Understanding diagnostic criteria is essential for social work practice and for success on the ASWB exam, particularly at the Clinical and Advanced Generalist levels. This comprehensive guide reviews the key DSM-5 diagnostic criteria relevant to the exam, providing condensed, exam-focused information on mental health conditions commonly tested on ASWB exams.
Disclaimer: This resource is designed for exam preparation purposes only and should not be used for clinical diagnosis. Always refer to the complete DSM-5 when making actual diagnostic determinations in practice.
DSM-5 Overview for Social Workers
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the standard classification system for mental disorders used by mental health professionals in the United States. As a social worker, understanding the DSM-5 is essential for effective assessment, treatment planning, and collaboration with other professionals.
History and Purpose of the DSM
- First published by American Psychiatric Association in 1952
- Current edition (DSM-5) released in 2013
- Text Revision (DSM-5-TR) released in 2022
- Provides common language for mental health professionals
- Facilitates reliable diagnosis
- Guides treatment planning and insurance reimbursement
- Supports research and statistical reporting
Multiaxial Assessment vs. Current Approach
The DSM-5 eliminated the multiaxial system used in previous editions:
Previous DSM-IV Multiaxial System:
- Axis I: Clinical disorders
- Axis II: Personality disorders and intellectual disabilities
- Axis III: General medical conditions
- Axis IV: Psychosocial and environmental problems
- Axis V: Global Assessment of Functioning (GAF)
Current DSM-5 Approach:
- Single-axis listing of all diagnoses (mental disorders and medical conditions)
- Dimensional assessments for symptoms and impairment
- Cross-cutting symptom measures to assess domains relevant across disorders
- Specific severity measures for individual disorders
- World Health Organization Disability Assessment Schedule (WHODAS 2.0) replaces GAF
Social Work Perspective on Diagnosis
Social workers bring a unique perspective to the diagnostic process:
- Emphasis on person-in-environment framework
- Recognition of social determinants of mental health
- Focus on strengths alongside challenges
- Consideration of cultural factors affecting presentation
- Awareness of potential for diagnostic labels to stigmatize
- Balance of medical model with recovery and empowerment perspectives
- Integration of diagnosis with social work values and ethics
Biopsychosocial-Spiritual Assessment Integration
Social workers integrate DSM-5 diagnosis within a holistic assessment:
- Biological: Genetics, neurochemistry, physical health, medication
- Psychological: Emotions, thoughts, behaviors, personality traits
- Social: Family dynamics, support systems, community resources
- Spiritual: Meaning, purpose, values, belief systems, cultural practices
- Environmental: Housing, employment, education, socioeconomic status
- Strengths and Protective Factors: Resilience, coping skills, talents
Cultural Considerations in Diagnosis
The DSM-5 includes enhanced attention to cultural factors:
- Cultural Formulation Interview (CFI) to assess cultural factors
- Cultural concepts of distress (idioms, syndromes, explanations)
- Cultural variations in symptom expression
- Impact of cultural beliefs on help-seeking behaviors
- Consideration of cultural explanations for symptoms
- Risk of misdiagnosis when cultural factors are overlooked
Depressive and Bipolar Disorders
Depressive and bipolar disorders are among the most commonly tested conditions on the ASWB exam, especially at the Clinical level.
Major Depressive Disorder Criteria
Core Criteria: Five or more of the following symptoms during a 2-week period, representing a change from previous functioning; at least one symptom must be depressed mood or loss of interest/pleasure:
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in almost all activities
- Significant weight loss/gain or decreased/increased appetite
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive guilt
- Diminished ability to think or concentrate; indecisiveness
- Recurrent thoughts of death, suicidal ideation, or suicide attempt
Additional Requirements:
- Symptoms cause clinically significant distress or impairment
- Not attributable to substance or medical condition
- Not better explained by other mental disorders
- No history of manic or hypomanic episodes
Specifiers include:
- With anxious distress
- With mixed features
- With melancholic features
- With atypical features
- With psychotic features
- With peripartum onset
- With seasonal pattern
Persistent Depressive Disorder (Dysthymia)
Core Criteria: Depressed mood for most of the day, for more days than not, for at least 2 years (1 year for children/adolescents), plus two or more of:
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
Additional Requirements:
- During 2-year period, person has never been without symptoms for more than 2 months
- Clinically significant distress or impairment
- Not attributable to substance, medical condition, or other mental disorder
- No history of manic or hypomanic episodes
Bipolar I and II Disorders
Bipolar I Disorder:
- At least one manic episode (abnormally elevated/irritable mood AND increased energy/activity for at least 1 week, causing marked impairment)
- Manic episode includes 3+ of: grandiosity, decreased sleep need, pressured speech, flight of ideas, distractibility, increased goal-directed activity, excessive involvement in risky activities
- May include major depressive episodes before or after manic episodes
- Not better explained by other disorders
Bipolar II Disorder:
- At least one hypomanic episode (elevated/irritable mood AND increased energy/activity for at least 4 days, observable by others but not causing marked impairment)
- At least one major depressive episode (see criteria above)
- No history of manic episodes
- Not better explained by other disorders
Differential Diagnosis Considerations
Depression vs. Normal Grief:
- Grief may include feelings of emptiness, preoccupation with the deceased
- Grief symptoms typically decrease in intensity over time
- Self-esteem generally preserved in grief
- Suicidal thoughts in grief typically focus on joining the deceased
Depression vs. Medical Conditions:
- Hypothyroidism can mimic depression
- Anemia may cause fatigue and concentration problems
- Medications can cause depressive symptoms (beta-blockers, steroids)
- Neurological conditions may present with depressive features
Bipolar vs. ADHD:
- ADHD has chronic pattern from childhood
- ADHD lacks distinct mood episodes
- ADHD hyperactivity not accompanied by euphoria or grandiosity
- Family history and age of onset may provide clues
Bipolar vs. Borderline Personality Disorder:
- BPD mood shifts are reactive to interpersonal stressors
- BPD mood changes typically brief (hours to days)
- BPD includes chronic pattern of unstable relationships
- BPD features identity disturbance and chronic emptiness
Common Exam Questions About Mood Disorders
The ASWB exam frequently tests:
- Distinguishing between types of depressive and bipolar disorders
- Recognizing suicide risk factors in depressed clients
- Identifying appropriate interventions for different mood disorders
- Understanding how cultural factors influence symptom presentation
- Determining when to refer for medication evaluation
- Recognizing interaction between mood disorders and substance use
Clinical Application for Social Workers
Assessment Considerations:
- Always assess for suicide risk in depressed clients
- Screen for past manic/hypomanic episodes in all depressed clients
- Evaluate impact on functioning across domains
- Consider developmental, cultural, and gender influences
- Assess for co-occurring conditions (anxiety, substance use)
Treatment Approaches:
- Cognitive-Behavioral Therapy (CBT) for depression
- Interpersonal Therapy (IPT) for depression
- Dialectical Behavior Therapy (DBT) skills for emotional regulation
- Psychoeducation for bipolar disorder
- Family involvement in treatment planning
- Collaboration with prescribing professionals
Anxiety Disorders
Anxiety disorders are frequently tested on the ASWB exam at all levels, with particular focus on differentiating between various types.
