Diagnosing with the DSM-5


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This is the lecture version last uploaded/updated April 16, 2015 for a presentation made on April 17, 2015 for the NCADD of Middlesex County, NJ.

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Diagnosing with the DSM-5

  1. 1. Copyright © 2015, Glenn Duncan Do not reproduce any workshop materials without express written consent. Diagnosing with the DSM-5 Glenn Duncan LPC, LCADC, CCS, ACS
  2. 2. PPT online at SlideShare http://slidesha.re/Wp9KmB
  3. 3. DSM-5 Controversies  National Institute of Mental Health – “NIMH will be re-orienting its research away from DSM categories,” towards it’s own research oriented criteria. “NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.” http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml  NIMH also stated that future research projects utilizing DSM-5 criteria will likely not be funded, and researchers will need to use RDoC’s to gain funding.  Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life Hardcover - by Allen Frances (Chair of the DSM-IV Task Force) http://www.amazon.com/Saving-Normal-Out-Control-Medicalization/dp/0062229257
  4. 4. DSM-5 Controversies  Psychiatry's New Diagnostic Manual: “Don't Buy It. Don't Use It. Don't Teach It.” ‘That's what psychiatrist Allen Frances, chair of the DSM-IV task force, has to say about DSM-5.’ – Motherjones.com: http://www.motherjones.com/politics/2013/05/psychiatry-allen-frances- saving-normal-dsm-5-controversy  Allen went on to make the following quote: “It's important that the diagnostic system be taken away from the American Psychiatric Association. It needs to be in safer hands.”  He also had this to say about Big Pharma’s influence on the DSM: “We're spending a fortune on treating kids who don't have ADD with drugs rather than taking care of the schools.”
  5. 5. Differential Diagnosis as Used by the DSM  "Differential diagnosis" is the method by which a clinician determines what DSM-5 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-5 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 looks at a disorder being discussed and how the disorder is distinguished behaviors that are NOT classified as disorders.
  6. 6. Differential Diagnosis as Used by the DSM  Differential Diagnosis also looks at the disorder being discussed and how they ARE distinguished from other disorders (of the same class) in the DSM.  Finally, the disorder, or class of disorders, being discussed and how they ARE distinguished from other disorders, diseases or conditions outside of the DSM.  The process of differential diagnosis can be broken down into 4 basic steps: 1. Ruling out malingering and factitious disorders (i.e., ruling out if the person is not being honest about the nature of or severity of their symptoms) 2. Ruling out substance related cause for the disorder (i.e., whether the symptoms exhibited are arising from a substance exerting a direct effect on the central nervous system) 3. Ruling out a medical conditional causing the disorder (i.e., whether the symptoms are due to a general medical condition). 4. Determining the primary disorder.
  7. 7. SUD exercise – The Secretary A 35 year old secretary sought consultation for “anxiety attacks”. A thorough history revealed that the attacks started again within the past 2 days. She has a history of anxiety and stated she was diagnosed with “an anxiety disorder” after the attacks that occurred on 9/11 as she worked in NYC near ground zero. She reported past feelings of nervousness and anxiety, irritability and anger and difficulty sleeping. She stated that shortly after being diagnosed, she tried many different [benzodiazepine] medications that made her drowsy and ineffective at work, so she stopped them.
  8. 8. SUD exercise – The Secretary Due to the fact that no medications worked for her and her “anxiety problem” persisted, she stated she took matters into her own hand and started smoking marijuana. At first her marijuana usage was once per week, but starting in 2008 she increased her slowly, at first to 2-3 times per week, but by 2010 she was smoking marijuana daily. Since 2012 she smokes daily, smoking several times per day at least 4-5 days of the week. Her company recently initiated a new drug screen policy and told all employees that there will be a mandatory drug test for all within the next month, so she decided to stop smoking marijuana. Her last use of marijuana was 3 days ago. Using differential diagnosis, come up with 2 possible disorders this person could be suffering from, and decide which of the 2 best fit the clinical picture.
  9. 9. 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.”
  10. 10. Clinically Significant (statistically uncommon) 2.5% - 5% In psychological testing clinically significant is 2 standard deviations above the norm. For example, 130 I.Q., 70 on the MMPI-2 2.5% - 5%
  11. 11. What constitutes a “mental disorder”? DSM-5 Definition of Mental Disorder:  A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.  Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.  An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.  Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders 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).
  12. 12. DSM-5 Symptoms vs. Signs  Symptoms Versus Signs: Important to Keep in Mind  In order to assess an individual using the DSM, a professional must be aware of signs and symptoms reported by the client/patient.  Symptoms  Symptoms are subjective. They are what a patient can feel and therefore what they complain about.  Signs  Signs are objective. Signs are what a counselor can see when looking at a patient.    Cautionary Note regarding DSM-5 Symptoms  The symptoms contained in the respective diagnostic criteria sets do not constitute comprehensive definitions of underlying disorders, which encompass cognitive, emotional, behavioral, and physiological processes that are far more complex than can be described in the brief [DSM-5] summaries.
  13. 13. DSM-5 – Removal of the Multiaxial System  DSM-5 will move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III.  Separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).  DSM-5’s 20 chapters are restructured based on disorders’ apparent relatedness to one another, as reflected by similarities in disorders’ underlying vulnerabilities and symptom characteristics.  The changes will align DSM-5 with the World Health Organization’s (WHO) International Classification of Diseases, eleventh edition (ICD-11 – which is due out in October, 2014) and are expected to facilitate improved communication and common use of diagnoses across disorders within chapters.  Axis V is dropped for “SEVERAL” reasons including its lack of clarity and questionable psychometrics (that would be a “COUPLE” of reasons, not several).
  14. 14. Replacing the Multiaxial System Is …  Non axial system  Axis I, II and III are simply listed as independent diagnoses.  Axis IV (psychosocial, environmental problems) can be listed in a paragraph form using the DSM-IV content areas. It can also be listed as ICD-9 V codes.  Axis V is eliminated. The argument being that diagnostic categories now have severity scales (mild, moderate, severe) listed for each diagnosis.  The DSM-5 does give some guidance that if you like, you can use the WHO Disability Schedule (WHODAS) in place of Axis V (Global Assessment of Functioning Scale). The DSM-5 includes instructions for using this measure, which captures the degree of disability. However, they don’t endorse it and state it has not been sufficiently validated.
  15. 15. Replacing Not Otherwise Specified (NOS) is …  “Other Specified” or “Unspecified”  Of course they would like you to diagnose it … at the very least see if it fits MILD on a severity scale of a disorder.  If not, use the classification “Other Specified” and explain what it is that keeps the individual from meeting the standard diagnostic criteria (e.g., insufficient symptoms, insufficient duration)  Use the classification “Unspecified” if the clinician decides not to specify a reason that the standard diagnostic criteria cannot be met.  BOTTOM LINE: The DSM-5 stated they want to eliminate the NOS category as some studies were showing upwards of 20% of diagnosing used this category. In DSM-5 Beta, they first changed this to NEC (not elsewhere classified), but then stated they were not going to allow this type of categorization to occur in the DSM-5. What we ended up with are TWO NOS categories … “Other Specified” and Unspecified”.
