perceptions of
his/her capability to cope with obstacles and to succeed in
change.

 The client not only can, but must make this change for
themselves.

 There is hope in the range of alternative approaches available.
Thus a person who has failed in the past, may not have found
the right approach.

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Co-Occurring Further Defined
In the substance abuse field specifically, co-occurring usually refers
to the following conditions existing with a DSM-IV-TR substance
abuse or dependence disorder.

 Psychological illness

 Criminality including Domestic Violence

 Developmental Disabilities

 Chronic illness (medical)
- Many of the more conservative definitions of co-occurring
disorders tend to shy away from this last category.
- Conservative definitions tend to strictly apply mental health
related disorders found in the DSM-IV-TR as the disorders
(other than substance abuse/dependence) that define “co-
occurring”.

3 Epidemiological Models

 In the first model, psychiatric disorders lead to the use of drugs,
which then can lead to abuse or dependence usage.

 It may be that adverse parental factors are risk factors for both
psychiatric disorders and drug use.

 Many researchers have shown that those diagnosed with
depression are particularly vulnerable to drug abuse. Depressive
symptoms have been found to be associated with later drug use.

 Conduct disorders/Oppositional Defiant Disorders have also been
found to increase the risk of drug use in both earlier and later
adolescence.


 The second possible model postulates that psychiatric disorders
and drug use are correlated because both conditions share
common etiological factors. Thus both problems are caused by
these factors and not related to the onset of the occurrence of
one or the other.

 Predisposing biological or genetic vulnerabilities, brain deficits,
disorders of neurotransmitter functioning or metabolism.

 Psychosocial factors include risks from the broad socio-cultural
context or from peer, family, and personality domains. For
example early exposure to stress or trauma.


 A third possible model would be that drug use leads to certain
psychiatric disorders, perhaps as a result of the
psychopharmacological or toxic effects of drugs of abuse on
brain functioning or metabolism, or drug effects on
psychological functioning.

 Drugs of abuse can cause abusers to experience one or more
symptoms of another mental illness. Though research is more
sparse on this etiological theory, the premise is that some
latent, or subclinical symptomatology can be exacerbated by
drug use, causing the once subclinical features to take on
clinical feature even though the drug use has
decreased/stopped.

Defining Differential Diagnosis
 "Differential diagnosis" is the method by which a clinician
determines what [DSM-IV-TR] disorder caused a client's
symptoms.

 The clinician considers all relevant potential causes of the
symptoms and then eliminates alternative causes based on a
clinical interview, use of standardized assessment tool(s) that
provide a DSM-IV-TR diagnosis, and a thorough case history
using corroborative information from significant people in the
client’s life.

 Thus differential diagnosis is the determination of which of two
or more disorders with similar symptoms is the one from which
the client is suffering, by a systematic comparison and
contrasting of the clinical findings.

Differential Diagnosis as Used by the DSM
 The DSM has a section for each disorder, or at times class of disorders
(e.g., substance intoxication, covering a group of substances) which
they entitle “Differential Diagnosis”.

 In this section they discuss the disorder, or class of disorders, being
discussed and how they are distinguished behaviors that are NOT
classified as disorders. For example:

 “Substance-Related Disorders are distinguished from non-
pathological substance use (e.g., “social” drinking) and from the
use of medications for appropriate medical purposes by the
presence of a pattern of multiple symptoms occurring over an extended
period of time (e.g., tolerance, withdrawal, compulsive use) or the
presence of substance-related problems (e.g., medical complications,
disruption in social and family relationships, vocational or financial
difficulties, legal problems). Repeated episodes of Substance
Intoxication are almost invariably prominent features of Substance
Abuse or Dependence. However, one or more episodes of
Intoxication alone are not sufficient for a diagnosis of either Substance
Dependence or Abuse.”


Differential Diagnosis (continued):

 In this section they can also discuss the disorder, or class of disorders,
being discussed and how they ARE distinguished from other disorders
(of the same class) in the DSM. For example in discussing the
differential diagnosis of substance intoxication:

 “It may sometimes be difficult to distinguish between Substance
Intoxication and Substance Withdrawal. If a symptom arises
during the time of dosing and then gradually abates after dosing stops,
it is likely to be part of Intoxication. If the symptom arises after
stopping the substance , or reducing its use, it is likely to be part of
Withdrawal.”


Differential Diagnosis (continued):

 Finally, in this section they can discuss the disorder, or class of
disorders, being discussed and how they ARE distinguished from other
disorders, diseases or conditions outside of the DSM. For example:

 “Many neurological (e.g., head injuries) or metabolic conditions
produce symptoms that resemble, and are sometimes misattributed to,
Intoxication or Withdrawal (e.g., fluctuating levels of consciousness,
slurred speech, in-coordination). The symptoms of infectious diseases
may also resemble Withdrawal from some substance (e.g., viral
gastroenteritis [stomach flu] can be similar to Opioid Withdrawal). If
the symptoms are judged to be a direct physiological consequence of a
general medical condition, the appropriate Mental Disorder Due to a
General Medical Condition should be diagnosed.”

Case – The Innkeeper
Andy, aged 34, was admitted to the hospital only an hour ago.
He understands the questions put to him, but cannot quite
hear some of them, and gives a rather absentminded
impression. He states his name and age correctly …. Yet he
does not know the doctors, calls them by the names of his
acquaintances, and thinks he has been here for two or three
days. He does not know the date. He moves about in his
chair, looks around him a great deal, starts slightly several
times, and keeps on playing with his hands. Suddenly he gets
up, and begs to be allowed to play on the piano for a little.

He sits down again immediately, on persuasion by staff, but
then wants to go home so he can tell his wife “something else
that he has forgotten”. He gradually gets more and more
excited, saying that his fate is sealed; he must leave the world
now; they might telegraph to his wife that her husband is lying
at the point of death.


We learn, by questioning him, that he is going to be executed by
electricity, and also that he will be shot. “The picture is not
clearly painted,” hey says; “every moment someone stands now
here, now there, waiting for me with a revolver. When I open
my eyes, they vanish.” He says a stinking fluid has been injected
into his head and between his toes, which was done by
government agents. With this he looks eagerly at the window,
where he sees houses and trees vanishing and reappearing. If
you show him a speck on the floor, he tries to pick it up,
thinking it is money. The clients mood is apprehensive. His
head is flushed, pulse is rapid, yet weak to the touch. His face
is bloated and his eyes are watery. His breath smells strongly of
alcohol, and his hands tremble when he stretches them outward.

Andy has drunk hard since the age of 13. He currently drank
last approximately 1 hour before coming to the hospital. He
reports that it now takes him seven or eight liters of wine to get
him intoxicated. He stated that it used to take him ½ of that
amount before getting the injection of stinking fluid. He has not
worked for years due to his “condition”, and that his last work
mission was top secret (which is why he was tortured by
government agents wielding stinking fluid syringes). While
noting that his hands were trembling currently, he reported “you
should see me after a couple of days with no wine”, and “I never
shook like this before the injections”. He then stated that it was
great to be back at the Inn, his favorite watering hole. Though
he readily complained about the lack of wine at the “Inn”.