Generalized Anxiety Disorder Criteria
Core Criteria:
- Excessive anxiety and worry, occurring more days than not for at least 6 months
- Difficulty controlling the worry
- Three or more of the following symptoms:
- Restlessness or feeling keyed up or on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance
Additional Requirements:
- Causes significant distress or impairment
- Not attributable to substance or medical condition
- Not better explained by another mental disorder
Panic Disorder
Core Criteria:
- Recurrent unexpected panic attacks
- At least one attack followed by 1+ month of:
- Persistent concern about additional attacks
- Worry about implications of attacks
- Significant change in behavior related to attacks
Panic Attack Features:
- Abrupt surge of intense fear reaching peak within minutes
- Four or more of the following:
- Palpitations or accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath
- Feelings of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, lightheaded
- Chills or heat sensations
- Paresthesias (numbness or tingling)
- Derealization or depersonalization
- Fear of losing control or “going crazy”
- Fear of dying
Social Anxiety Disorder
Core Criteria:
- Marked fear or anxiety about social situations where scrutiny by others is possible
- Fear of negative evaluation (acting in a way that will be humiliating, embarrassing)
- Social situations almost always provoke fear or anxiety
- Social situations are avoided or endured with intense anxiety
- Fear is out of proportion to actual threat
- Duration of at least 6 months
Additional Requirements:
- Causes significant distress or impairment
- Not attributable to substance, medical condition, or other mental disorder
Specific Phobias
Core Criteria:
- Marked fear or anxiety about a specific object or situation
- Phobic object or situation almost always provokes immediate fear
- Object or situation is actively avoided or endured with intense distress
- Fear is out of proportion to actual danger
- Duration of at least 6 months
Specifiers:
- Animal type
- Natural environment type
- Blood-injection-injury type
- Situational type
- Other type
Differential Diagnosis Considerations
Anxiety vs. Medical Conditions:
- Thyroid disorders can mimic anxiety symptoms
- Cardiac conditions may present with similar physical symptoms
- Caffeine or substance use can cause anxiety-like symptoms
- Neurological conditions may include anxiety features
Distinguishing Between Anxiety Disorders:
- Social anxiety: fear of negative evaluation in social settings
- Specific phobia: fear limited to specific objects/situations
- Panic disorder: unexpected panic attacks and worry about attacks
- GAD: persistent worry across multiple domains
Anxiety vs. OCD:
- OCD features intrusive thoughts and compulsive behaviors
- OCD focus on preventing harm/reducing distress through rituals
- Anxiety disorders feature worry without compulsions
- Both may include avoidance behaviors
Common Exam Questions About Anxiety Disorders
The ASWB exam frequently tests:
- Differentiating between types of anxiety disorders
- Recognizing physical symptoms of anxiety
- Identifying appropriate evidence-based interventions
- Understanding how avoidance maintains anxiety
- Recognizing cultural variations in anxiety expression
- Distinguishing normal anxiety from anxiety disorders
Clinical Application for Social Workers
Assessment Considerations:
- Evaluate impact on daily functioning and relationships
- Assess avoidance behaviors and safety behaviors
- Consider developmental, cultural, and gender influences
- Screen for co-occurring conditions (depression, substance use)
- Distinguish between situational and chronic anxiety
Treatment Approaches:
- Cognitive-Behavioral Therapy (CBT)
- Exposure therapy for phobias and social anxiety
- Mindfulness-based interventions
- Relaxation training and stress management
- Psychoeducation about anxiety
- Referral for medication evaluation when appropriate
Trauma and Stressor-Related Disorders
Trauma-related disorders are heavily emphasized on the ASWB exam, particularly for Clinical and Master’s levels.