  16. 16. DSM-5 and the ICD-10  The official coding system in use in the United States is the International Classification of Diseases, Tenth revision, Clinical Modification (ICD-10-CM). Most DSM-5 disorders have a numerical ICD-10 code that precedes the name of the disorder in the classification and accompanies the criteria set for each disorder. ICD-10-CM codes are next to the DSM-5 codes.  The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes.  ICD is used by physicians, nurses, other providers, researchers, health information managers and coders, health information technology workers, policy-makers, insurers and patient organizations  Finally, ICD is used for reimbursement and resource allocation decision-making by countries.
  17. 17. Diagnostic Classification History  Emil Kraepelin (1856-1926)  Working as Director at the University of Dorpat in Livonia (now University of Tartu in Estonia), Kraepelin created detailed histories of a variety of patients.   These records led to his first breakthrough in psychiatry.  Prior to Kraepelin, the disorders “dementia praecox” (now called schizophrenia) and manic-depression were viewed as a unitary concept.   Kraepelin separated them and described the pattern of symptoms and course associated with each disorder.  He determined that manic-depression was intermittent while dementia praecox was deteriorating.  (Later, it became clear that dementia praecox was not always associated with mental decline; therefore, it was renamed by Eugene Bleuler.) Kraepelin’s contribution to classification is significant because of its organization.   Although predecessors had grouped diseases based on similarity of symptoms, Kraepelin used a medical model and grouped them based on a pattern of symptoms.   He realized that the same symptom could occur across disorders but that different disorders have different patterns of symptoms.
  18. 18. History of the DSM  1840 1 Dx – U.S. Census – Idiocy/Insanity  Also in the 1840s, southern alienists discovered a malady called Drapetomania - the inexplicable, mad longing of a slave for freedom.  1880 7 Dx’s – U.S. Census  Mania – mostly as defined today, a condition characterized by severely elevated mood.  Melancholia – would be noted as depression today.  Monomania - Pathological obsession with a single subject or idea. Excessive concentration of interest upon one particular subject or idea. The difference between monomania and passion can be very subtle and difficult to recognize.  Paresis – general or partial paralysis. (This would not be the last time that a physical affliction crept into the psychological arena; among the disorders described in the DSM-IV –TR is snoring, or Breathing Related Sleep Disorder 780.59, pp. 615-622).  Dementia – as described today as characterized by multiple cognitive deficits that include impairment in memory (most common Alzheimer's).  Dipsomania - An insatiable craving for alcoholic beverages.  Epilepsy
  19. 19. History of the DSM  1940 – 26 Dx's (ICD-6; WHO)  Which took its nomenclature from the US Army and Veterans Administration nomenclature. The WHO system included 10 categories for psychoses, 9 for psychoneuroses, and 7 for disorders of character, behavior, and intelligence)  1952 DSM – 106 Dx’s  DSM-I included 3 categories of psychopathology: organic brain syndromes, functional disorders, and mental deficiency.  These categories contained 106 diagnoses.  Only one diagnosis, Adjustment Reaction of Childhood/Adolescence, could be applied to children.  1968 DSM-II – 185 Dx’s (revised DSM-II, 1974)  It had 11 major diagnostic categories.  Increased attention was given to the problems of children and adolescence with the categorical addition of Behavior Disorders of Childhood-Adolescence.   This category included Hyperkinetic Reaction, Withdrawing Reaction, Overanxious Reaction, Runaway Reaction, Unsocialized Aggressive Reaction, and Group Delinquent Reaction.
  20. 20. DSM-II and Homosexuality Up until 1973 (and finally ratified in 1974) Homosexuality was considered a form of deviant sexual acts and was psychiatric disorder.
  21. 21. DSM, Homosexuality and Science  The famous decision to remove homosexuality did not come about as a result of a lengthy professional debate on the scientific merits, just as its inclusion was not based on science.  Both came about as a political and social opinion/pressure.  The outing of homosexuality from the DSM came from a time when the APA (and many scholars) didn’t want to be seen as Vietnam/Watergate/Establishment authoritarianism.
  22. 22. DSM, Homosexuality and Science  This anti-authoritarian atmosphere undoubtedly contributed to the willingness of the head of the APA to "do the right thing" and remove homosexuality from the DSM.  His decision occurred immediately before the actual vote, and as a result of being taken into a room in which many psychiatrists he knew personally were present and came out to him as homosexual.  Thus, this major change in the legal status of homosexuals turned on a knife edge and actually had nothing to do with "scientific evidence".  The issue had never been about "science", only about political prejudice posturing as "science".  The fear that the APA would be stigmatized as an "establishment institution" was the primary driving factor behind the change in the DSM.
  23. 23. History of the DSM  1980 DSM-III – 265 Dx’s (roughly coincided with ICD-9 which came out in 1979).  DSM-III included multiaxial system.  Explicit diagnostic criteria.  Descriptive approach neutral to etiology theory.  Unlike its predecessors, DSM-III was based on scientific evidence.  Its reliability was improved with the addition of explicit diagnostic criteria and structured interviews.   Although ICD and DSM were similar in terms of criteria, their codes were very different.  1987 DSM-III-R – 297 Dx’s  Occurred because DSM-III revealed a number of inconsistencies in the system and a number of instances in which the criteria were not entirely clear.  1994 DSM-IV – 365 Dx’s – (ICD 10)  DSM-III nomenclature allowed more precise research of disorders for the DSM-IV and DSM- IV-TR.  2000 DSM-IV-TR – 365 Dx’s
  24. 24. History of the DSM  2013 DSM-5  Excoriation (skin-picking) disorder is new to DSM-5 and will be included in the Obsessive- Compulsive and Related Disorders chapter.  Hoarding disorder is new to DSM-5. This disorder was added due to the ongoing popularity of “Hoarders” – 7 p.m. Sunday’s on TLC.  Autistic disorders will undergo a reshuffling and renaming: “[Autism] criteria will incorporate several diagnoses from DSM-IV including autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified) into the diagnosis of Autism Spectrum Disorder.” Other new proposed disorders include:  Complex post-traumatic stress disorder  Depressive personality disorder  Olfactory Reference Syndrome  Disruptive Mood Dysregulation Disorder (or DMDD)  Relational disorder  Sluggish cognitive tempo  Binge Eating
  25. 25. History of the DSM  "This is one of major public health significance because every department of public health in every county in the country has to deal with a hoarding issue, whether it’s animal-related or other forms of excessive acquisition," Dr. Regier (vice chair of the DSM-5 task force) said.
  26. 26. IN BRIEF: Sluggish Cognitive Tempo  We have come full circle in the DSM … in a politically correct way!  2013 – Sluggish Cognitive Tempo  1840 1 Dx – U.S. Census – Idiocy?  Meant to be added to the inattention category of Attention Deficit Hyperactivity Disorder. Symptoms include:  frequent daydreaming  tendency to become confused easily  mental fogginess  sluggish-lethargic behavior  drowsiness  frequent staring into space  slow processing of information  poor memory retrieval  social passiveness, reticence and withdrawal  It was not added to the current DSM inattention category because they have been found to have only a weak association with the other inattention symptoms. It is the best diagnosis to never make it into the DSM!