Which disorder(s) do you think Andy is potentially
suffering from? Using Differential Diagnosis which is the
most likely diagnosis?

What is “abnormal”?
Abnormal:

Statistically uncommon, maladaptive cognitions, affect, and/or
behaviors that are at odds with social expectations and that
result in distress or discomfort.

“What is defined as psychopathology are those characteristics
that differ from the dominant culture’s definition of normalcy,
and vary over time, and with culture.”

Clinically Significant (statistically uncommon)
In psychological testing clinically significant is 2 standard deviations above
the norm. For example, 130 I.Q., 70 on the MMPI-2. Thus for mental
health/substance use disorders, we are looking at symptoms that are 2
standard deviations from the norm when making a diagnosis.

2.5% - 5%
2.5% - 5%

What constitutes a “mental disorder”?
DSM-IV-TR Definition of Mental Disorder:

3. Clinically significant behavioral or psychological syndrome or pattern that occurs in an
individual.

5. This pattern is associated with present distress (e.g., a painful symptom) or disability
(i.e., impairment in one or more important areas of functioning) or with a
significantly increased risk of suffering death, pain, disability, or an important loss of
freedom.

7. In addition, this syndrome or pattern must not be merely an acceptable and
culturally sanctioned response to a particular event, for example, the death of a
loved one.

9. Whatever its original cause, it must currently be considered a manifestation of a
behavioral, psychological, or biological dysfunction in the individual.

11. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are
primarily between individual and society are mental disorders unless the deviance or
conflict is a symptom of a dysfunction in the individual, as described above.

What constitutes a “mental disorder”?
Proposed DSM-5 Definition of Mental Disorder:

 A Mental Disorder is a health condition characterized by significant dysfunction in an
individual’s cognitions, emotions, or behaviors that reflects a disturbance in the
psychological, biological, or developmental processes underlying mental functioning.

 Some disorders may not be diagnosable until they have caused clinically significant
distress or impairment of performance.

 A mental disorder is not merely an expectable or culturally sanctioned response to a
specific event such as the death of a loved one.

 Neither culturally deviant behavior (e.g., political, religious, or sexual) nor a conflict that is
primarily between the individual and society is a mental disorder unless the deviance or
conflict results from a dysfunction in the individual, as described above.

 NOTE: The diagnosis of a mental disorder is not equivalent to a need for treatment. Need for treatment is a
complex clinical decision that takes into consideration such factors as symptom severity, symptom salience (e.g.,
the presence of suicidal ideation), the patient’s distress (mental pain) associated with the symptom(s), disability
related to the patient’s symptoms, and other factors (e.g., psychiatric symptoms complicating other illness).

IN FOCUS: Substance-Use &
Addictive Disorders (DSM-5)
Substance-Use Disorder
B.A problematic pattern of [substance] use leading to clinically significant impairment
or distress.

D.Two (or more) of the following occurring within a 12-month period:

1. [Substance] is often taken in larger amounts or over a longer period than was
intended
2. There is a persistent desire or unsuccessful effort to cut down or control
[substance] use
3. A great deal of time is spent in activities necessary to obtain [substance] , use
the substance, or recover from its effects
4. Recurrent [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; substance-related absences, suspensions, or
expulsions from school; neglect of children or household)
5. Continued [substance] use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the substance

Substance-Use Disorder (continued)
B.Two (or more) of the following occurring within a 12-month period:
1. Important social, occupational, or recreational activities are given up
or reduced because of [substance] use
2. 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
3. [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
4. Tolerance, as defined by either or both of the following:
a. A need for markedly increased amounts of [substance] to
achieve intoxication or desired effect
b. Markedly diminished effect with continued use of the same
amount of the substance
(Note: Tolerance is not counted for those taking medications
under medical supervision)

B.Two (or more) of the following occurring within a 12-month period:
1. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for [substance] (refer to
Criteria A and B of the criteria set for Withdrawal)
b. The same (or a closely related) substance is taken to relieve or
avoid withdrawal symptoms
(Note: Withdrawal is not counted for those taking medications
under medical supervision such as analgesics)
2. Craving or a strong desire or urge to use [substance]


The Severity of each Substance Use Disorder is based on:
 0 criteria or 1 criterion: No diagnosis
 2-3 criteria: Mild Substance Use Disorder
 4-5 criteria: Moderate Substance Use Disorder
 6 or more criteria: Severe Substance Use Disorder

 Among adolescents, 2 or 3 criteria identify a group with severity of alcohol use
disorder very close to that of adolescents with DSM-IV alcohol abuse, while 4
or more criteria identify a group with severity very close to that of DSM-IV
dependence. Using criterion counts results in much more homogeneous
groups than DSM-IV’s abuse and dependence groups.

 In the empirical research among adults, the proposed cutoff points have been
shown to yield similar prevalence and high concordance in relation to the
combined DSM-IV substance abuse and dependence diagnoses. However, it
is still unclear as to whether 4-5 or 6 or more constitute what used to
be substance dependence in adults.


In a May 29, 2012 response to Washington Post article citing difficulties
with these proposed changes, the APA responded with the following:

Regarding Dependence, Addiction and the Changes: Research shows that the
symptoms of people with substance use problems do not fall neatly into two discrete
disorders. Also, the term “dependence” is misleading; people often confuse that with
“addiction” when in fact the tolerance and withdrawal patients experience are actually
very normal responses to some prescribed medications that affect the central nervous
system.

Regarding How the New System Reflects DSM’s Old Definition of
Dependence - By contrast, the higher end of the substance use disorder
spectrum would be more equivalent to the prior substance dependence
disorder and entails a distinct syndrome that includes compulsive drug-
seeking behavior, loss of control, craving, and marked decrease in social and
occupational functioning. Revising and clarifying these criteria should alleviate
some misunderstanding around these issues.

Substance-Use Disorder (Legal Problems – OUT; Cravings – IN)

Craving is defined as a strong desire for a substance, usually a specific
substance. It is a common clinical symptom, tending to be present on the severe
end of the severity spectrum. It has been variously defined as a trait with a time
component (present or recent past) or as a lifetime component (ever experienced
in your life).

Brain imaging studies have demonstrated subjective craving precipitated by
drug-related cues and correlated with increased activity (blood flow) and
dopamine release (PET study) in specific parts of the brain reward system.

Recurrent substance-related legal problems (e.g., arrests for substance related
disorderly conduct. DSM-5 aggregate research all indicate that the legal problems
criterion has an extremely low prevalence relative to other criteria, and its
removal from the diagnosis has very little effect on the prevalence of substance
use disorders while adding little information to the diagnoses in the aggregate.