Posttraumatic Stress Disorder Criteria
Trauma Exposure: Exposure to actual or threatened death, serious injury, or sexual violence through:
- Direct experience
- Witnessing the event
- Learning event occurred to close family/friend
- Repeated or extreme exposure to aversive details (e.g., first responders)
Symptom Categories: Symptoms from each category following trauma exposure:
- Intrusion Symptoms (1+ required):
- Recurrent, involuntary, intrusive memories
- Traumatic nightmares
- Dissociative reactions (flashbacks)
- Intense distress at trauma reminders
- Marked physiological reactions to reminders
- Avoidance (1+ required):
- Avoidance of trauma-related thoughts or feelings
- Avoidance of trauma-related external reminders
- Negative Alterations in Cognition and Mood (2+ required):
- Inability to remember important aspects of trauma
- Persistent negative beliefs about self/world
- Distorted blame of self or others
- Persistent negative emotional state
- Diminished interest in significant activities
- Feeling detached from others
- Persistent inability to experience positive emotions
- Alterations in Arousal and Reactivity (2+ required):
- Irritable behavior and angry outbursts
- Reckless or self-destructive behavior
- Hypervigilance
- Exaggerated startle response
- Problems with concentration
- Sleep disturbance
Additional Requirements:
- Duration more than 1 month
- Clinically significant distress or impairment
- Not attributable to substance or medical condition
Specifiers:
- With dissociative symptoms (depersonalization or derealization)
- With delayed expression (full criteria not met until 6+ months after event)
Acute Stress Disorder
Core Criteria:
- Exposure to actual or threatened death, serious injury, or sexual violence
- Presence of 9+ symptoms from PTSD categories (intrusion, negative mood, dissociation, avoidance, arousal)
- Duration of 3 days to 1 month after trauma exposure
- Causes significant distress or impairment
- Not attributable to substance or medical condition
Adjustment Disorders
Core Criteria:
- Emotional or behavioral symptoms developing within 3 months of identifiable stressor
- Symptoms are clinically significant:
- Marked distress out of proportion to severity of stressor
- Significant impairment in functioning
- Not meeting criteria for another mental disorder
- Not an exacerbation of preexisting disorder
- Once stressor terminates, symptoms do not persist beyond 6 months
Specifiers:
- With depressed mood
- With anxiety
- With mixed anxiety and depressed mood
- With disturbance of conduct
- With mixed disturbance of emotions and conduct
- Unspecified
Differential Diagnosis Considerations
PTSD vs. Acute Stress Disorder:
- ASD occurs within first month of trauma
- ASD focuses more on dissociative symptoms
- PTSD diagnosed only after symptoms persist beyond one month
- Similar symptom clusters but different timeframes
Trauma Disorders vs. Adjustment Disorders:
- Adjustment disorders follow less severe stressors
- Adjustment disorders lack specific trauma symptom clusters
- Adjustment disorders resolve when stressor ends
- Both involve response to identifiable stressor
PTSD vs. Major Depression:
- Both may include negative mood, sleep disturbance
- PTSD requires trauma exposure
- PTSD includes trauma-specific symptoms
- May co-occur; assess for both conditions
PTSD vs. Anxiety Disorders:
- Both may include hypervigilance, avoidance
- PTSD requires specific trauma exposure
- PTSD includes intrusion symptoms
- PTSD features trauma-specific triggers
Common Exam Questions About Trauma Disorders
The ASWB exam frequently tests:
- Recognizing trauma symptoms across different presentations
- Distinguishing between trauma-related disorders
- Identifying trauma-informed intervention approaches
- Understanding risk and protective factors for PTSD
- Recognizing how cultural factors influence trauma responses
- Identifying appropriate treatment approaches by diagnosis
Clinical Application for Social Workers
Assessment Considerations:
- Use trauma-informed approach in assessment process
- Consider developmental timing of trauma
- Assess for co-occurring conditions
- Evaluate impact on functioning across domains
- Consider cultural expressions of trauma
- Screen for suicidality and substance use
Treatment Approaches:
- Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
- Eye Movement Desensitization and Reprocessing (EMDR)
- Cognitive Processing Therapy (CPT)
- Prolonged Exposure Therapy (PE)
- Skills Training in Affective and Interpersonal Regulation (STAIR)
- Safety planning and stabilization before trauma processing
Schizophrenia Spectrum and Psychotic Disorders
Psychotic disorders are significant content areas on the ASWB Clinical and Advanced Generalist exams.
Schizophrenia Criteria
Core Criteria: Two or more of the following for a significant portion of time during a 1-month period (at least one must be from first three):
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms (diminished emotional expression, avolition)
Additional Requirements:
- Level of functioning significantly below previous levels
- Continuous signs of disturbance for at least 6 months
- Not attributable to substance or medical condition
- Not better explained by another mental disorder
Schizoaffective Disorder
Core Criteria:
- Uninterrupted period of illness with major mood episode (depression or mania) concurrent with Criterion A symptoms of schizophrenia
- Delusions or hallucinations for 2+ weeks in absence of mood episode
- Symptoms meeting mood episode criteria present for majority of active and residual periods of illness
- Not attributable to substance or medical condition
Specifiers:
- Bipolar type
- Depressive type
Brief Psychotic Disorder
Core Criteria:
- Presence of one or more of: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior
- Duration at least 1 day but less than 1 month
- Eventually full return to premorbid level of functioning
- Not better explained by another condition or substance
Specifiers:
- With marked stressor(s)
- Without marked stressor(s)
- With postpartum onset
Differential Diagnosis Considerations
Psychotic Disorders vs. Mood Disorders with Psychotic Features:
- In mood disorders, psychotic features occur primarily during mood episodes
- Schizophrenia includes periods of psychosis without mood symptoms
- Schizoaffective disorder requires periods of psychosis without mood symptoms
- Historical course and pattern of symptoms guide diagnosis
Psychosis vs. Medical Conditions:
- Delirium typically includes fluctuating consciousness
- Dementia features progressive cognitive decline
- Certain medical conditions can cause psychotic symptoms
- Medication and substance effects must be ruled out
Primary Psychotic Disorders vs. Substance-Induced Psychosis:
- Substance-induced psychosis resolves with abstinence
- Timeline of symptom development relative to substance use
- History of psychotic symptoms during abstinence periods
- May co-occur; comprehensive assessment needed
Common Exam Questions About Psychotic Disorders
The ASWB exam frequently tests:
- Distinguishing between different psychotic disorders
- Recognizing positive vs. negative symptoms
- Identifying appropriate intervention approaches
- Understanding risk assessment with psychotic clients
- Recognizing cultural factors in psychosis presentation
- Knowledge of recovery-oriented approaches
Clinical Application for Social Workers
Assessment Considerations:
- Evaluate safety risks (suicide, self-neglect, vulnerability)
- Assess functional impairment across domains
- Gather collateral information when possible
- Consider cultural interpretations of experiences
- Distinguish between cultural/religious beliefs and delusions
- Screen for co-occurring conditions
Treatment Approaches:
- Coordinated Specialty Care for first-episode psychosis
- Cognitive Behavioral Therapy for psychosis (CBTp)
- Family psychoeducation and support
- Case management and community support
- Recovery-oriented services
- Collaboration with prescribing professionals
- Crisis planning and relapse prevention
Substance-Related and Addictive Disorders
Substance use disorders are heavily emphasized across all ASWB exam levels, with increased complexity at the Clinical level.