  27. 27. Substance Use Disorders and Science  The removal of abuse and dependence from the DSM-5 was touted as being because of clinical utility and the need for a better continuum of severity than existed in previous versions of the DSM.  Thus the replacement of abuse and dependence occurred with substance use disorder mild (2-3 symptoms), moderate (4-5 symptoms) and severe (6 or more symptoms).  The decision to remove abuse and dependence occurred through a sub- committee vote. During the time of publication for the DSM-IV the substance abuse workgroup voted on whether or not to retain or remove abuse and dependence and abuse and dependence were voted to remain in the DSM-IV by one committee vote.  The DSM-5 substance abuse workgroup voted to remove abuse and dependence. The critique of this is that the decision was made not based on research but on committee vote.
  28. 28. DSM-5 and Culture  Historically, the construct of the culture-bound syndrome has been a key interest in cultural psychiatry. In the DSM-5, this construct has been replaced by three concepts that offer greater clinical utility: 1. Cultural syndrome is a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context. The syndrome may or may not be recognized as an illness within the culture (e.g., it may be labeled in various ways), but such cultural patterns of distress and features of illness may nevertheless be recognizable by an outside observer.
  29. 29. DSM-5 and Culture (continued) 2. Cultural idiom of distress is a linguistic term, phrase, or a way of talking about suffering among individuals of a cultural group (e.g., similar ethnicity or religion) referring to shared concepts of pathology and ways of expressing, communicating, or naming essential features of distress. An idiom of distress need not be associated with specific symptoms, syndromes, or perceived causes. It may be used to convey a suffering due to social circumstances rather than mental disorders. For example, most cultures have common bodily idioms of distress used to express a wide range of suffering and concerns. 3. Cultural explanation or perceived cause is a label, attribution, or feature of an explanatory model that provides a culturally conceived etiology or cause for symptoms, illness, or distress. Causal explanations may be salient features of folk classifications of disease used by laypersons or healers.
  30. 30. DSM-5 Diagnoses Associated with Class of Substance Use -Mild Use – Mod/Sev Intoxication Withdrawal Alcohol X X X X Cannabis X X X New to DSM- 5 Caffeine X New to DSM- 5 Amphetamines X X X X Cocaine X X X X Hallucinogens X X X Phencyclidine (PCP) X X X Tobacco New to DSM- 5 X X Opioids X X X X Inhalants X X X Sedatives, Hypnotics X X X X Polysubstanc e Out in DSM-5
  31. 31. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5) Substance-Use Disorders Overall, the diagnosis of substance use disorder is based on a pathological pattern of behaviors related to the use of the substance. To assist with organization, Criterion A criteria can be considered to fit with 4 overall groupings:   1. Impaired control (Criteria 1 – 4) 2. Social impairment (Criteria 5 – 7) 3. Risky Use (Criteria 8 – 9) 4. Pharmacological Impairment (Criteria 10 – 11)
  32. 32. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5) Substance-Use Disorder  A. A problematic pattern of [substance] use leading to clinically significant impairment or distress. B. 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. Craving or a strong desire or urge to use [substance] 5. Recurrent [substance] use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued [substance] use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
  33. 33. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5) Substance-Use Disorder (continued) B. Two (or more) of the following occurring within a 12-month period: 7. Important social, occupational, or recreational activities are given up or reduced because of [substance] use 8. Recurrent [substance] use in situations in which it is physically hazardous. 9. Continued [substance] use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance 10. 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: This criterion is not considered to be met for those taking [substance] solely under appropriate medical supervision)
  34. 34. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5) Substance-Use Disorder (continued) B. Two (or more) of the following occurring within a 12-month period: 11. Withdrawal, as manifested by either of the following: a. The characteristic [substance] withdrawal syndrome (refer to Criteria A and B of the criteria set for Withdrawal) b. [Substance] (or a closely related substance) is taken to relieve or avoid withdrawal symptoms (Note: This criterion is not considered to be met for those taking [substance] solely under appropriate medical supervision)
  35. 35. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5)  Withdrawal symptoms vary greatly across drug classes. Marked and generally easily measured physiological signs of withdrawal are provided for the drug classes and will be spelled out below. Marked and generally easily measured physiological signs of withdrawal are common with the following classes of substances: 1. Alcohol 2. Opioids 3. Sedatives, Hypnotics or Anxiolytics  Withdrawal signs and symptoms for the following classes are often present but may be less apparent: 1. Caffeine 2. Cannabis 3. Stimulants (amphetamines and cocaine) 4. Tobacco
  36. 36. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5)  Significant withdrawal has NOT been documented in humans after repeated use of the following classes of substances: 1. Hallucinogens (Phencyclidine and other hallucinogens) 2. Inhalants  Neither tolerance nor withdrawal is necessary for a diagnosis of a substance use disorder. However, for most classes of substances, a past history of withdrawal is associated with a more severe clinical course (i.e., an earlier onset of a substance use disorder, higher levels of substance intake, and a greater number of substance-related problems).
  37. 37. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5) Substance-Use Disorder (continued) Specify if: In early remission: After full criteria for [substance] use disorder were previously met, none of the criteria for [substance] use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, (“Craving, or a strong desire to urge to use [substance],” may be met). In sustained remission: After full criteria for [substance] use disorder were previously met, none of the criteria for [substance] use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, (“Craving, or a strong desire to urge to use [substance],” may be met).
  38. 38. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5) Specify if: On maintenance therapy: This additional specifier is used if the individual is taking prescribed agonist medication such as methadone or buprenorphine and none of the criteria for opioid use disorder have been met for that class of medication (except for tolerance to, or withdrawal from, the agonist). This category also applies to those individuals being maintained on a partial agonist, an agonist/antagonist, or full antagonist such as oral naltrexone or depot naltrexone. In a controlled environment: This additional specifier is used if the individual in an environment where access to [substance] is restricted. NOTE: The “on maintenance therapy” specifier applies as a further specifier of remission if the individual is both in remission and receiving maintenance therapy (i.e., in early remission on maintenance therapy or in sustained remission on maintenance therapy).
  39. 39. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5) Substance-Use Disorder (continued) 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.
  40. 40. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5) Substance-Use Disorder (continued) 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.
  41. 41. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5) 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. 
  42. 42. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5) Substance-Use Disorder (Cravings) "Craving." An innovation in the diagnosis of substance use disorders is a requirement that the patient report or demonstrate craving for the particular substance. Workgroup chairman Charles O'Brien, MD, of the University of Pennsylvania, said this is the key symptom that separates addiction from mere heavy use. He added that a wealth of recent research has established that craving can be measured -- he had hoped that an objective test might be included in the DSM-5 criteria, but his workgroup felt it was not ready quite yet.