Substance-Use Disorder (Legal Problems – OUT; Cravings – IN)

Alcohol Use Disorder
Cannabis Use Disorder
Hallucinogen Use Disorder (which has subsumed Phencyclidine [PCP])
Inhalant Use Disorder
Opioid Use Disorder
Sedative/Hypnotic Use Disorder (changed from Sedative, Hypnotic or
Anxiolytic Disorder)
Stimulant Use Disorder (combining DSM-IV-TR’s Cocaine and Amphetamine
Abuse and Dependence)
Tobacco Use Disorder
Unknown Substance Use Disorder
Gambling Disorder

There are no Caffeine Use or Internet Use Disorders in the DSM-5.

Synthetic Cathinones (aka “Bath
Salts”) Effects Summary Sheet

 Aggression  Hypertension (high  Nausea, stomach cramps,
 Agitation blood pressure) and digestive problems
 Breathing difficulty
 Increased  Nosebleeds
alertness/awareness Psychotic delusions
 Bruxism (grinding 
 Increased body
teeth)  Pupil dilation
temperature, chills,
 Confusion sweating
 Renal failure
 Dizziness  Insomnia  Rhabdomyolysis (release
 Extreme anxiety  Kidney pain of muscle fiber contents
sometimes  Lack of appetite [myoglobin] that could
progressing to violent  Liver failure lead to kidney problems)
behavior
 Loss of bowel control  Severe paranoia
 Muscle spasms Suicidal thoughts
 Fits and delusions 
 Muscle tenseness
 Hallucinations  Tachycardia (rapid
 Vasoconstriction
 Headache (narrowing of the blood heartbeat)
vessels)  Tinnitus

The LIST … Substituted Cathinones
Substituted cathinones, which include some stimulants and entactogens, are derivatives of
cathinone. The derivatives may be produced by substitutions at four different locations of the
cathinone molecule.
•Cathinone •DMEC 4-MeMABP 4-MePPP
•Methcathinone •Methedrone 4-Me-NEB MOPPP
•Ethcathinone •Ethedrone 4-Methoxybuphedrone FPPP
•Buphedrone •3-MOMC Butylone MPBP
•NEB •2-FMC Eutylone Pyrovalerone
•NEP •2-FEC BMDB (O-2371)
•Pentedrone •3-FMC bk-DMBDB MPHP
•Dimethylcathinone •3-FEC 5-Methylmethylone MDPPP
•Diethylpropion •3-CMC 5-Methylethylone MDPBP
•Bupropion •3-BMC 2-Methylbutylone MDPV
•Mephedrone •Flephedrone 5-Methylbutylone FPVP
•3-MMC •4-FEC Pentylone O-2390
•3-MEC •Brephedrone MMP O-2494
•3-EMC •FMMC MEP Naphyrone (O-2482)
•3-EEC 2,5-DMOMC bk-Methiopropamine α-PVT
•4-EMC bk-MDA α-Phthalimidopropiophenone
•4-EEC 2,3-MDMC α-PPP
•Benzedrone Methylone α-PBP
•4-MEC Ethylone 3-MPBP
•N,N-DMMC BMDP EPBP
•N,N-DEMC bk-IMP MOPBP
•EDMC 4-Fluorobuphedrone O-2384
•3,4-DMMC 4-Bromobuphedrone α-PVP (O-2387)

Bath Salts and the Zombie Apocalypse
The Anecdotal “Evidence” …

 May 3, 2011. CHARLESTON, W.Va. – An Alum Creek man has been arrested after neighbors
allegedly found him standing over the dead body of a boy’s stolen pet pygmy goat while wearing
women's underwear. This was our trendsetter http://bit.ly/mr2xny.
 May and June, 2012 – A veritable outbreak of Zombie type behaviors with people the media
reported that were supposedly on bath salts (mostly in Florida … fill in your own thoughts on
this):

1. Florida Man (Rudy Eugene) Eats 75% of Another Man’s Face
2. NJ Man Flings His Own Intestines at Police Who Try to Arrest Him
3. Man on Bath Salts Bites a Chunk of Person’s Face in Domestic Dispute
4. Man on Bath Salts Threatens to Eat Police Who Try to Arrest Him

 Of course the most infamous of these is link #1, where the mother actually talked to the press to
announce that her now deceased son (they had to kill him as when the police tried to stop him
from eating the other man he merely growled at them) “was no zombie” and his former girlfriend
stated he was either drugged or possessed. Rudy Eugene was on marijuana only, not bath salts.
He was also found to have no human flesh in his stomach. However, the lab only tested for
6 chemicals, and as we have seen there are more than 6 chemicals being
used/labeled as “bath salts”.

 It doesn’t help that Center for Disease Control has
a permanent internet website dedicated to how to best handle a Zombie Apocalypse.

Not Zombies … Yet Bath Salts are deadly
More recent rash of bizarre and deadly bath salts incidents

 June 18, 2012. Houston, Texas - A man was found in the middle of a
busy street
shouting incoherently at oncoming traffic that swerved to miss him. Police
finally got him out of the traffic when he “displayed signs of excited
delirium” before he stopped breathing. He was pronounced dead at the
hospital and had bath salts on him.

 June 15, 2012. Robinson, Illinois - A
naked man grabs onto random car hood while naked and surfs car hood for 4 mil
. The driver calls 911 and drives 4 miles to meet police who then arrested
the man, who had vials purportedly containing bath salts on him. He was
“hallucinating wildly” … as opposed to hallucinating modestly.

 June 14, 2012. Miami, Florida - A
naked woman punched and choked her 3 year old son before the son was rescue
. She then grabbed her dog and did the same before the police came and
tasered. She died from cardiac arrest as a result of the tasering (and likely

Psychiatric Symptoms Associated with
Synthetic Marijuana (Spice/K2)
 The cannabinoid-like chemicals were developed in research
laboratories, for example, to study neuronal receptors found in the
body and brain.

 One of these synthetic cannabinoids, JWH-018, was
first made in 1995 for experimental purposes
in the lab of Clemson University
researcher John W. Huffman, PhD.

 These synthetic cannabinoids have been associated with attempted
suicides, and have been linked to such adverse effects as increased
anxiety, panic attacks, heart palpitations, respiratory complications,
aggression, mood swings, altered perception, and paranoia.



Ambiguities, Counselor Bias, and the DSM
 The DSM-IV-TR discusses the use of clinical judgment and makes the
following statement: "exercise of clinical judgment may justify giving a
certain diagnosis to an individual even though the clinical
presentation falls just short of meeting the full criteria for the
diagnosis as long as the symptoms present are persistent and severe”
(p. xxxii).

 Counselors, therefore, have a great deal of diagnostic leeway in
determining whether or not a diagnosis is given. Consequently, values,
biases, theoretical orientation, social status, privilege, and power may
influence diagnostic judgments.

 Counselors are inculcated with the dominant culture’s values and
beliefs about mental health and illness. Thus counselors acquire a
unconscious ideology that may remain unquestioned in the practice of
diagnosis.

 The dominant group’s power obscures the relationship between
dominance and subordination. The dominant ideology about normalcy
and psychopathology becomes unconscious.

