TPC-Journal-V4-Issue3

The Professional Counselor \Volume 4, Issue 3 236 will happen, or worries about losing control of oneself. The severity of the anxious distress specifier also is noted, using mild, moderate, moderate-severe and severe. This specifier was added because clinicians frequently described the presence of some symptoms of anxiety in their clients who have major depressive disorder. Often, the threshold is not met for a comorbid anxiety disorder diagnosis but the symptoms are significant nonetheless. Clients with anxious distress are more likely to attempt suicide and may require more intensive treatment than those with depression alone; therefore, it is essential that counselors note these symptoms in the diagnosis (APA, 2013; Goldberg, 2013). The specifier with mixed features applies when clients have subthreshold hypomania most days in addition to symptoms of depression. For example, the criteria require three of the following symptoms to be present nearly every day during most of the days in the depressive episode: elevated mood, grandiosity, pressured speech, racing thoughts, increased energy, involvement in risky activities or decreased need for sleep. This specifier is important to note because clients who have major depressive disorder with mixed features are more likely to develop bipolar I or bipolar II disorder (Coryell, 2013). Because treatment for the bipolar disorders is often different from treatment for major depressive disorder, noting the mixed features is important to help clinicians track changes in the client’s symptoms closely. A final change in DSM-5 that affects multiple diagnoses, including major depressive disorder, is the inclusion of cross-cutting symptom measures (APA, 2013). The goals of these instruments are to help clinicians understand client symptoms more effectively, to identify co-morbidity of symptoms and to track changes in symptoms over time (Clarke, 2013). The Level 1 Cross-Cutting Symptom Measure–Adult is a self-report measure for adults to provide clinicians with information about the presence of symptoms. This measure also can be completed by an informant if the individual lacks the capacity to do so (APA, 2013). The measure consists of 23 questions related to 13 domains such as depression, anger and anxiety. To complete the measure, an individual rates the presence of symptoms over the past 2 weeks using a 5-point Likert scale (0 = none or not at all to 4 = severe or nearly every day ). For most of the domains, a rating of mild or greater on any item is an indicator for a clinician to conduct a more detailed assessment (APA, 2013). However, for suicidality, psychosis and substance use, endorsement of any symptoms necessitates further investigation. Further assessment may include the use of the level 2 cross-cutting symptom measures. These domain-specific instruments are not included in DSM-5, but are available online at http://psychiatry.org/practice/dsm/dsm5/online-assessment- measures (APA, 2014). The cross-cutting measures can be administered numerous times for initial and ongoing assessment. Clinical trials revealed that the measures are easy to use and incorporate into daily practice and provide meaningful information (Clarke, 2013). Clients who participated in the clinical trials felt better understood by their clinicians when they used these measures (Clarke, 2013). Therefore, cross-cutting measures in the DSM-5 can be excellent information-gathering tools that counselors can use to make informed diagnostic and treatment decisions. Bipolar I Disorder As described above, bipolar I disorder is now included in a separate section for bipolar and related disorders, and the complete diagnostic criteria list is found in one place (i.e., APA, 2013, p. 123). The core prerequisite for bipolar I disorder continues to be the presence of at least one manic episode, and several of the criteria for the manic episode were revised to increase clarity. For example, criterion A for a manic episode in the DSM-IV-TR describes “a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)” (APA, 2000, p. 362). In the DSM-5 , the phrase “and present most of the day, nearly every day” was added to clarify how frequently the mood state must be present (APA, 2013, p. 124). Similarly, in criterion B, the DSM-5 specifies that the elevated, expansive or irritable mood must “represent a noticeable change from