  43. 43. IN FOCUS: Substance-Use & Addictive Disorders (DSM-5) Substance-Use and Addictive Disorders New Categories Alcohol Use Disorder Cannabis Use Disorder Hallucinogen Use Disorder (which has subsumed Phencyclidine [PCP]) Inhalant Use Disorder Opioid Use Disorder Sedative/Hypnotic/Anxiolytic Use Disorder Stimulant Use Disorder (combining DSM-IV-TR’s Cocaine and Amphetamine Abuse and Dependence) Tobacco Use Disorder Unspecified Other (or Unknown) Substance Use Disorder Gambling Disorder
  44. 44. IN FOCUS: Substance Use Disorders – Cannabis Withdrawal A. Cessation of cannabis use that has been heavy and prolonged (i.e., usually daily or almost daily use over a period of at least a few months). B. Three (or more) of the following signs and symptoms develop within approximately 1 week after Criterion A:  Irritability, anger or aggression.  Nervousness or anxiety.  Sleep difficulty (e.g., insomnia, disturbing dreams).  Decreased appetite or weight loss.  Restlessness.  Depressed Mood.  At least one of the following physical symptoms causing significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache. C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.
  45. 45. IN FOCUS: Gambling Disorder 1. The reclassification of pathological gambling alongside other addictive behaviors  In the current edition (DSM-IV), gambling disorder is classified as part of “Impulse- Control Disorders Not Elsewhere Classified,” which also includes disorders like kleptomania. In the new edition, gambling disorder will join substance-related addictions in a renamed group called “Addiction and Related Disorders.” 2. The lowering of the pathological gambling threshold to 4 symptoms  To be diagnosed with a gambling disorder, a certain set of behaviors must be present over a 12-month period—such as needing to bet with increased amounts of money, being preoccupied with gambling, or tending to chase losses. Currently, gamblers need to exhibit 5 of these behaviors to be diagnosed with a gambling disorder. In the DSM-5, the threshold will be lowered to 4.
  46. 46. IN FOCUS: Gambling Disorder 3. The removal of the ‘‘illegal acts’’ criterion for the disorder  Another change is that, where in the DSM-IV there are 10 behaviors listed, in the DSM-5 there will only be 9. Whether or not a gambler has committed an illegal act (like theft or fraud) to finance gambling will no longer be considered a sign of pathological gambling. 4. The Addition of a severity rating:  Mild – 4-5 Criteria  Moderate – 6-7 Criteria  Severe – 8-9 Criteria
  47. 47. IN FOCUS: Substance Use and Addictive Disorders – Final Points  Internet Gaming and Caffeine Disorder put in Section 3 (for further study)  Diagnostic Coding  Use disorder “Mild” has the same coding as the DSM-IV’s “abuse”. For example: Alcohol Use Disorder – Mild is 305.00 with the ICD-10-CM code being (F10.10).  Use disorder “Moderate” and “Severe” have the same diagnostic code and should be separated by the wording. For example moderate and severe alcohol use disorder are both coded 303.90 (F10.20) and will look like this: 1. 305.00 (F10.10) Mild Alcohol Use Disorder 2. 303.90 (F10.20) Moderate Alcohol Use Disorder 3. 303.90 (F10.20) Severe Alcohol Use Disorder
  48. 48. DSM-IV to DSM-5 Diagnosing Exercise Alex Lifeson is an 18 year old African American male who has been abusing substances since the age of 13. Alex reported using alcohol, marijuana, and cocaine. Alex reported using alcohol at the age of 13. At 13 he started out by drinking once a month (he reports that this was 1 - 40 oz. bottle of beer each time he drank). By 13 ½ he was consuming 80 oz. of beer (2 - 40oz. bottles) 2 times per week. By age 14 he was he was drinking 80 oz. of beer at least 3 - 4 times per week. This drinking frequency stayed the same till the age of 17 when he began drinking beer and vodka. The frequency of drinking at ages 17 and 18 remained consistently 80 oz. of beer 3 - 4 times per week and a fifth of vodka 1 - 2 times per week. Drinking the alcohol was the only route of administration. Alex reported craving alcohol when not using.   Alex started smoking marijuana at the age of 15 by smoking 1 blunt per week. By age 15 ½ he was smoking 1 blunt 2 - 3 times per week. By age 16 he was smoking 1 blunt per day. By age 17 he started smoking 2 -3 blunts per day and this remained constant till this evaluation by you. Smoking was the only route of administration. Alex reported craving marijuana when not using.
  49. 49. DSM-IV to DSM-5 Diagnosing Exercise Alex started snorting cocaine at age 16. From age 16 till age 17 Alex was snorting 1 line 1 - 2 times per week. At age 17 he started snorting cocaine more frequently by snorting a gram per week. He was unsure as to how many times per week he would do cocaine because sometimes he would snort the whole gram at a party during one day, and other times he would snort smaller amounts several times per week till the gram was gone. At age 18 this frequency stayed the same except for the last 2 weeks before being evaluated by you, he stated he was snorting 2 grams of cocaine per week. His drug/alcohol use was supported by his selling crack cocaine. Alex never smoked cocaine, his only route of administration was snorting cocaine. Alex reported craving cocaine when not using.
  50. 50. DSM-IV to DSM-5 Diagnosing Exercise Alex is a substance user with no clear preference of drug from a self report. However the only drug he stated that he used on a daily basis was marijuana. Alex reported having blackouts on several occasions due to too much alcohol usage. Alex also has shown a definite increase in tolerance to all substances he used. With alcohol, it currently takes him at least 60 oz. of beer to “get high” and at the beginning of his alcohol usage it only took him approximately 24 oz. to “get high”. It currently takes him 2 - 3 marijuana blunts to “get high” and when he first started smoking marijuana he would “get high” off of one blunt. Cocaine tolerance also increased for Alex. At the beginning of his cocaine usage he would “get high” off of one line, and upon entering treatment it took him about 3 lines to “get high” off of cocaine.
  51. 51. DSM-IV to DSM-5 Diagnosing Exercise Alex also exhibited loss of control. He would often only intend to drink 1 - 40 oz. of beer and would often end up drinking 2 - 40 oz. of beer and vodka. He also showed this loss of control with his cocaine usage. It was Alex’s intention to make a gram of cocaine last him throughout the week, but he would go to a party and end up snorting the whole gram as opposed to the 2 - 3 lines he first set out to snort. This would occur at least once every 2 months and sometimes once a month. Alex dropped out of school in 10th grade so he could “be out on the street and sell drugs more often”. He also continued usage despite knowing he would get drug screens from Probation and from his outpatient drug/alcohol programs, and that he could receive negative consequences from these positive urines. Alex had moderately elevated liver enzymes upon entering the evaluation, but according to his medical doctor (whom you requested information from), Alex didn’t have any other medical complications from his substance abuse.
  52. 52. DSM-IV to DSM-5 Diagnosing Exercise  What is Alex’s DSM-5 Diagnosis?
  53. 53. BRIEF FOCUS: Depressive Disorders  DSM-5 contains several new depressive disorders, including disruptive mood dysregulation disorder and premenstrual dysphoric disorder.  DMDD was added to address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children.  Based on strong scientific evidence, premenstrual dysphoric disorder has been moved from DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study,” to the main body of DSM-5.
