2Diagnostic groupings in IV-TR and 5 In DSM-IV TR, the diagnostic groupings had a separate category for children and adolescents.DSM 5 does not make a separate category for children and adolescentsIn DSM-IV TR some of the categories had names that made no sense-such as somatoform disordersDSM 5 attempts to simplify diagnostic category namesDSM 5 organizes diagnostic categories into 20 chapters, starting with diagnostic categories that are seen earlier in life and progressing to those that are seen later in life
3Changes throughout DSM XChanges throughout DSMAttention to severity assessment and specification of severity for each diagnosisInclusion of other specified disorder and unspecified disorder as a diagnosis for each group (Replaces that NOS)"Other specified disorder" permits clinician to communicate sub threshold diagnoses and specific reasons why client did not meet criteria for other diagnoses within that group
4DSM 5 changes in classification DSM 5 has 20 diagnostic groupings plus a group of other conditions that might be a focus clinically (V codes)DSM 5 organizes these categories beginning with those that might be seen earlier in life and progressing to those later in life
5Neuro developmentalNeurocognitive disordersSomatic symptom relatedSexual dysfunctionsDisruptive, impulse control disordersBipolarParaphilia disordersAnxietyTrauma relatedElimination disordersSchizophreniaDepressiveObsessive-compulsive and relatedDissociativeFeeding and eating disordersSleep wake disordersSubstance related and addictive disordersPersonality disorderOthersGender dysphoriaYoungerOlderThe progression from younger to older in the DSM is general and there are specific disorders such as some early childhood feeding disorders that clearly occur later
61. Neurodevelopmental disorders 2. schizophrenia spectrum and other psychotic disorders3. bipolar and related disorders4. depressive disorders5. anxiety disorders6. obsessive-compulsive and related disorders7. Trauma and related disorders8. dissociative disorders9. Somatic symptom and related disorders10. feeding and eating disorders11. elimination disorders12. sleep wake disorders13. sexual dysfunctions14. gender dysphoria15. disruptive, impulse control, and conduct disorders16. neurocognitive disorders17. paraphilia disordersWhich are your top 7 or 8
7Changes in the groupings: 1. Neurodevelopmental disorders SUMMARY mental retardation is removed intellectual disability is put in.Autism spectrum disorder is the new DSM 5 diagnosis encompassing autistic disorder. Aspergers and childhood disintegrative disorder as well as pervasive developmental disorder.Several changes have been made to ADHD- specifiers = combined; inattententive type; hyperactive/impulsive type
8MENTAL RETARDATION = INTELLECTUAL DISABILITY Severity level for intellectual disabilitySeverity levelConceptual domainSocial domainPractical domainMildPreschool = no obvious differences. School-aged children and adults = academic skills involving reading writing math time or money. In adults abstract thinking planning cognitive flexibility are somewhat impaired impaired. Tendency toward concrete thinkingImmaturity and social interactions; some difficulty picking up social cues communication conversation in language more concrete than peers. Possible difficulties in emotional regulation and age-appropriate behavior. Perhaps impairment in risk assessmentPersonal care may be age-appropriate, but more complex tasks might require support. For example grocery shopping, transportation home and childcare organization food prep banking and money managementModerateConceptual skills lag markedly language development and pre-academic skills slow to develop. School-age children = progress in reading writing mass understanding of time and money but slower than peers. Adults = academic skill development is at an elementary level. Ongoing assistance needed in conceptual decision-makingMarked differences in social and communication from peers. Spoken language is much less complex than peers. Capacity for relationships evident in familial friendship ties. Problems with perceiving social cues in social situations accurately. Social judgment and decision-making limited. Help is needed with life decisionsPersonal care is okay in adulthood. Adults typically can participate in all household tasks with teaching. Can work with considerable support in the workplaceSevereLimited attainment of conceptual skills. Little or no understanding of written language math, time and money. Extensive support for problem solving is neededSpoken language is limited in terms of vocabulary and grammar. Communication is focused on the here and now an everyday event. Relationships and relational ability is considerable.Support needed for all activities of daily living. Supervision required at all times. We will not make responsible decisions regarding well-being .skill acquisition is very limitedProfoundNo concept of symbolic processes, perhaps some functional use of objects, although this might be limited by disturbance and motor skills.Might understand simple instructions and cues. Social expression is often nonverbal. Can respond and enjoy relationships with people who were well known to them. Can initiate limited social interaction with such people through gestures. Sensory and physical impairments may prevent social activitiesDependent on others for all aspects of daily physical care. Participation in these activities is limited.. Some simple concrete tasks such as carrying dishes to the table might be accomplished. Co-occurring physical and sensory impairments are often barriers to participationSEVERITY DETERMINED BY ADAPTIVE FUNCTIONING NOT IQ
9Includes deficits in language speech and communication 1. Expressive language disorder2. Receptive-expressive language disorder3. Phonological (articulation) disorder= speech sound disorder (315.39) In DSM 54. Stuttering AKA Childhood onset fluency disorder (315.35) In DSM 5Combined into "language disorder" (315.39) in DSM 59
10Social pragmatic communication disorder 315.39 Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following;deficits in using communication for searching purposesimpairments of the ability to change communications to match the context or needs of the listenerdifficulties following rules for conversation and storytelling such as taking turns in conversation , rephrasing and knowing how to use verbal and nonverbal to regulate interactionDifficulties in understanding what is not explicitly statedDeficits result in functional limitations and effective communications. The onset is in the early developmental. (But deficits aren't fully noticeable until later in life)Not attributable to another medical condition or neurological condition and not better explained by other neurodevelopmental disordersDifferential diagnoses should always consider the possibility of autism spectrum disorder, in particular those with mild severity.Primary deficits of ADHD can cause some impairments in social communicationsocial anxiety disorder and social phobia can often appear with similar symptoms and again mild intellectual developmental disorder might also mask symptoms
11LEARNING DISORDERS DEFINED INDEPENDENT FROM GENERAL INTELLIGENCE DIAGNOSED WHEN AN INDIVIDUAL’S ACHIEVEMENT ON INDIVIDUALLY ADMINISTERED STANDARDIZED TESTS IN READING, MATH OR WRITTEN EXPRESSION IS SUBSTANTIALLY BELOW THAT FOR EXPECTED AGE AND INTELLIGENCEDSM IVDyslexia – reading disorderDyscalculia – math disorderDysgraphia – written expression disorder
12DSM 5 criteria – no separation Difficulty learning and using academic skills indicated by the presence of at least one of the following symptoms for at least 6 months despite interventions.Inaccurate or slow and effortful word readingDifficulty understanding the meaning of what is readDifficulties with spellingDifficulties with written expressionDifficulties mastering number sense, number facts, or calculationDifficulty with mathematical reasoningAffected academic skills are substantially and quantifiably below those expected for the individual's chronological age causing significant interference with performance (quantifiable suggest testing)The learning difficulties begin during school way cheers but might not become apparent until those faculties require more regular useNot better accounted for by intellectual disabilities visual or auditory deficits other mental or neurological disorders etc.