Cultural Competence Issues
 Cultural Competence – counselors are encouraged to strive for cultural
competence when working with clients.
 Cultural competence is a multidimensional phenomenon comprised of
scientific mindedness, dynamic sizing, and culture-specific skills.

3. Scientific mindedness
 The formation of hypotheses to be tested via data collection (i.e.,
assessment) during assessment and treatment rather than relying on
counselor assumptions or beliefs.

4. Dynamic sizing
 Knowing when to generalize and be inclusive and knowing when to
individualize and be exclusive in working with clients. This skill refers to
the knowing how to use information regarding the potential impact and
importance of clients’ cultural background without stereotyping individual
clients based on their cultural background.

5. Cultural Specific Skills
 Those skills counselors possess that are specific to particular cultural
backgrounds (e.g., knowledge of the impact prejudice may have on
racially diverse clients, or the proper assessment )

Steps to Improve Cultural Competence
No matter what the client problem (addictions, anxiety, depression), the
following are a set of steps all counselors can take to be more culturally
competent.

3. Self-awareness of own cultural background and worldview (as well as an
understanding that clients’ backgrounds and worldviews may differ from your
own)
4. Assessment of client including degree of acculturation, cultural values.
5. Pre-therapy intervention that orients clients to expectations regarding
therapy/program.
6. Hypothesizing and hypothesis testing.
7. Attending to credibility of the treatment and therapist (e.g., do clients believe
treatment will be effective? Do they believe therapist can help them meet
their goals?).
8. Understanding the nature of therapist discomfort in treating clients of
different cultural backgrounds.
9. Understanding clients’ perspectives.
10. Develop treatment plan collaboratively so it is not inconsistent with cultural
beliefs.
11. Willingness to consult with those who have experience with clients of a
particular cultural background.

Ethnicity vs. Organizational Culture
Exercise
You have entered into an mental health/substance abuse
outpatient treatment organization as the new director of
outpatient/intensive outpatient substance abuse treatment
services. This is a mid sized organization that specializes in 3
distinct departments: mental health services, substance abuse
services, and a specialized case management department for
working with HIV+ clients. This outpatient facility states that it
does short-medium term outpatient care for clients. During your
second week in the organization, you attend your first bi-
weekly, interdepartmental group supervision meeting. In this
meeting the head of the outpatient mental health department
presents a case.

This is a case of a Colombian female in her 40’s who was
referred for treatment due to depression. She had been in
treatment for approximately 9 months, and shared some news
with her therapist (the outpatient director, lets call her Melissa).

Exercise
The news the client presented was the happy news (according
to the client) that her daughter was pregnant. The client was
ecstatic over the news and delighted in sharing with her
therapist. The therapist asked pointed questions, such as
asking what the daughter will do about her college career (she
is a Sophomore). The client stated that the daughter would
drop out and return “eventually”, but the important thing would
be focusing on her child, not her own education. The therapist
then asked if the daughter would need help in rearing the child,
the client responded “oh it will be great, I’ll mother her, her
mother will mother her, her aunt will mother her, the baby will
be well taken care of.” One last question the therapist put forth
was a question concerning the father of the child. The client
stated the father was not involved, nor was it necessary to have
a male in the picture. “The baby will be more than cared for by
us all, and my oldest son (14) will be a male role model for the
baby.”

Exercise
The therapist Melissa then described how upset she was about this, and was at a loss
as to how to convey to the client that while this is a blessed event, it is also a bit of a
crisis given the fact that the daughter will drop out of school and no man is involved
in the picture.

This therapist (the mental health outpatient director) is a white woman in her mid
50’s, and in the past 5 years made a career change from working in New York City in
the fashion industry (making well into the 6 figures per year), to becoming a
therapist. This fact alone makes you question her sanity, which you do so quietly to
yourself, not daring to state it in the meeting. However, the thought did cross your
mind to just skip this woman’s treatment “crisis” and make the meeting interesting by
asking her the reason for making the switch.

The therapist then asked the team for guidance on how to best handle the situation.
Thinking to yourself that this therapist was biased in her view of the client and not
taking her culture into account when viewing the problem, you were sure others
would give her this feedback. What ensued became a bizarre interaction of
suggestions for the therapist to help “the client realize the crisis she was in” by other
staff members. Not one other member suggested that this is not a crisis at all.

Ethnicity vs. Organization Culture Exercise

You begin thinking to yourself how bizarre this set of transactions just
was, though thinking to yourself how useful this could be in some
future workshop exercise. Since nobody in the room seemed to be
responding to reality, you decide to dissociate and let your mind
continue to wander away from the content of the meeting and drift
towards thoughts of the group makeup. Thinking first about the fact
that you’re the only male member, to how one therapist’s hair has
surely taken on the unintended tint of blue, and then finally drifting to
remind yourself to again search the employment section of Star Ledger
this Sunday. Suddenly, and quite rudely, you’re awakened from what
appeared to you as a more useful pursuit of your mental energies, as
the focus of the group has turned to you. The director has asked you
specifically to give some feedback on this issue to the group.

3. What feedback do you give to the director? Give reasons why you
decided to say what you said.
4. What organization cultural issues exist in this program (that we know
of)? How do these issues impact our decision making for question 1?

Substance Use Disorders &
Anxiety/Depression
 A powerful relationship exists between substance use disorders
and mood and anxiety symptoms/disorders.

 Individuals with substance use disorders are nearly twice as
likely to have a mood or anxiety disorder, and the inverse is
also true.

 Also, many clients with substance use disorders experience one
or more symptoms of a mental disorder but do not meet
diagnostic thresholds.

Addiction and Sub-Acute Anxiety
 Symptoms and sensitivity to these symptoms occur along a continuum
of intensity from mild to severe, but depart from anxiety disorders in 3
ways:
1. Pattern of avoidance
2. Level of anticipation of re-experiencing anxiety or panic
3. Degree of impairment in performing normal daily routines and
responsibilities.

 Increased anxiety symptoms and sensitivity in substance use disorders
has been linked to:
1. Continued substance use while in treatment
2. Poorer treatment retention
3. Greater post-treatment substance use
4. Greater relapse rate (even after prolonged periods of sobriety)
5. More severe withdrawal symptoms
6. Increases in cravings
7. Greater risk for the development of anxiety disorders if untreated

Addressing Anxiety In Addictions Tx.
 Addressing anxiety symptoms (interventions focused on anxiety
symptoms) in substance use disorder treatment can be enormously
beneficial. It can help:
1. Decrease cravings
2. Allow clients to develop more effective coping skills
3. Clients will show improvements in affect tolerance and emotional
regulation
4. Helps to decrease anxiety levels during substance use treatment

Nature of Anxiety – Anxiety on the Continuum

Threatening Anxiety
Extreme Anxiety
– the anxiety we feel
Symptoms – these
when somebody in
are maladaptive
the car in front of us
anxiety symptoms,
stops suddenly and
that occur but not
we need to react
enough to warrant
quickly to avoid an
a diagnosis. These
Appropriate Anxiety accident. Anxiety Disorders –
are sub-acute and
– e.g., feeling can also be treated Enough symptoms
nervous when by a trained to make a
wanting to impress addictions diagnosis and
somebody. Anxiety professional. should only be
we all feel. treated by a
licensed mental
health professional.