  54. 54. BRIEF FOCUS: Persistent Depressive Disorder (Dysthymia) & Bipolar Disorders  This disorder represents a consolidation of the DSM-IV defined Chronic Major Depressive Disorder and Dysthymic Disorder  The largest revelation from this consolidation was the fact that there was a disorder in the DSM-IV called Chronic Major Depressive Disorder … who knew?!  Diagnostic criteria for bipolar disorders now include both changes in mood and changes in activity or energy.  Other Specified Bipolar and Related Disorders now allows for diagnosing this condition if hypomania bipolar II is less than 4 days (i.e., 2-3 days), or if too few symptoms of hypomania are met but the duration is 4 days.  Thus if you can’t meet the criteria to meet Bipolar II D/O, we’ll give you another shot at having some Bipolar diagnosis. We LOVE Bipolar Disorder!!!
  55. 55. Bereavement Exclusion Dropped The bereavement exclusion is omitted in DSM-5 for several reasons. 1.The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. 2.Second, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section III.
  56. 56. Bereavement Exclusion Dropped The bereavement exclusion is omitted in DSM-5 for several reasons. 3.Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes. 4.Finally, the depressive symptoms associated with bereavement- related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression.
  57. 57. Specifiers for Depressive Disorders The DSM-5 provides guidance on the assessment of suicidal thinking, plans, and the presence of other risk factors in order to make a determination of the prominence of suicide prevention in treatment planning for a given individual. A new specifier to indicate the presence of mixed symptoms has been added across both the bipolar and the depressive disorders, allowing for the possibility of manic features in individuals with a diagnosis of unipolar depression. A lot of research showing anxiety is a factor in depressive disorders, thus the inclusion of the “with anxious distress” specifier (to rate the severity of anxious distress) in all individuals with bipolar or depressive disorders.
  58. 58. BRIEF FOCUS: Disorders of Infancy, Childhood, or Adolescence  In the DSM-IV-TR these disorders were largely gathered in this section.  In the DSM-5 they are now spread out in different sections:  Neurodevelopmental Disorders – Intellectual Disabilities, Autism Spectrum Disorder, Attention Deficit/Hyperactivity Disorder, Specific Learning Disorders, Motor Disorders  Elimination Disorders (now has its own section)  Disruptive, Impulse-Control, and Conduct Disorders – Oppositional Defiant Disorder, Conduct Disorder  Trauma- and Stressor-Related Disorders – Adjustment Disorders (while not a childhood disorder this class of disorders is given to people under 18).  Depressive Disorders – (NEW) – Disruptive Mood Dysregulation Disorder
  59. 59. IN FOCUS: Disruptive Mood Dysregulation Disorder (DMDD)  Disruptive mood dysregulation disorder has two symptom criteria: A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression towards people or property) that are grossly out of proportion in intensity or duration to the situation or provocation. B. The temper outbursts are inconsistent with developmental level. C. The temper outbursts occur, on average, 3-4 times per week. D. The mood between outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers).
  60. 60. IN FOCUS: Disruptive Mood Dysregulation Disorder (DMDD) E. Criteria A-D have been present 12 months or more. During that time there has not been a 3 consecutive month period (or more) without all of the symptoms A-D. F. Criteria A-D are present in at least 2 of the 3 following areas: home, school or with peers, and are severe in at least one of these. G. The diagnosis should not be made for the first time before the age of 6 or after the age of 18. H. By history of observation, the age of onset for Criteria A-E is before the age of 10. I. There has never been a distinct period lasting more than 1 day in which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder. NOTE: This diagnosis cannot coexist with Oppositional Defiant Disorder (OPD). If an individual meets the criteria of both DMDD and OPD, the diagnosis of DMDD should be made.
  61. 61. IN FOCUS: Disruptive Mood Dysregulation Disorder (DMDD)  The new diagnosis is designed to help families and children who “have never been successfully treated for extreme, explosive rages,” says David Kupfer, chairman of the DSM-5 task force and a professor of psychiatry at the University of Pittsburgh  “Too many severely impaired children like this have fallen through the cracks because they suffer from a disorder that had not yet been defined.”  In field trials this disorder had poor inter-rater reliability. There were 2 main problems: 1. Field trials had trouble distinquishing between Oppositional Defiant Disorder and DMDD. 2. There problems with “rage attack” durations, and commenters emphasize the importance of the durations, frequency and persistence criteria.
  62. 62. IN FOCUS: Disruptive Mood Dysregulation Disorder (DMDD)  Treatment Implications  The treatment would differ from Bipolar disorder where the first line treatment would be mood stabilizing drugs, which could have many side effects for younger populations.  The belief is that younger people with DMDD would, untreated, evolve into depressive or anxiety disorders. There is talk of first line treatment being either stimulants or antidepressants.  The only treatment trial for this group, before the DSM-5 came out, was a small trial of lithium, which produced negative impact.
  63. 63. Paraphillic Disorders Characteristics of Paraphilic Disorders Most people with atypical sexual interests do not have a mental disorder. To be diagnosed with a paraphilic disorder, DSM-5 requires that people with these interests: 1. Feel personal distress about their interest, not merely distress resulting from society’s disapproval; or 2. Have a sexual desire or behavior that involves another person’s psychological distress, injury, or death, or a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent. In the case of pedophilic disorder, the notable detail is what wasn’t revised in the new manual. Although proposals were discussed throughout the DSM- 5 development process, diagnostic criteria ultimately remained the same as in DSM-IV TR. Only the disorder name will be changed from pedophilia to pedophilic disorder to maintain consistency with the chapter’s other listings.
  64. 64. The Controversy of Pedophilic Disorder Being a “Sexual Orientation”  “The American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has recently been published after a comprehensive multi-year research and review of all of its diagnostic categories,” the statement reads.  “In the case of pedophilic disorder, the diagnostic criteria essentially remained the same as in DSM-IV-TR. Only the disorder name was changed from 'pedophilia' to ‘pedophilic disorder’ to maintain consistency with the chapter’s other disorder listings.  “'Sexual orientation’ is not a term used in the diagnostic criteria for pedophilic disorder and its use in the DSM-5 text discussion is an error and should read ‘sexual interest.’ In fact, APA considers pedophilic disorder a ‘paraphilia,’ not a ‘sexual orientation.’ This error will be corrected in the electronic version of DSM-5 and the next printing of the manual.  “APA stands firmly behind efforts to criminally prosecute those who sexually abuse and exploit children and adolescents. We also support continued efforts to develop treatments for those with pedophilic disorder with the goal of preventing future acts of abuse.”
  65. 65. BRIEF FOCUS: Gender Dysphoria  Gender dysphoria is a new diagnostic class in DSM-5 and reflects a change in conceptualization of the disorder’s defining features by emphasizing the phenomenon of “gender incongruence” rather than cross-gender identification per se (DSM-IV delineation).  In DSM-IV, the chapter “Sexual and Gender Identity Disorders” included three relatively disparate diagnostic classes: gender identity disorders, sexual dysfunctions, and paraphilias. Gender identity disorder, however, is neither a sexual dysfunction nor a paraphilia.  The experienced gender incongruence and resulting gender dysphoria may take many forms.  Gender dysphoria thus is considered to be a multicategory concept rather than a dichotomy, and DSM-5 acknowledges the wide variation of gender -incongruent conditions.  Separate criteria sets are provided for gender dysphoria in children and in adolescents and adults.