Substance Use Disorder Criteria
Core Criteria: A problematic pattern of substance use leading to clinically significant impairment or distress, manifested by at least 2 of the following within a 12-month period:
- Taking substance in larger amounts or over longer period than intended
- Persistent desire or unsuccessful efforts to cut down or control use
- Significant time spent obtaining, using, or recovering from substance
- Craving or strong urge to use the substance
- Recurrent use resulting in failure to fulfill major role obligations
- Continued use despite persistent social or interpersonal problems
- Important activities given up or reduced because of substance use
- Recurrent use in physically hazardous situations
- Continued use despite knowledge of physical or psychological problem likely caused or exacerbated by substance
- Tolerance (need for increased amounts or diminished effect)
- Withdrawal (characteristic syndrome or substance taken to avoid withdrawal)
Severity Specifiers:
- Mild: 2-3 symptoms
- Moderate: 4-5 symptoms
- Severe: 6+ symptoms
Course Specifiers:
- In early remission (3-12 months without criteria except craving)
- In sustained remission (12+ months without criteria except craving)
- In a controlled environment
- On maintenance therapy
Specific Substance Categories
The DSM-5 lists substance use disorders for:
- Alcohol
- Cannabis
- Hallucinogens
- Inhalants
- Opioids
- Sedatives, hypnotics, or anxiolytics
- Stimulants
- Tobacco
- Other/unknown substances
Each follows the same general criteria pattern with substance-specific features.
Substance-Induced Disorders
These include:
- Substance Intoxication
- Substance Withdrawal
- Substance-Induced Mental Disorders (e.g., psychotic, bipolar, depressive, anxiety, obsessive-compulsive, sleep, sexual dysfunction, delirium, and neurocognitive disorders)
Key Features:
- Symptoms develop during or shortly after substance use/withdrawal
- Substance involved is capable of producing the symptoms
- Symptoms not better explained by independent mental disorder
- Symptoms cause significant distress or impairment
Differential Diagnosis Considerations
Substance Use vs. Substance-Induced Disorders:
- Substance use disorders focus on problematic pattern of use
- Substance-induced disorders focus on mental symptoms caused by substances
- May co-occur and require separate diagnosis and treatment
Substance-Induced vs. Independent Mental Disorders:
- Timeline of symptom development relative to substance use
- Symptom persistence during periods of abstinence
- Family history and pre-substance use history
- Response to treatment for the mental disorder
Distinguishing Between Substances:
- Characteristic intoxication and withdrawal patterns
- Duration of effects
- Method of administration
- Typical behavioral patterns
- Physical examination findings
Common Exam Questions About Substance Disorders
The ASWB exam frequently tests:
- Recognizing criteria for substance use disorders
- Identifying appropriate level of care based on severity
- Understanding stages of change in addiction treatment
- Recognizing withdrawal symptoms for different substances
- Understanding motivational interviewing techniques
- Identifying evidence-based treatment approaches
- Recognizing co-occurring disorders
Clinical Application for Social Workers
Assessment Considerations:
- Use validated screening tools
- Assess readiness for change
- Evaluate risk (withdrawal, suicidality, medical complications)
- Screen for co-occurring mental health conditions
- Consider family/social system impacts
- Assess for functional impairment across domains
Treatment Approaches:
- Motivational Interviewing
- Cognitive Behavioral Therapy
- Relapse Prevention
- Contingency Management
- Harm Reduction approaches
- Family therapy and education
- Support group referrals
- Collaboration with medical providers for medication-assisted treatment
Neurodevelopmental Disorders
Neurodevelopmental disorders appear frequently on ASWB exams, particularly at the Bachelor’s and Master’s levels.
Attention-Deficit/Hyperactivity Disorder Criteria
Core Criteria: Persistent pattern of inattention and/or hyperactivity-impulsivity interfering with functioning or development:
Inattention: Six or more symptoms (five for 17+ years) persisting for at least 6 months:
- Fails to give close attention to details/makes careless mistakes
- Difficulty sustaining attention in tasks or play
- Does not seem to listen when directly addressed
- Does not follow through on instructions/fails to finish tasks
- Difficulty organizing tasks and activities
- Avoids tasks requiring sustained mental effort
- Loses things necessary for tasks/activities
- Easily distracted by extraneous stimuli
- Forgetful in daily activities
Hyperactivity/Impulsivity: Six or more symptoms (five for 17+ years) persisting for at least 6 months:
- Fidgets or taps hands/feet or squirms in seat
- Leaves seat when remaining seated is expected
- Runs or climbs excessively (restlessness in adolescents/adults)
- Unable to play or engage in leisure activities quietly
- “On the go” or acts as if “driven by a motor”
- Talks excessively
- Blurts out answers before questions completed
- Difficulty waiting turn
- Interrupts or intrudes on others
Additional Requirements:
- Several symptoms present before age 12
- Several symptoms present in two or more settings
- Symptoms interfere with functioning
- Symptoms not better explained by another disorder
Specifiers:
- Combined presentation
- Predominantly inattentive presentation
- Predominantly hyperactive/impulsive presentation
- In partial remission
Autism Spectrum Disorder
Core Criteria:
A. Social Communication/Interaction Deficits: Persistent difficulties across multiple contexts, as manifested by all three:
- Deficits in social-emotional reciprocity
- Deficits in nonverbal communicative behaviors
- Deficits in developing, maintaining, and understanding relationships
B. Restricted, Repetitive Patterns of Behavior, Interests, or Activities: At least two of:
- Stereotyped or repetitive movements, speech, or object use
- Insistence on sameness, rigid routines, or ritualized patterns
- Highly restricted, fixated interests of abnormal intensity
- Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects
Additional Requirements:
- Symptoms present in early developmental period
- Cause clinically significant impairment
- Not better explained by intellectual disability or global developmental delay
Severity Levels:
- Level 1: Requiring support
- Level 2: Requiring substantial support
- Level 3: Requiring very substantial support
Specific Learning Disorders
Core Criteria:
- Difficulties learning and using academic skills, with at least one symptom persisting for 6+ months despite intervention:
- Inaccurate or slow and effortful word reading
- Difficulty understanding the meaning of what is read
- Spelling difficulties
- Written expression difficulties
- Difficulties mastering number sense, number facts, or calculation
- Difficulties with mathematical reasoning