Components of Anxiety
 Anxiety is comprised of at least three components: 1) physiological component;
2) thoughts or cognitive component; and 3) behavioral component.
 Physiological component to perceived threat – these are the physical feelings in
the body that occur when we perceive a situation as threatening:
1. Increased heart beat, sweating, ringing in the ears, shortness of breath,
feelings of choking, blurred vision, headaches, chest pains, nausea,
trembling, numbness, chills, hot flashes, muscle aches.
 If any of these feelings occur during times when a client is not reporting anxiety,
then a referral to a medical professional would be appropriate.
 Notable differences between anxiety and panic attacks are that panic attacks are
very time limited (peaking within 5-10 minutes) and are usually accompanied by
fears of dying, losing control or going crazy.

 Thoughts or cognitive responses to perceived threat – Thoughts can play a large
role on the onset, maintenance, and worsening of anxiety.
1. Through our interpretations of situations (e.g., interpreting them as being
threatening or dangerous), we influence the anxiety levels we experience.

Components of Anxiety

 Behavioral component to perceived threat – experiencing anxiety can
result in a wide range of behavioral responses. They can range from
avoidance behaviors (fleeing a scene that causes anxiety, not hanging
out with friends because of social anxiety), to behaviors that only occur
when anxiety is present (biting nails, becoming fidgety)
1. By avoiding a situation that is a perceived threat, the person
succeeds in avoiding the components of anxiety.
2. These avoidant safety behaviors help to maintain the anxiety.
3. When somebody avoids a situation, the deprive themselves of
learning the situation may not have been as dangerous as they
perceived it to be.
4. They also start to believe that the only way to escape unpleasant
anxiety is to avoid the situation, or to experience the situation in
an altered state (under the influence of substances).

The Relationship between Substance Use
Disorders and Anxiety Disorders
 Substance use can increase anxiety – it is postulated that 3 factors
increase anxiety vulnerability among substance users:
n The physiological effects of drug/alcohol use. Some substances
have clear anxiety-increasing properties that may produce chronic
anxiety as a result of prolonged and/or heavy usage.
n Craving – people may use drugs or alcohol to manage not only
craving but the associated anxiety that comes with craving.
n Withdrawal – anxiety, stress and irritability are among the most
common withdrawal symptoms associated with a variety of
substances.

 Mutual Maintenance Model
1. Anxiety can lead to substance use.
2. Substance use and withdrawal can increase anxiety.
3. Subsequently continued substance use occurs to manage anxiety
symptoms, which then can cause the very symptoms they are
trying to manage, causing a circular, continuous feeding effect.

DSM-5 Changes to Anxiety Disorders

Anxiety Disorders are being carved out into 3 categories.

Anxiety Disorders

5. Separation Anxiety Disorder
6. Panic Disorder
7. Agoraphobia
8. Specific Phobia
9. Social Anxiety Disorder (Social Phobia)
10. Generalized Anxiety Disorder
11. Substance-Induced Anxiety Disorder
12. Anxiety Disorder Attributable to Another Medical Condition
13. Anxiety Disorder Not Elsewhere Classified
Panic Attack



Obsessive-Compulsive and Related Disorders

5. Obsessive-Compulsive Disorder
6. Body Dysmorphic Disorder
7. Hoarding Disorder
8. Hair-Pulling Disorder (Trichotillomania)
9. Skin Picking Disorder
10. Substance-Induced Obsessive-Compulsive or Related Disorders
11. Obsessive-Compulsive or Related Disorder Attributable to Another
Medical Condition
12. Obsessive-Compulsive or Related Disorder Not Elsewhere Classified

 While suggested (cough)anonymously(cough) in the last go-around of
DSM-5 open comment period, Nose Picking Disorder did not make it.



Trauma- and Stressor-Related Disorders

n Reactive Attachment Disorder
n Disinhibited Social Engagement Disorder
n Acute Stress Disorder
n Posttraumatic Stress Disorder
n Adjustment Disorders (now placed in this category)
n Trauma- or Stressor- Related Disorder Not Elsewhere Classified

PTSD – No longer an “anxiety disorder”

Posttraumatic Stress Disorder – The Shared Anxiety Symptoms

 Phenomenologically, PTSD shares a number of symptoms (especially
from its Hyperarousal/D Criterion cluster) with other anxiety disorders
such as insomnia, irritability, poor concentration, and startle reactions.
PTSD avoidance behavior is similar to phobic and anxious avoidance.

 Physiological arousal and dissociation (e.g., derealization and
depersonalization) also occur in panic disorder.

 Persistent intrusive thoughts or memories are commonly observed
across anxiety disorders, including generalized anxiety disorder (GAD),
obsessive-compulsive disorder (OCD), panic disorder, and social
Phobia.

PTSD – No longer an “anxiety disorder”

Posttraumatic Stress Disorder – The Differentiation
 PTSD is primarily a disorder of reactivity, along with specific and social
phobia, rather than a syndrome with a consistent alteration of the
tonic/basal state, such as depression and GAD.

 Furthermore, anxiety is present in most psychiatric disorders. It is not a
particularly sensitive and specific index to posttraumatic reactions,
normal or abnormal.

 A number of symptoms observed in PTSD, such as numbing, alienation,
and detachment, are frequent depressive symptoms, and can be
responsible for the high co-morbidity between the two disorders.

 Although there is overlap between other anxiety disorders and
depression, as well, this pattern suggests that PTSD is more than
simply an anxiety disorder.

IN FOCUS – PTSD (DSM-5 Proposed Criteria)

A. Exposure to actual or threatened a) death, b) serious injury, or c)
sexual violation, in one or more of the following ways:

1. directly experiencing the traumatic event(s)
2. witnessing, in person, the traumatic event(s) as they occurred to
others
3. learning that the traumatic event(s) occurred to a close family
member or close friend; cases of actual or threatened death must
have been violent or accidental
4. experiencing repeated or extreme exposure to aversive details of
the traumatic event(s) (e.g., first responders collecting human
remains; police officers repeatedly exposed to details of child
abuse); this does not apply to exposure through electronic media,
television, movies, or pictures, unless this exposure is work-
related.