  66. 66. BRIEF FOCUS: Gender Dysphoria  The previous Criterion A (cross-gender identification) and Criterion B (aversion toward one’s gender) have been merged, because no supporting evidence from factor analytic studies supported keeping the two separate.  In the wording of the criteria, “the other sex” is replaced by “some alternative gender.” Gender instead of sex is used systematically because the concept “sex” is inadequate when referring to individuals with a disorder of sex development.  The subtyping on the basis of sexual orientation has been removed because the distinction is not considered clinically useful.  A posttransition specifier has been added because many individuals, after transition, no longer meet criteria for gender dysphoria; however, they continue to undergo various treatments to facilitate life in the desired gender.  Although the concept of posttransition is modeled on the concept of full or partial remission, the term remission has implications in terms of symptom reduction that do not apply directly to gender dysphoria.
  67. 67. Substance Use Disorder Exercise #2  Francis is a client referred to you for an evaluation. The client has been sent to you for her 3rd VOP on a 4 year old charge of fraudulent prescription writing (opiates). Since that time, the client has been to a new doctor and continues getting a prescription of opiates from a different doctor. Francis reported an increase in tolerance to the prescription opiates. When contacting the doctor (Dr. Bombay), he reported that Francis is doing well on her medication and has the physical pain and problems proven in her MRI/CAT scan workups that back up her claims.  When asked if the doctor ever performs urine drug screens or monitoring of medication counts while in the office, the doctor stated he did not. The client came up positive for oxycodone upon the evaluation, but refused to bring in her medication (during both the evaluation and the follow-up session). She stated that her reason for “refusing” was that she simply forgot. When asking the Probation Officer if she was aware of the medications that Francis was on she stated she was and has done pill counts on 5 occasions (in the past 5 months due to her suspicions of Francis), 2 of which the pill counts were off by 17 – 24 pills. Francis also pulled 2 negative urine drug screens on those 2 occasions while the other 3 were positive for oxycodone, which is consistent with her prescription. Her test was positive for oxycodone & morphine during your evaluation.
  68. 68. Substance Use Disorder Exercise #2  Francis admitted to developing a tolerance to her prescription, and stated she goes through withdrawals when not using the medications. When asked about substituting other drugs (confronting her about the morphine/codeine positive that came up on her most recent urine drug screen), she admitted to hoarding her pills in fear that she will run and substituting her pill use with either heroin or suboxone at times. She stated that she only uses heroin or suboxone when not taking her medication, and usually uses 4 bags per day of heroin to account for the number of pills she takes, or takes 16-24mg of suboxone per day. She stated she only needed 2 bags of heroin at first but within the past year she has increased her tolerance and needs 4 bags, which she stated she takes by snorting.  When asked about her pill count being off, and her negative urine drug screens, she denied selling her pills and stated that she merely “saves” them “just in case”.  She spends a great time of time using her substances, and trying to obtain and use substitute substances. She gets into frequent fights with her husband over her use as he feels she does not need the medications anymore. She feels strongly that she still does.
  69. 69. Substance Use Disorder Exercise #2  She has tried going without all opiates, but when she does she does not successfully do so for long. She states this occurs for 2 reasons: 1) she endures terrible withdrawal feelings and cannot stop thinking about using the substances and has repeated strong desires to use the substances; and 2) she states that the pain becomes so bad that it is unbearable and has to return to using the opiate medication.  She is currently on short-term disability and unable to return to work. She reported that her husband complains that she is unable to do many things that she used to do, and now that she has more time since she is home all the time, she is unable to do (such as her designated home-related work assignments that she reports she and her husband used to divide equally, but admits that he now does mostly all of them). 1. Give her DSM-5 Diagnosis and justification of specific criteria used to decide 1) if she has a substance use disorder, and 2) if so, is it mild (2-3), moderate (4-5) or severe (6 or more).
  70. 70. 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: 1. 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. 2. Craving – people may use drugs or alcohol to manage not only craving but the associated anxiety that comes with craving. 3. 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.
  71. 71. DSM-5 Changes to Anxiety Disorders Anxiety Disorders are being carved out into 3 categories. Anxiety Disorders 1. Separation Anxiety Disorder 2. Selective Mutism 3. Specific Phobia 4. Social Anxiety Disorder (Social Phobia) 5. Panic Disorder 6. Agoraphobia 7. Generalized Anxiety Disorder 8. Substance/Medication-Induced Anxiety Disorder 9. Anxiety Disorder Due to Another Medical Condition 10. Other Anxiety Disorder 11. Unspecified Anxiety Disorder Panic Attack
  72. 72. DSM-5 Changes to Anxiety Disorders Anxiety Disorders are being carved out into 3 categories. Obsessive-Compulsive and Related Disorders 1. Obsessive-Compulsive Disorder 2. Body Dysmorphic Disorder 3. Hoarding Disorder 4. Trichotillomania (Hair-Pulling Disorder) 5. Excoriation (Skin Picking Disorder) 6. Substance/Medication-Induced Obsessive-Compulsive or Related Disorders 7. Obsessive-Compulsive or Related Disorder Attributable to Another Medical Condition 8. Other Specified Obsessive-Compulsive or Related Disorder 9. Unspecified Obsessive-Compulsive or Related Disorder
  73. 73. DSM-5 Changes to Anxiety Disorders Anxiety Disorders are being carved out into 3 categories. Trauma- and Stressor-Related Disorders 1. Reactive Attachment Disorder 2. Disinhibited Social Engagement Disorder 3. Posttraumatic Stress Disorder 4. Acute Stress Disorder 5. Adjustment Disorders (with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct) 6. Other Specified Trauma- or Stressor- Related Disorder 7. Unspecified Trauma- or Stressor- Related Disorder
  74. 74. IN FOCUS: Hoarding Disorder
  75. 75. IN FOCUS: Hoarding Disorder A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities or The Learning Channel). D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).
  76. 76. IN FOCUS: Hoarding Disorder F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder). Specify if: With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. Specify if: With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. With poor insight: The individual is mostly convinced that the hoarding- related beliefs and behaviors (listed above) are not problematic despite evidence to the contrary. With absent insight/delusional beliefs: The individual is completely convinced that the hoarding-related believes and behaviors are not problematic despite evidence to the contrary.
  77. 77. IN FOCUS: Hoarding Disorder  Hoarding Disorder appears to be comorbid with clients organic brain disorders such as schizophrenia, autism, and developmental delays.  People found to be living in squalor as a result of their hoarding behavior have a high prevalence of the following disorders: 1. Depression 51% 2. ADHD 28% 3. Anxiety 24%  Hoarding does not appear to respond well to SSRI’s or typical psychotherapy approaches.  The best approach is a cognitive therapy approach, working with clients by supervising them in the practice organizing and discarding items, along with working on irrational belief systems.  Studies have shown this work to be difficult as many hoarding participants are unable to complete homework assignments.