Additional Requirements:
- Skills substantially below expected for age
- Significantly interfere with academic performance or daily activities
- Begin during school-age years
- Not better explained by other factors or conditions
Specifiers:
- With impairment in reading
- With impairment in written expression
- With impairment in mathematics
Differential Diagnosis Considerations
ADHD vs. Autism Spectrum Disorder:
- Both may feature attention difficulties
- ADHD lacks social communication deficits
- ADHD lacks restricted/repetitive behaviors
- May co-occur; comprehensive assessment needed
Learning Disorders vs. Intellectual Disability:
- Learning disorders show specific deficits with normal general cognitive ability
- Intellectual disability shows limitations across all cognitive domains
- Both may co-occur; assess for patterns of strengths and weaknesses
ADHD vs. Normal Development:
- Normal development includes age-appropriate attention span and activity level
- ADHD symptoms are significantly beyond developmental expectations
- ADHD symptoms persist across settings and cause impairment
- Consider cultural expectations and environmental factors
Common Exam Questions About Neurodevelopmental Disorders
The ASWB exam frequently tests:
- Recognizing diagnostic criteria for common neurodevelopmental disorders
- Understanding appropriate school accommodations
- Identifying evidence-based interventions
- Recognizing how symptoms manifest differently across development
- Understanding family-centered approaches to intervention
- Knowledge of interdisciplinary collaboration in treatment
Clinical Application for Social Workers
Assessment Considerations:
- Gather information from multiple sources and settings
- Consider developmental and cultural factors
- Assess functional impact across domains
- Screen for co-occurring conditions
- Review educational history and testing
- Consider environmental influences on symptoms
Treatment Approaches:
- Behavioral interventions
- Parent management training
- School-based accommodations and supports
- Social skills training
- Collaboration with educational professionals
- Family education and support
- Coordination with prescribing professionals
Personality Disorders
Personality disorders are extensively tested on Clinical and Advanced Generalist exams.
Cluster Overview
Personality disorders are grouped into three clusters:
Cluster A (Odd/Eccentric):
- Paranoid Personality Disorder
- Schizoid Personality Disorder
- Schizotypal Personality Disorder
Cluster B (Dramatic/Emotional/Erratic):
- Antisocial Personality Disorder
- Borderline Personality Disorder
- Histrionic Personality Disorder
- Narcissistic Personality Disorder
Cluster C (Anxious/Fearful):
- Avoidant Personality Disorder
- Dependent Personality Disorder
- Obsessive-Compulsive Personality Disorder
Borderline Personality Disorder Criteria
Core Criteria: Pervasive pattern of instability in interpersonal relationships, self-image, affects, and marked impulsivity, beginning by early adulthood and present in various contexts, as indicated by five or more of:
- Frantic efforts to avoid real or imagined abandonment
- Pattern of unstable and intense interpersonal relationships
- Identity disturbance with markedly and persistently unstable self-image
- Impulsivity in at least two potentially self-damaging areas
- Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior
- Affective instability due to marked reactivity of mood
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress-related paranoid ideation or severe dissociative symptoms
Antisocial Personality Disorder Criteria
Core Criteria: Pervasive pattern of disregard for and violation of the rights of others occurring since age 15, as indicated by three or more of:
- Failure to conform to social norms concerning lawful behaviors
- Deceitfulness, repeated lying, use of aliases, or conning others
- Impulsivity or failure to plan ahead
- Irritability and aggressiveness with repeated physical fights or assaults
- Reckless disregard for safety of self or others
- Consistent irresponsibility in work or financial obligations
- Lack of remorse for consequences of actions
Additional Requirements:
- Individual is at least age 18
- Evidence of conduct disorder onset before age 15
- Not occurring exclusively during schizophrenia or bipolar disorder
Narcissistic Personality Disorder Criteria
Core Criteria: Pervasive pattern of grandiosity, need for admiration, and lack of empathy, beginning by early adulthood and present in various contexts, as indicated by five or more of:
- Grandiose sense of self-importance
- Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
- Believes they are “special” and unique
- Requires excessive admiration
- Sense of entitlement
- Interpersonally exploitative
- Lacks empathy
- Often envious of others or believes others are envious of them
- Shows arrogant, haughty behaviors or attitudes
Differential Diagnosis Considerations
Personality Disorders vs. Other Mental Disorders:
- Personality disorders feature enduring, inflexible patterns of inner experience and behavior
- Symptoms present by early adulthood
- Stable across time and situations
- Other mental disorders may feature episodic symptoms
- May co-occur and require separate diagnosis
Differentiating Between Personality Disorders:
- Consider predominant pattern of interpersonal difficulties
- Evaluate emotional regulation strategies
- Assess self-concept and identity formation
- Consider core motives and fears
- Evaluate reality testing and cognitive patterns
Cultural Considerations:
- Behavior must deviate from cultural norms to be considered disordered
- Cultural context influences expression of personality traits
- Avoid pathologizing cultural differences
- Consider acculturation and cultural conflict
Common Exam Questions About Personality Disorders
The ASWB exam frequently tests:
- Distinguishing between different personality disorders
- Identifying appropriate therapeutic approaches
- Understanding countertransference reactions
- Recognizing splitting and other defense mechanisms
- Identifying risk assessment and management strategies
- Understanding boundary challenges in treatment
Clinical Application for Social Workers
Assessment Considerations:
- Gather comprehensive history and collateral information
- Assess impact on functioning across domains
- Evaluate risk (suicide, self-harm, aggression)
- Consider trauma history and attachment patterns
- Screen for co-occurring conditions
- Be aware of potential countertransference reactions
Treatment Approaches:
- Dialectical Behavior Therapy (DBT) for Borderline Personality Disorder
- Mentalization-Based Therapy
- Schema-Focused Therapy
- Transference-Focused Psychotherapy
- Cognitive-Behavioral approaches
- Establishing clear boundaries and consistency
- Long-term treatment planning and realistic goal-setting
Neurocognitive Disorders
Neurocognitive disorders are increasingly emphasized on ASWB exams, particularly at the Clinical level.