A. Presence of one or more of the following intrusion symptoms associated with the
traumatic event(s), beginning after the traumatic event(s) occurred:
n spontaneous or cued recurrent, involuntary, and intrusive distressing
memories of the traumatic event(s) (Note: In children, repetitive play may
occur in which themes or aspects of the traumatic event(s) are expressed.)
n recurrent distressing dreams in which the content or affect of the dream is
related to the event(s) (Note: In children, there may be frightening dreams
without recognizable content. )
n dissociative reactions (e.g., flashbacks) in which the individual feels or acts
as if the traumatic event(s) are recurring (such reactions may occur on a
continuum, with the most extreme expression being a complete loss of
awareness of present surroundings. (Note: In children, trauma-specific
reenactment may occur in play.)
n intense or prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic
event(s)
n marked physiological reactions to reminders of the traumatic event(s)

A. Persistent avoidance of stimuli associated with the traumatic event(s),
beginning after the traumatic event(s) occurred, as evidenced by
avoidance or efforts to avoid one or more of the following:
1. distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s)
2. external reminders (i.e., people, places, conversations, activities,
objects, situations) that arouse distressing memories, thoughts, or
feelings about, or that are closely associated with, the traumatic
event(s)

A. Negative alterations in cognitions and mood associated with the traumatic
event(s), beginning or worsening after the traumatic event(s) occurred), as
evidenced by two or more of the following:
1. inability to remember an important aspect of the traumatic event(s)
(typically due to dissociative amnesia that is not due to head injury,
alcohol, or drugs)
2. persistent and exaggerated negative beliefs or expectations about oneself,
others, or the world (e.g., “I am bad,” “No one can be trusted,” "The world
is completely dangerous"). (Alternatively, this might be expressed as, e.g.,
“I’ve lost my soul forever,” or “My whole nervous system is permanently
ruined”).
3. persistent, distorted blame of self or others about the cause or
consequences of the traumatic event(s)
4. persistent negative emotional state (e.g., fear, horror, anger, guilt, or
shame)
5. markedly diminished interest or participation in significant activities
6. feelings of detachment or estrangement from others
7. persistent inability to experience positive emotions (e.g., unable to have
loving feelings, psychic numbing)

A. Marked alterations in arousal and reactivity associated with the
traumatic event(s), beginning or worsening after the traumatic event(s)
occurred, as evidenced by two or more of the following:
1. irritable or aggressive behavior
2. reckless or self-destructive behavior
3. hypervigilance
4. exaggerated startle response
5. problems with concentration
6. sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep)

A. Marked alterations in arousal and reactivity associated with the
traumatic event(s), beginning or worsening after the traumatic event(s)
occurred, as evidenced by two or more of the following:
1. irritable or aggressive behavior
2. reckless or self-destructive behavior
3. hypervigilance
4. exaggerated startle response
5. problems with concentration
6. sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep
B. Duration of the disturbance (Criteria B, C, D, and E) is more than 1
month.
C. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

A. The disturbance is not attributed to the direct physiological effects of a
substance (e.g., medication, drugs, or alcohol) or another medical
condition (e.g. traumatic brain injury).

 Specify if:
 With Delayed Expression: if the diagnostic threshold is not exceeded
until at least 6 months after the event (although the onset and
expression of some symptoms may be immediate).

 Subtype: Posttraumatic Stress Disorder in Preschool Children

 Subtype: Posttraumatic Stress Disorder – With Prominent
Dissociative (Depersonalization/Derealization) Symptoms

IN FOCUS – PTSD (What did they change?)
 Revision of Criterion A1 – to remove ambiguities and tighten the definition
of “traumatic event”

 Deletion of Criterion A2 – because it has no utility (“the person’s response
involved fear, helplessness or horror”)

 Slight revision to Criterion B
 B1 clarified to define “intrusive recollection” and eliminate depressive
rumination
 B2 slight changes make the criterion more applicable across cultures
 B3 clarified to indicate that flashbacks are dissociative symptoms that occur
on a continuum

 Dividing DSM-IV Criterion C into two separate clusters (e.g., DSM-5 Criteria
C and D) Thereby resulting in four, rather than three distinct diagnostic
clusters.
 Revising and adding diagnostic symptoms for Criterion D (Negative

IN FOCUS – PTSD (What did they change?)
 D2 (DSM-IV “foreshortened future”) clarified & expanded to encompass
exaggerated negative beliefs and expectations about the future

 D3 (new symptom) –persistent distorted blame of self or others

 D4 (new symptom) – persistent negative emotional state
 Revising and adding diagnostic symptoms for Criterion E (“Alterations in
Arousal and Reactivity”)

 E1 – clarifying that this pertains to behavior (“irritable or aggressive”)

 E2 (new symptom) = reckless or self-destructive behavior

 Eliminating the Acute vs. Chronic specifier
 Addition of a Preschool Subtype
 Addition of a Dissociative Subtype.

IN FOCUS: Generalized Anxiety Disorder
(DSM-IV-TR vs. DSM-5)

IN FOCUS: Generalized Anxiety Disorder
(DSM-IV-TR vs. DSM-5)

B. The disturbance is not better accounted for by another mental disorder
(e.g., anxiety about Panic Attacks in Panic Disorder, negative
evaluation in Social Anxiety Disorder, contamination or other
obsessions in Obsessive-Compulsive Disorder, separation from
attachment figures in Separation Anxiety Disorder, reminders of
traumatic events in Posttraumatic Stress Disorder, gaining weight in
Anorexia Nervosa, physical complaints in Somatic Symptom Disorder,
perceived appearance flaws in Body Dysmorphic Disorder, or having a
serious illness in Illness Anxiety Disorder).

“Depressive Symptoms” – below disorder threshold

 The term “depressive symptoms” refers to symptoms experienced by people
who, although failing to meet DSM-IV-TR diagnostic criteria for a mood disorder,
experience sadness, depressed mood, or “the blues,” and one or more additional
possible symptoms:
1. Loss of interest in most activities
2. Significant unintentional change in weight or appetite
3. Sleep disturbances
4. Decreased energy, chronic fatigue or tiredness, feeling exhausted
5. Feelings of excessive guilt
6. Feelings of low self-esteem, low self-confidence, or worthlessness
7. Feelings of despair or hopelessness (pervasive pessimism about the future)
8. Avoidance of normal familial and social contacts
9. Frequent agitation, restlessness
10. Psychologically or emotionally detached
11. Feelings of irritability or frustration
12. Decrease in activity, effectiveness, or productivity
13. Difficulty in thinking (poor concentration, poor memory, or indecisiveness)
14. Excessive or inappropriate worries
15. Being easily moved to tears
16. Anticipation of the worst
17. Thoughts of suicide

“Depressive Symptoms” – below disorder threshold

 For individuals experiencing depressive symptoms:
1. The symptoms might be more pervasive extending beyond an expected time
frame.
2. Some affects may feel too powerful to the individual and have to be blocked or
distorted.
3. While the affect expressed might feel “normal” or appropriate to the person,
others might consider the person to be emotionally over- or under reacting.
4. A person will get stuck in an emotion, such as fearful or sad and not be able to
shake it, or he or she may look to an outside influence, such as a drug, to
change the mood.
5. There may be significant impairment in a life-functioning area, such as
relationships or work performance.
6. There may be significant reduction in use of healthy coping styles, resulting in
adaptive responses that limit choice or alienate others.
7. There might be a significant negative or pessimistic cognitive bias, resulting in a
person seeing life through negative filters.
8. A person might not be able to consistently identify his or her mood or might
label an affect in a way that seems confusing to others. For instance, a person
may identify himself as scared when he seems sad to others.