  78. 78. IN BRIEF: Anxiety Disorders  Agoraphobia is now distinct from panic disorder  Panic Attack (not-coded) can be used as a specifier across other diagnoses.  Social Phobia is now labeled as Social Anxiety Disorder.  Separation Anxiety Disorder may have “adult onset”.  Specific Phobia and Social Anxiety Disorder will have a duration requirement.  Specific Phobia and Social Anxiety Disorder will no longer require the client recognize the fear as unreasonable. The clinician will make that decision.  Obsessive-Compulsive Disorder (the class of disorders were all removed from anxiety disorders) was removed due to the belief that OCD is not due to anxiety but is due to a neurological “short-circuit” that causes obsessive thoughts and behaviors (similar to Body Dysmorphic and Tourrettes Disorder.
  79. 79. 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.
  80. 80. 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.
  81. 81. IN BRIEF – PTSD (Changes to Criterion A in the DSM-5) 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.
  82. 82. IN BRIEF – PTSD (DSM-5) H. 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
  83. 83. Brief Overview – Schizophrenia Changes  The requirement of at least 2 Criterion A symptoms must be present). 1. Delusions 2. Hallucinations 3. Disorganized Speech (e.g., frequent derailment or incoherence) 4. Grossly Disorganized or Catatonic Behavior 5. Negative Symptoms (i.e., diminished emotional expression or avolition).  One of those Criterion A symptoms must be either delusions, hallucinations or disorganized speech.  The DSM-IV subtypes have been eliminated (Paranoid, Bizarre, Catatonic, Undifferentiated, Residual) due to their limited diagnostic stability, low reliability, and poor validity.
  84. 84. Brief Overview – Schizophrenia Changes  Specifiers include:  First episode, currently in acute episode – first manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.  First episode, currently in partial remission – partial remission is a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are partially fulfilled.  First episode, currently in full remission – full remission is a period of time after a previous episode during which no disorder-specific criteria are present.  Also multiple episodes (more than 2), currently in acute episode, currently in partial remission, or currently in full remission, Continuous (symptoms remain for the majority of
  85. 85. Brief Overview – Catatonia  In DSM-5, catatonia may be diagnosed as a specifier for depressive, bipolar, and psychotic disorders; as a separate diagnosis in the context of another medical condition; or as an other specified diagnosis.  DSM-5 states that research shows that catatonia is under-diagnosed and is present in more disorders than previously thought.  Therefore they are proposing that it be removed from the psychotic disorders as being exclusively part of this set of disorders.  It is now a specifier for ALL the psychotic disorders, as well as for various medical conditions and mood disorders (depressive and bipolar disorders).
  86. 86. Brief Overview – Schizophreniform D/O  The main thing that remains the same between the DSM-IV-TR and the DSM-5 with this disorder is: 1. Still nobody knows what this disorder is. 2. Nor what purpose it still serves.  Think of schizophreniform as the transient period between: 1. Brief Psychotic Reaction (which lasts for more than 1 day but remits after 1 month) and; 2. Schizophrenia (which cannot be diagnosed until a duration of 6 months. 3. Meet … Schizophreniform – (1 month – 6 month duration).  Think of schizophreniform as middle school between elementary and high school.
  87. 87. Substance Use Disorder Exercise #3  Mark, a 48 year old male, comes to you for a drug court evaluation. He reports using marijuana and alcohol in his lifetime. He reported that his alcohol use has always been sporadic in his lifetime. He did state that his use was heavier in college, and he received 1 DWI while in college. However, he did not admit to any signs or symptoms of alcohol use disorder besides the occasional college binge drinking and the 1 DWI. He reported that his father was killed by a drunk driver and after the DWI he changed his drinking pattern to what it is now, drinking 1-2 times per year, usually consuming 1-2 glasses of wine per occasion. He also reported that he only drank and drove that one time, which caused guilt in him for doing so because after his father’s death (which occurred when he was 15) he swore he would never engage in such behaviors.  Mark’s marijuana history is more pronounced and starting at the age of 18 he began smoking once a week. This use stayed constant throughout college and throughout his 20’s. When he was 32 he started smoking more, and started to sell marijuana to add to his job income and support his increasing smoking frequency. In his late 30’s he received his first legal charge for CDS. He was put on probation for 1 year, and had 2 subsequent VOPs for continued CDS charges and the last charge was CDS with the intent to distribute.
  88. 88. Substance Use Disorder Exercise #3  Mark stated his use increased to smoking 1-2 times per week, but would often smoke 3-4 times per week, finances depending. He reported last year his job found out about his marijuana use after a random urine test and fired him on the spot. He did state that he would often drive after smoking pot and didn’t see this as the same issue regarding his viewpoints on drinking and driving. He stated within the past year he has driven under the influence of marijuana approximately 12 times.  He also stated that he would get into verbal fights about his marijuana often with his girlfriend and when he lost his job last year, she told him that was the final straw and left him due to his continued marijuana use.  When asked if he ever tried to cut down, he stated no because he never thought his use was problematic. He denied ever using more than he intended to, and denied ever building up a tolerance to marijuana or having any types of withdrawal symptoms from it. When asked if his marijuana use caused any psychological changes/problems such as paranoia or memory loss, he denied this and he denied having any physical problems caused by, or made worse by his marijuana use. When asked if he ever experienced any strong desires to use, or any psychological or physiological cravings for pot, he denied experiencing these.
  89. 89. Substance Use Disorder Exercise #3  When asked how much time he put into smoking, obtaining the substance he stated that his selling supported his ability to smoke, and between smoking and all other activities he stated he spent about 30 – 40 hours per week engaged around his pot use/selling.  He is legally eligible for admission into drug court, and your team has to decide if he meets the clinical criteria to support admission into the drug court program, which will of course depend on the results of your evaluation. 1. Give her DSM-5 Diagnosis and justification of specific criteria used to decide 1) if she has a substance use disorder, and 2) if so, is it mild (2-3), moderate (4-5) or severe (6 or more). 2. Does he meet admission criteria? Why/Why not? Do the types of criteria he does meet impact your decision on whether or not to accept him into drug court?
  90. 90. What is Personality? This is a solo exercise. Identify 3 important factors that characterize you as a person. Personality is made up the characteristic patterns of thoughts, feelings, and behaviors that make a person unique. It arises from within the individual and remains fairly consistent throughout life.
  91. 91. What is a Personality Disorder?  Personality disorders are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating markedly from those accepted by the individual's culture. 1. These patterns develop early, are inflexible, and are associated with significant distress or disability. 2. Personality disorders are defined by experiences and behaviors that differ from societal norms and expectations. 3. Those diagnosed with a personality disorder may experience difficulties in cognition, emotiveness, interpersonal functioning, or control of impulses. 4. In general, personality disorders are diagnosed in 40–60 percent of psychiatric patients, making them the most frequent of all psychiatric diagnoses.
  92. 92. Changes from the DSM-IV-TR to the DSM-5 In developing diagnostic criteria for personality disorders, the DSM-5 Work Group initially proposed a somewhat dramatic new approach: 1.Maintain 6 personality disorder diagnoses from the prior 10 in DSM-IV, and move from a categorical to a trait-based, dimensional classification system (dropped are Dependent • Histrionic • Paranoid • Schizoid). 2.Per the categorical system, a patient either has a diagnosis or not, whereas a dimensional system better captures the nuances of human personality by measuring a variety of traits on a continuum. 3.The proposal was ultimately voted down; however, the alternative hybrid dimensional-categorical model is included in a separate chapter in Section 3 of DSM-5 to stimulate further research on this modified classification system.