Major and Mild Neurocognitive Disorder Criteria
Major Neurocognitive Disorder:
- Evidence of significant cognitive decline from previous level of performance in one or more cognitive domains:
- Complex attention
- Executive function
- Learning and memory
- Language
- Perceptual-motor
- Social cognition
- Cognitive deficits interfere with independence in everyday activities
- Not occurring exclusively during delirium
- Not better explained by another mental disorder
Mild Neurocognitive Disorder:
- Evidence of modest cognitive decline from previous level of performance in one or more cognitive domains
- Cognitive deficits do not interfere with independence in everyday activities (may require greater effort or compensatory strategies)
- Not occurring exclusively during delirium
- Not better explained by another mental disorder
Specifiers for Both:
- With or without behavioral disturbance
- Etiological subtype (e.g., Alzheimer’s disease, vascular, frontotemporal, etc.)
Alzheimer’s Disease
Core Features:
- Insidious onset and gradual progression of impairment
- Clear evidence of decline in memory and learning
- Steadily progressive cognitive decline without extended plateaus
- No evidence of mixed etiology
- Often includes:
- Memory impairment (especially recent events)
- Word-finding difficulties
- Visuospatial deficits
- Executive dysfunction
Three Stages (Major NCD due to Alzheimer’s):
- Mild: Difficulty learning new information, word-finding problems, getting lost on familiar routes
- Moderate: Memory of recent events severely impaired, disorientation, need for assistance with ADLs
- Severe: Unable to retain new information, limited speech, complete dependence for basic care
Vascular Neurocognitive Disorder
Core Features:
- Onset often related to cerebrovascular event
- May have stepwise progression (sudden changes followed by periods of stability)
- Fluctuating, patchy cognitive deficits
- Evidence of cerebrovascular disease on imaging
- Often includes:
- Slowed processing speed
- Impaired executive function
- Variable memory impairment
- Mood changes and apathy
Differential Diagnosis Considerations
Neurocognitive Disorders vs. Normal Aging:
- Normal aging involves modest cognitive changes without functional impairment
- Age-associated memory impairment less progressive than dementia
- Consider premorbid functioning and expectations
- Extensive assessment may be needed to differentiate mild NCD from normal aging
Alzheimer’s vs. Vascular Dementia:
- Alzheimer’s typically shows gradual, steady decline
- Vascular dementia often shows stepwise progression
- Mixed presentations are common
- Neuroimaging helps distinguish vascular contributions
- Family history and risk factors provide clues
Neurocognitive Disorders vs. Depression:
- “Pseudodementia” may occur with severe depression
- Depressed patients often emphasize cognitive problems
- Cognitive symptoms may improve with depression treatment
- Can co-occur; comprehensive assessment needed
- Neuropsychological testing may help differentiate
Common Exam Questions About Neurocognitive Disorders
The ASWB exam frequently tests:
- Distinguishing between different types of neurocognitive disorders
- Identifying appropriate interventions for various stages
- Understanding capacity and ethical decision-making
- Recognizing caregiver stress and support needs
- Knowledge of advance care planning
- Understanding behavioral interventions for dementia-related behaviors
Clinical Application for Social Workers
Assessment Considerations:
- Gather comprehensive history from multiple informants
- Consider cultural and educational factors in presentation
- Assess functional abilities (ADLs, IADLs)
- Evaluate safety risks (driving, medication management, wandering)
- Screen for depression, anxiety, and psychosis
- Assess caregiver stress and resources
Treatment Approaches:
- Environmental modifications for safety and function
- Behavioral approaches for challenging behaviors
- Caregiver education and support
- Advance care planning
- Referrals for appropriate level of care
- Coordination with healthcare providers
- Connecting to community resources
Diagnostic Assessment in Practice
Effective diagnostic assessment goes beyond simply identifying symptoms that match DSM-5 criteria.