Major Depressive Episode – DSM-5
 A. Five (or more) of the following criteria 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 medical condition.
n Depressed mood most of the day, nearly every day, as indicated by
either subjective report (e.g., feels sad, empty, or hopeless) or
observation made by others (e.g., appears tearful). Note: In children
and adolescents, can be irritable mood.
n 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)
n 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 gain

1. Insomnia or hypersomnia nearly every day
2. Psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings of
restlessness or being slowed down)
3. Fatigue or loss of energy nearly every day
4. Feelings of worthlessness or excessive or inappropriate guilt
(which may be delusional) nearly every day (not merely self-
reproach or guilt about being sick)
5. Diminished ability to think or concentrate, or indecisiveness,
nearly every day (either by subjective account or as observed
by others)
6. 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

n The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning. (Language
regarding “impairment” may change for consistency with DSM-IV
conventions)

n The episode is not attributable to the direct physiological effects of a
substance or another medical condition

n The Major Depressive Episode is not better accounted for by
Schizoaffective Disorder and is not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not
Elsewhere Classified.

n There has never been a Manic Episode or a Hypomanic Episode.

Note: This is NOT a codeable disorder

Note: The normal and expected response to an event involving
significant loss (e.g., bereavement, financial ruin, natural disaster),
including feelings of intense sadness, rumination about the loss,
insomnia, poor appetite and weight loss, may resemble a depressive
episode.

The presence of symptoms such as feelings of worthlessness, suicidal
ideas (as distinct from wanting to join a deceased loved one),
psychomotor retardation, and severe impairment of overall function
suggest the presence of a Major Depressive Episode in addition to the
normal response to a significant loss.

DSM-5 - Suicidal Behavior Disorder
A. The individual has initiated a behavior in the expectation that it would lead to the
individual’s own death within the last 24 months.
B. The behavior did not meet criteria for non-suicidal self-injury - that is, it did not
involve self-injury directed to the surface of the body undertaken to induce relief
from a negative feeling/cognitive state or to achieve a positive mood state without
risk of death. Having undertaken one or more acts of non-suicidal self-injury in the
past is not incompatible with the diagnosis.
C. The “time of initiation” is the time when the self-initiated behavior was undertaken
by the individual who receives the diagnosis. The term “suicide attempt” can,
therefore, apply to individuals who initiated the behavior and survived because of
the timely interruption by a third party (sometimes known as an interrupted suicide)
or because the individual changed his or her intent and decided to seek help
(sometimes known as an aborted suicide).
D. The act was not initiated during a confused or delirious state. However, attempts
initiated during intoxication or while under the influence of a substance do not
preclude this diagnosis.
E. The act was not undertaken solely for a political or religious objective.

Suicidal & Homicidal Ideation
 One needs to check for past and current levels of suicidal and
homicidal ideation, gestures, and/or attempts.

 Ideations are thoughts, and can range from fleeting thoughts, to well
thought out plans. Gestures are non life threatening attempts at
hurting oneself or another (e.g., superficially cutting oneself on the
wrist, but to the point where one’s life was never in danger). Attempts
are potential life threatening actions taken by an individual towards
oneself or another.

 Means, intent, lethality are key components to this assessment.

 Other important red flags include, but not limited to, severe losses in
ones life, identification with someone who killed themselves/others,
chronic illnesses, depressive disorders, giving away one’s possessions.

Debunking Common Suicide Myths
 Some of the common myths about suicidality include:
 MYTH: Clients will not make a suicide attempt if they promise the
counselor to not harm themselves.
 FACT: A variety of circumstances can influence suicidal behavior. A
promise by a client not to harm himself may not apply when a
client is confronted with a variety of environmental, interpersonal,
and psychological stressors. A “commitment to treatment” plan is
generally considered more useful than a “no-suicide pact”

 MYTH: Talking about suicidal thoughts will put the idea in a client’s
head and make the problem worse.
 FACT: Most clients want to talk about their suicidal thoughts and
plans with someone. Talking with a nonjudgmental, accepting
person about suicide can offer relief.

Debunking Common Suicide Myths
 Some of the common myths about suicidality include:
 MYTH: Changing a client’s perception of the events in her life will
change her suicidality.
 FACT: Events are only one variable in an individual’s suicidality.
Other variables include the individual’s interpersonal support
system; psychological variables such as depressive symptoms,
depressive illness, despair and emptiness; cultural values and
influences regarding suicidal behavior; and access to a method for
suicide

 MYTH: A client is not at risk of suicide unless he can describe a
plan.
 FACT: People sometimes impulsively act on suicidal thoughts,
without a well-defined plan

What to do with clients re: Suicide
 Some “do’s” for working with clients who have suicidal thoughts or
plans include:
1. Seek the clinical support and input of supervisors, consultants, and
treatment team members.
2. Obtain the informed consent of the client to consult with a
supervisor, appropriate mental health professionals, and referral
resources about the client’s care.
3. Listen to the client’s experience and feelings without judgment.
4. Encourage clients to talk about their suicidal ideation, whether
plans have been considered or made, and whether a method (a
gun or medication, for instance) is available. This is important
information to have when you consult with a supervisor or mental
health professional.

What to do with clients re: Suicide
 Some “do’s” for working with clients who have suicidal thoughts or
plans include:
1. Don’t allow yourself to be sworn to secrecy about the client’s
suicidal thoughts or intent.
2. Engage the client in participating in a plan of care to intervene
with suicidal thoughts and/or behaviors.
3. If possible, involve the client’s family and significant others in
supporting the client.
4. Have a clear understanding of the ethical, legal, and agency
guidelines in working with clients who are suicidal.

Imminent Danger Defined
Imminent danger is a concept used to describe problems that can
lead to dire consequences for the client (and others). Imminent
danger is defined as the following 3 components:

3. A strong probability that certain behaviors (such as continued
alcohol or drug use or continued self harm) will occur.

5. The potential for such behaviors to present a significant risk of
serious adverse consequences to the individual and/or others.

7. The likelihood that such harmful events will occur in the near
future.

The Duty to Warn
 Case Name: Vitaly TARASOFF v. REGENTS OF UNIV OF CA., et.
al. Date, Location, Cite: 1976 CA. 131 Cal Rptr 14, 551 p2d 334.
 CA Supreme Court: Prosenjit Poddar told student health he
wanted to kill Tatiana Tarasoff. Psychologist told supervising
psychiatrist, who told campus police, who checked & let Poddar
go.
 Poddar killed Tatiana. Parents sued for "failure to warn"- Trial
Court said no duty existed, but CA Supreme Court cited
Simenson v Swenson, ordered trial; heard twice, settled out:
n “Tarasoff #1” -"Privilege ends where public peril begins.“
n “Tarasoff #2” - Therapist has an obligation to use
reasonable care to protect potential victim.
 SUPER LAND MARK - created whole new cause for action, but
based on Simenson v Swenson because settled out of court.