  93. 93. Changes from the DSM-IV-TR to the DSM-5  In the DSM-5 field trials, only borderline personality disorder had good inter-rater reliability.  Inter-rater reliability: inter-rater agreement, or concordance is the degree of agreement among raters. It gives a score of how much homogeneity, or consensus, there is in the ratings given by judges.  In contrast, obsessive-compulsive personality disorder and antisocial personality disorder were in the questionable reliability range.  All other personality disorders had too few patients to test their reliability.
  94. 94. Current Personality Disorder Configuration Current Configuration (10 Personality Disorders): Cluster A • Paranoid • Schizoid • Schizotypal Cluster B • Antisocial • Borderline • Histrionic • Narcissistic Cluster C • Avoidant • Dependent • Obsessive-compulsive Cluster A personality disorders: these are disorders in which odd or eccentric behavior is considered to be central. For example in schizotypal, schizoid and paranoid personality disorders. Cluster B personality disorders: this group includes personality disorders in which dramatic and erratic emotional responses are common. Borderline, antisocial, histrionic and narcissistic personality disorders belong in this cluster. Cluster C personality disorders: personality disorders which are classified as belonging to cluster C are those in which anxious and fearful behavior are central – including avoidant, dependent and obsessive compulsive personality disorders.
  95. 95. Proposed Overarching Changes to PD Current Configuration (10 Personality Disorders): Cluster A • Paranoid • Schizoid • Schizotypal Cluster B • Antisocial • Borderline • Histrionic • Narcissistic Cluster C • Avoidant • Dependent • Obsessive-compulsive Proposed Configuration (6 Personality Disorders): Antisocial Personality Disorder Avoidant Personality Disorder Borderline Personality Disorder Narcissistic Personality Disorder (almost didn’t make the cut) Obsessive-Compulsive Personality Disorder Schizotypal Personality Disorder
  96. 96. General Criteria for Personality Disorder The essential features of a personality disorder are: A.Moderate or greater impairment in personality (self/interpersonal) functioning (Criterion A for each disorder). B.One or more pathological personality traits (Criterion B for each disorder). C.The impairments in personality functioning and the individual’s personality trait expression are relative inflexible and pervasive across a broad range of personal and social situations. D.The impairments in personality functioning are the individual’s trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood. E.The impairments in personality functioning and the individual’s personality trait expression are not better explained by another mental disorder. F.The impairments in personality functioning and the individual’s personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma). G.The impairments in personality functioning and the individual’s trait expression are not better understood as normal for an individual’s developmental stage or sociocultural environment.
  97. 97. Alternative DSM-5 Model for Personality Disorders Criterion A: Level of Personality Functioning Disturbances in self and interpersonal functioning constitute the core of personality psychopathology. Self (Identity and Self-direction) and Interpersonal (Empathy and Intimacy). Self 1.Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience. 2.Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial standards of behavior; ability to self-reflect productivity. Interpersonal nEmpathy: Comprehension and appreciate of others’ experiences and motivations; tolerance of differing perspectives; understanding of one’s own behavior on others. nIntimacy: Depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior. Impairment in personality functioning predicts the presence of a personality disorder, and the severity of impairment predicts whether a person has more than 1 personality disorder, or one of the more particularly severe personality disorders. A MODERATE LEVEL OF IMPAIRMENT IN PERSONALITY FUNCTIONING IS REQUIRED FOR THE DIAGNOSIS OF A PERSONALITY DISORDER.
  98. 98. Alternative DSM-5 Model for Personality Disorders Criterion B: Pathological Personality Traits Pathological personality traits are organized into broad domains: 1. Negative Affectivity 2. Detachment 3. Antagonism 4. Disinhibition 5. Psychoticism Within the 5 broad trait domains are 25 specific trait facets.
  99. 99. Personality Disorders – 5 Traits and Facets  Negative Affectivity (vs. Emotional Stability) – traits include Emotional Liability, Anxiousness, Separation Insecurity, Submissiveness, Hostility, Perseveration, Depressivity, Suspiciousness, Restricted Affectivity (or lack of).  Detachment (vs. Extraversion) – Withdrawal, Intimacy Avoidance, Anhedonia (lack of enjoyment, enjoyment or energy in life’s experiences), Depressivity, Restricted Affectivity, Suspiciousness.  Antagonism (vs. Agreeableness) – Manipulativeness, Deceitfulness, Grandiosity, Attention Seeking, Callousness.  Disinhibition (vs. Conscientiousness) – Irresponsibility, Impulsivity, Distractibility, Risk Taking, Rigid Perfectionism (or lack of).  Psychoticism (vs. Lucidity) – Unusual Beliefs and Experiences, Eccentricity, Cognitive and Perceptual Dysregulation (odd or unusual thought processes).
  100. 100. Alternative DSM-5 Model for Personality Disorders  Criterion C and D: Pervasiveness and Stability  Impairments in personality functioning across a range of social contexts (social, occupational, or other important pursuits).  Criterion E, F, and G: Alternative Explanations for Personality Pathology (Differential Diagnosis)  On some occasions, what appears to be a personality disorder be better explained by another mental disorder, the effects of a substance or another medical condition, or a normal developmental stage (e.g., adolescence, late life).
  101. 101. Section 3: Borderline Personality Disorder PROPOSED DIAGNOSTIC CRITERIA A.Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas: 1. Identity: Markedly impoverished, poorly developed, or unstable self- image, often associated with excessive self-criticism; chronic feelings of emptiness, dissociative states under stress. 2. Self-direction: Instability in goals, aspirations , values, or career plans. 3. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased towards negative attributes or vulnerabilities. 4. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over- involvement and withdrawal.
  102. 102. Section 3: Borderline Personality Disorder PROPOSED DIAGNOSTIC CRITERIA B.Four or more of the following seven pathological personality traits, at least one of which must be (5) Impulsivity, (6) Risk taking, or (7) Hostility: 1. Emotional liability (an aspect of Negative Affectivity): Unstable emotional experiences and frequent mood changes; emotions that are easily aroused , intense, and/or out of proportion to events and circumstances. 2. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervousness, tenseness or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensiveness, or threatened by uncertainty; fears of falling apart or losing control. 3. Separation insecurity (an aspect of Negative Affectivity): Fears of rejection by – and/or separation from – significant others , associated with fears of excessive dependency and complete loss of autonomy. 4. Depressivity (an aspect of Negative Affectivity): Frequent feelings of being down, miserable, an/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behavior.
  103. 103. Section 3: Borderline Personality Disorder PROPOSED DIAGNOSTIC CRITERIA (B CONTINUED) B.Four or more of the following seven pathological personality traits, at least one of which must be (5) Impulsivity, (6) Risk taking, or (7) Hostility: 5. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in response to immediate stimuli; acting on momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress. 6. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and potential self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger. 7. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
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