Taking a Diagnostic History
A comprehensive diagnostic history includes:
- Presenting problem (onset, duration, severity, context)
- Previous mental health history and treatment
- Medical history and current conditions
- Medication history (prescribed, over-the-counter, supplements)
- Substance use history
- Family history of mental health and medical conditions
- Developmental history
- Trauma history
- Social and relationship history
- Educational and occupational history
- Cultural and spiritual background
- Strengths and coping strategies
- Current stressors and supports
Mental Status Examination Elements
The Mental Status Examination (MSE) includes assessment of:
- Appearance: Grooming, dress, physical characteristics
- Behavior: Psychomotor activity, eye contact, unusual movements
- Speech: Rate, volume, articulation, fluency
- Mood: Self-reported emotional state
- Affect: Observed emotional expression (range, intensity, appropriateness)
- Thought Process: Flow of thought, organization, coherence
- Thought Content: Preoccupations, obsessions, delusions, suicidal/homicidal ideation
- Perceptual Disturbances: Hallucinations, illusions, depersonalization
- Cognition: Orientation, attention, memory, concentration, abstraction
- Insight: Awareness of condition and need for treatment
- Judgment: Decision-making ability and foresight
Screening Tools and Assessments
Commonly used screening tools include:
- Depression: Patient Health Questionnaire (PHQ-9)
- Anxiety: Generalized Anxiety Disorder 7-item scale (GAD-7)
- PTSD: PTSD Checklist for DSM-5 (PCL-5)
- Substance Use: CAGE, AUDIT, DAST
- Bipolar Disorder: Mood Disorder Questionnaire (MDQ)
- Cognitive Screening: Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA)
- ADHD: Adult ADHD Self-Report Scale (ASRS), Conners Rating Scales
- Trauma: Adverse Childhood Experience (ACE) Questionnaire
Documenting Diagnostic Impressions
Effective diagnostic documentation includes:
- Specific DSM-5 diagnosis with code
- Supporting evidence for diagnosis (symptoms, timeline, impairment)
- Rule-out diagnoses requiring further assessment
- Differential diagnostic considerations
- Severity and specifiers when applicable
- Contextual factors influencing presentation
- Areas needing further assessment
- Provisional nature of diagnosis when appropriate
- Cultural formulation when relevant
Common Exam Questions About Assessment Process
The ASWB exam frequently tests:
- Applying the biopsychosocial assessment framework
- Selecting appropriate screening tools
- Distinguishing between symptoms of different disorders
- Recognizing when to refer for specialized assessment
- Understanding cultural factors in assessment
- Identifying key components of mental status examination
Diagnostic Challenges and Considerations
Accurate diagnosis faces many challenges that social workers must navigate.
Cultural Formulation in Diagnosis
The DSM-5 Cultural Formulation framework includes:
- Cultural identity of the individual
- Cultural conceptualizations of distress
- Psychosocial stressors and cultural features of vulnerability/resilience
- Cultural features of the relationship between individual and clinician
- Overall cultural assessment for diagnosis and care
Cultural considerations include:
- Cultural variations in symptom expression
- Culture-bound syndromes
- Impact of acculturation and migration
- Religious and spiritual beliefs
- Cultural norms regarding help-seeking
- Language barriers in assessment
- Cultural stigma around mental health
Co-occurring Conditions
Challenges with co-occurring conditions include:
- Symptom overlap between disorders
- One condition masking symptoms of another
- Interaction effects between conditions
- Prioritizing treatment targets
- Distinguishing between primary and secondary conditions
- Integrated treatment approaches
- Impact on prognosis and recovery
Developmental Considerations
Developmental factors influencing diagnosis include:
- Age-appropriate vs. pathological behaviors
- Developmental manifestations of symptoms across the lifespan
- Impact of developmental delays on presentation
- Continuity and discontinuity of disorders across development
- Parent/caregiver reports vs. self-report
- Assessment approaches appropriate to developmental level
- Normative transitions vs. disorder-related impairment
Substance Use Complicating Diagnosis
Substance use creates diagnostic challenges including:
- Distinguishing substance-induced vs. independent disorders
- Timing of symptom onset relative to substance use
- Persistence of symptoms during abstinence periods
- Self-medication patterns
- Withdrawal symptoms mimicking other disorders
- Need for reassessment after period of abstinence
- Integrated assessment of both conditions
Medical Conditions that Mimic Psychiatric Symptoms
Medical conditions to consider include:
- Thyroid disorders (hyper/hypothyroidism)
- Neurological conditions (seizure disorders, dementia, brain injury)
- Vitamin deficiencies (B12, folate)
- Endocrine disorders
- Autoimmune conditions
- Infections (urinary tract infections in elderly, HIV, syphilis)
- Sleep disorders
- Medication side effects
How These Complexities Appear on the Exam
The ASWB exam frequently includes scenarios that:
- Present complex cases with multiple potential diagnoses
- Require distinguishing between disorders with similar presentations
- Include cultural factors influencing symptom expression
- Test knowledge of medical conditions affecting mental status
- Evaluate understanding of substance effects on presentation
- Require consideration of developmental contexts
Diagnostic Criteria Study Strategies
Effective study of diagnostic criteria requires systematic approaches.
Effective Approaches to Learning Criteria
- Focus on understanding conceptual frameworks rather than memorizing criteria lists
- Study related disorders together to understand distinctions
- Create comparison charts of similar disorders
- Learn core features that distinguish disorder categories
- Connect criteria to case examples for contextual understanding
- Review criteria regularly using spaced repetition
- Teach concepts to others to reinforce understanding
Creating Diagnostic Decision Trees
Diagnostic decision trees help organize thinking:
- Start with broad categories (mood, anxiety, psychotic disorders)
- Branch to specific disorders based on key distinguishing features
- Include duration and severity thresholds
- Note exclusion criteria
- Include medical and substance considerations
- Create visual diagrams showing decision points
Mnemonic Devices for Key Criteria
Mnemonics help recall complex criteria sets:
- Major Depression: SIGECAPS (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidal)
- PTSD: TRAUMA (Trigger avoidance, Re-experiencing, Unable to function, Month+ duration, Arousal increased)
- Borderline Personality Disorder: EMOTIONALLY UNSTABLE (Empty, Moods unstable, Out of control, Temper, Identity issues, Outbursts, Notions of abandonment, Attempts at self-harm, Labile relationships, Unstable self-image, Neurotic anxiety, Stress-related paranoia, Temptation for impulsivity, Angry, Black-and-white thinking, Lethal behavior, Empty relationships)
- Generalized Anxiety Disorder: WATCHER (Worry, Appetite disturbance, Tense, Concentration problems, Hypervigilance, Energy decreased, Restlessness)
Practice with Differential Diagnosis
- Analyze case vignettes and identify potential diagnoses
- List evidence supporting and contradicting each possible diagnosis
- Consider alternative explanations for symptoms
- Apply decision trees to complex cases
- Practice explaining rationale for final diagnosis
- Review common misdiagnosis patterns
Self-Testing Methods
- Create flashcards with symptoms on one side, diagnosis on other
- Develop case scenarios and determine diagnosis
- Take practice tests with diagnostic questions
- Explain diagnostic criteria to peers without reference materials
- Convert criteria to question format and quiz yourself
- Use online resources with diagnostic practice exercises
Resources for Further Study
- DSM-5 and DSM-5-TR
- DSM-5 Clinical Cases book
- ASWB practice exams focusing on diagnosis
- Case studies with diagnostic explanations
- Clinical assessment textbooks
- Online differential diagnosis resources
Practice MCQs on Diagnostic Criteria
Question 1
A social worker is conducting an assessment with a 32-year-old client who reports persistent sadness, loss of interest in usually enjoyable activities, fatigue, difficulty concentrating, and insomnia for the past month following the death of her mother. The symptoms have caused significant distress but have not impaired her ability to work. Which of the following is the MOST appropriate diagnostic consideration?