Ohio’s Duty to Warn Law
Section 2305.51(F) Duty to Protect – Ohio Revised Code

(F) "KNOWLEDGEABLE PERSON" means an individual who has reason to believe
that a mental health client or patient has the intent and ability to carry out an explicit
threat of inflicting imminent and serious physical harm to or causing the death of a
clearly identifiable potential victim or victims and who is either an immediate family
member of the client or patient or an individual who otherwise personally knows the
client or patient.

(2) for the purpose of this section, in the case of a threat to a readily identifiable
structure, "CLEARLY IDENTIFIABLE POTENTIAL VICTIM" includes any potential
occupant of the structure.

Section 2305.51(B) Duty to Protect – Ohio Revised Code

A mental health professional or mental health organization may be held
liable in damages in a civil action, or may be made subject to disciplinary
action by an entity with licensing or other regulatory authority over the
professional or organization, for serious physical harm or death resulting from
failing to predict, warn of, or take precautions to provide protection from the
violent behavior of a mental health client or patient,
 Only if the client or patient or a knowledgeable person has
communicated to the professional or organization an explicit threat of
inflicting imminent and serious physical harm to or causing the death
of one or more clearly identifiable potential victims;
 The professional or organization has reason to believe that the client
or patient has the intent and ability to carry out the threat, and;
 The professional or organization fails to take one or more of the
following actions in a timely manner:

One or more of the following actions must be taken in timely if
a Duty to Warn and Protect exists: Section 2305.51(B)

4.Exercise any authority the professional or organization possesses to hospitalize the
client or patient on an emergency basis pursuant to section 5122.10 of the revised
code;
5.Exercise any authority the professional or organization possesses to have the client
or patient involuntarily or voluntarily hospitalized under chapter 5122. of the revised
code;
6.Establish and undertake a documented treatment plan that is reasonably
calculated, according to appropriate standards of professional practice, to eliminate
the possibility that the client or patient will carry out the threat, and, concurrent
with establishing and undertaking the treatment plan, initiate arrangements for a
second opinion risk assessment through a management consultation about the
treatment plan with, in the case of a mental health organization, the clinical director
of the organization, or, in the case of a mental health professional who is not acting
as part of a mental health organization, any mental health professional who is
licensed to engage in independent practice;

One or more of the following actions must be taken in timely if
a Duty to Warn and Protect exists: Section 2305.51(B)

4.Communicate to a law enforcement agency with jurisdiction in the area where
each potential victim resides, where a structure threatened by a mental health client
or patient is located, or where the mental health client or patient resides, and if
feasible, communicate to each potential victim or a potential victim's parent or
guardian if the potential victim is a minor or has been adjudicated incompetent, all
of the following information:

a. The nature of the threat;
b. The identity of the mental health client or patient making the threat;
c. The identity of each potential victim of the threat.

All of the following applies if one or more of
section B is acted upon: Section 2305.51(C)

n All of the following apply when a mental health professional or organization
takes one or more of the actions set forth in divisions (b)(1) to (4) of this
section:

nThe mental health professional or organization shall consider each of the
alternatives set forth and shall document the reasons for choosing or rejecting
each alternative.

nThe mental health professional or organization may give special consideration
to those alternatives which, consistent with public safety, would least abridge
the rights of the mental health client or patient established under the revised
code, including the rights specified in sections 5122.27 to 5122.31 of the
revised code.

All of the following applies if one or more of
section B is acted upon: Section 2305.51(C)

4.The mental health professional or organization is not required to take an action that, in
the exercise of reasonable professional judgment, would physically endanger the
professional or organization, increase the danger to a potential victim, or increase the
danger to the mental health client or patient.
5.The mental health professional or organization is not liable in damages in a civil action,
and shall not be made subject to disciplinary action by any entity with licensing or other
regulatory authority over the professional or organization, for disclosing any confidential
information about a mental health client or patient that is disclosed for the purpose of
taking any of the actions.
a. The immunities from civil liability and disciplinary action conferred by this section
are in addition to and not in limitation of any immunity conferred on a mental
health professional or organization by any other section of the revised code or
by judicial precedent.
b. This section does not affect the civil rights of a mental health client or patient
under Ohio or federal law.

42-CFR-Part 2 – Exceptions to
Confidentiality
§ 2.22 Notice to patients of Federal confidentiality requirements.

The confidentiality of alcohol and drug abuse patient records maintained by this program is
protected by Federal law and regulations. Generally, the program may not say to a person
outside the program that a patient attends the program, or disclose any information
identifying a patient as an alcohol or drug abuser Unless:
1) The patient consents in writing:
2) The disclosure is allowed by a court order; or
3) The disclosure is made to medical personnel in a medical emergency or to qualified
personnel for research, audit, or program evaluation.
Violation of the Federal law and regulations by a program is a crime. Suspected violations
may be reported to appropriate authorities in accordance with Federal regulations.
Violation of the Federal law and regulations by a program is a crime. Suspected violations
may be reported to appropriate authorities in accordance with Federal regulations. Federal
law and regulations do not protect any information about a crime committed by a patient
either at the program or against any person who works for the program or about any threat
to commit such a crime. Federal laws and regulations do not protect any information about
suspected child abuse or neglect from being reported under State law to appropriate State or
local authorities.

Confidentiality

§ 2.22 Notice to patients of Federal confidentiality requirements.

Federal law and regulations do not protect any information about a crime
committed by a patient either at the program or against any person who works
for the program or about any threat to commit such a crime. Federal laws and
regulations do not protect any information about suspected child abuse or
neglect from being reported under State law to appropriate State or local
authorities.

§ 2.14 Minor patients (d)(2) The applicant's situation poses a substantial
threat to the life or physical well being of the applicant or any other individual
which may be reduced by communicating relevant facts to the minor's parent,
guardian, or other person authorized under State law to act in the minor's
behalf.

Confidentiality
§ 2.63 Confidential communications.
b)A court order under these regulations may authorize disclosure of confidential
communications made by a patient to a program in the course of diagnosis,
treatment, or referral for treatment only if:
1) The disclosure is necessary to protect against an existing threat to life
or of serious bodily injury, including circumstances which constitute
suspected child abuse and neglect and verbal threats against third
parties;
2) The disclosure is necessary in connection with investigation or
prosecution of an extremely serious crime, such as one which directly
threatens loss of life or serious bodily injury, including homicide, rape,
kidnapping, armed robbery, assault with a deadly weapon, or child
abuse and neglect; or
3) The disclosure is in connection with litigation or an administrative
proceeding in which the patient offers testimony or other evidence
pertaining to the content of the confidential communications.

Treating Co-Occurring Mood & Anxiety Disorders with Substance Use Disorders

Treating Co-Occurring Mood & Anxiety Disorders with Substance Use Disorders

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