A) Major Depressive Disorder B) Persistent Depressive Disorder C) Adjustment Disorder with Depressed Mood D) Uncomplicated Bereavement
Answer: C) Adjustment Disorder with Depressed Mood
Explanation: While the symptoms include depressive features, the one-month duration and clear connection to a specific stressor (mother’s death) point toward Adjustment Disorder. Major Depressive Disorder would require two weeks of symptoms but also significant functional impairment. Persistent Depressive Disorder requires two years of symptoms. Uncomplicated Bereavement is not a DSM-5 diagnosis; grief reactions are considered in the context of potential adjustment or depressive disorders.
Question 2
A social worker is assessing a 40-year-old client who reports a lifelong pattern of unstable relationships, chronic feelings of emptiness, intense fear of abandonment, and multiple episodes of self-harm when feeling rejected. The client also describes mood swings that typically last a few hours to a few days. Which diagnosis would be MOST consistent with these symptoms?
A) Bipolar II Disorder B) Borderline Personality Disorder C) Major Depressive Disorder with anxious distress D) Histrionic Personality Disorder
Answer: B) Borderline Personality Disorder
Explanation: The symptoms described match key criteria for Borderline Personality Disorder, including unstable relationships, chronic emptiness, fear of abandonment, self-harm behaviors, and affective instability. The brief duration of mood shifts (hours to days) is characteristic of BPD rather than Bipolar Disorder, which features longer mood episodes. The pattern is described as lifelong, consistent with personality disorders.
Question 3
A social worker is evaluating a 28-year-old client who reports recurrent, unexpected panic attacks with intense fear, heart palpitations, shortness of breath, and fear of dying. The client has become increasingly worried about having additional attacks and has started avoiding crowded places where attacks have occurred. Which diagnosis is MOST appropriate?
A) Generalized Anxiety Disorder B) Panic Disorder C) Agoraphobia D) Social Anxiety Disorder
Answer: B) Panic Disorder
Explanation: The description includes key diagnostic criteria for Panic Disorder: recurrent unexpected panic attacks followed by persistent concern about additional attacks and avoidance behavior. While avoidance is present, it’s specifically related to places where panic attacks have occurred, which is consistent with Panic Disorder. Agoraphobia would involve broader fear and avoidance of multiple situations due to concerns about escape or help availability. Generalized Anxiety and Social Anxiety do not feature panic attacks as the central symptom.
Question 4
A social worker at a community mental health center is conducting an assessment with a 25-year-old client who reports using cocaine every weekend for the past year. The client has tried unsuccessfully to cut down, spends significant time obtaining and using cocaine, has developed tolerance, and continues to use despite relationship problems caused by the use. The MOST appropriate diagnosis would be:
A) Cocaine Use Disorder, Mild B) Cocaine Use Disorder, Moderate C) Cocaine Use Disorder, Severe D) Cocaine Intoxication
Answer: B) Cocaine Use Disorder, Moderate
Explanation: The client exhibits at least 4 symptoms of Substance Use Disorder: unsuccessful efforts to cut down, significant time spent obtaining/using, tolerance, and continued use despite social problems. Under DSM-5 criteria, 4-5 symptoms indicate Moderate Substance Use Disorder. Mild would involve 2-3 symptoms, while Severe requires 6+ symptoms. Cocaine Intoxication would describe the acute effects of cocaine use rather than the pattern of problematic use.
Question 5
A social worker is evaluating a 72-year-old client who displays gradually worsening memory problems over the past 18 months, particularly for recent events. The client now requires assistance with managing finances and medications, has become repetitive in conversations, and gets disoriented in unfamiliar settings. Medical evaluation has ruled out other causes. Which diagnosis is MOST likely?
A) Major Neurocognitive Disorder due to Alzheimer’s Disease B) Mild Neurocognitive Disorder due to Alzheimer’s Disease C) Adjustment Disorder with Anxiety D) Major Depressive Disorder with cognitive symptoms
Answer: A) Major Neurocognitive Disorder due to Alzheimer’s Disease
Explanation: The client shows significant cognitive decline that interferes with independence (requiring assistance with finances and medications), which is consistent with Major Neurocognitive Disorder. The gradual progression and prominent memory impairment are typical of Alzheimer’s etiology. Mild Neurocognitive Disorder would not involve significant interference with independent functioning. Depression can cause cognitive symptoms but typically doesn’t show the progressive pattern described, and an adjustment disorder would be connected to a specific stressor rather than showing gradual progression.
Call to Action
Understanding diagnostic criteria is essential for effective social work practice and success on the ASWB exam. To enhance your diagnostic knowledge:
- Practice applying diagnostic criteria to case scenarios
- Study related disorders together to understand subtle distinctions
- Review common comorbidities and differential diagnosis considerations
- Connect diagnostic knowledge to appropriate interventions
- Explore how cultural factors influence symptom presentation and diagnosis
For comprehensive exam preparation, pair your diagnostic knowledge with understanding of evidence-based interventions, theoretical approaches, and professional terminology. Practice applying diagnostic concepts with our diagnosis content area practice tests and level-specific practice exams.
Remember, while diagnostic knowledge is critical, the social work perspective emphasizes seeing the whole person beyond any diagnosis, focusing on strengths and recovery in addition to symptom management.