13ADHDXIn DSM-IV TR, ADHD was grouped in the diagnostic domain of "disruptive behavior disorders seen in childhood and adolescence"DSM 5 has moved it to neurodevelopmental disordersDSM-IV TR separated ADHD into 2 subtypes:predominantly attention deficitpredominantly hyperactivity impulsivityDSM 5 has moved these two sub-types to specifiers
14Diagnostic Criteria for ADHD (DSM-IV) XDSM 5 has moved onset age limit to 12!Must occur before age 7 yearsPresent for at least 6 monthsCauses impairment in at least 2 settingsMeets 6 of 9 symptoms of inattentionAND/OR 6 of 9 symptoms of hyperactivity/impulsivity– Must be developmentally inappropriate levelsNow requires “SEVERAL SYMPTOMS”across settings
15DSM 5 criteriaXPersistent pattern of inattention and or hyperactivity-impulsivity that interferes with functioning or development as characterized by inattention and or hyperactivity/impulsivityInattention: 6 or more of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic activitiesOften fails to give close attention to details or makes careless mistakes in schoolworkHas difficulty sustaining attention in tasks or play activitiesAnd remaining focusedOften does notseem to listen when spoken to directlyDoes not follow through on instructions and fails to finish schoolwork chores or dutiesHas difficulty organizing tasks and activitiesAvoids dislikes or is reluctant to engage in tasks that require sustained mental effortLoses things necessary for tasks or activitiesIs easily distractedIs forgetful in daily activities
17Other important changes ADHD XOther important changes ADHDADHD can now be co-morbid with Autism spectrumSymptom threshold has been specified for adultsAdults require a minimum of 5 symptoms – not 6Developmentally appropriate example of symptoms are offered
18Autism Spectrum disorder XAutism Spectrum disorderRepresents a new classification of several disorders that were considered different forms of autismPreviously, these were separate diagnoses.Autistic disorderRetts disorderChildhood disintegrative disorderAspergersPDD NOS
19PDDs in DSM IV TR Autistic disorder Retts disorder Childhood disintegrative disorderAspergersPDD NOSAll characterized by severe deficits andpervasive impairment in multiple areas of developmentReciprocal social interactionCommunication impairedStereotyped behavior, interests and activities
20XWith the new DSM 5. Those separate disorders have now been consolidated and ASD is evaluated in terms of severity rather than separate diagnosisRETTS Disorder removed because it has been established as a physical disease
21Xmajor changes for ASDThree domains from the DSM IV-TR became two: 1Social interaction; 2 communication deficits; 3 repetitive behavior/fixated interest =1) Social interaction/communication deficits2) Fixated interests and repetitive behaviorsDeficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms with contextual and environmental specificitiesDelays in language are not unique nor universal in ASD and are more accurately considered as a factor that influences the clinical symptoms of ASD, rather than defining the ASD diagnosisRequiring both criteria to be completely fulfilled improves specificity of diagnosis without impairing sensitivityProviding examples for subdomains for a range of chronological ages and language levels increases sensitivity across severity levels from mild to more severe, while maintaining specificity with just two domainsDecision based on literature review, expert consultations, and workgroup discussions; confirmed by the results of secondary analyses of data from CPEA and STAART, University of Michigan, Simons Simplex Collection databases
22DSM 5 criteria for all ASD XDSM 5 criteria for all ASDA. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction,2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in peopleB. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases). 2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)D. Symptoms together limit and impair everyday functioning.E. Symptoms are not better explained by intellectual developmental disorder or global developmental delay
23Specifiers X With or without accompanying intellectual impairment With her without accompanying language impairmentAssociated with a known medical or genetic condition or environmental factorWith catatoniaSpecify severity level
24severity X Severity level ASD Social communication and interaction Restricted interests and repetitive behaviors3.Requires very substantial supportSevere deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others. Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres. Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly2 requires substantial supportMarked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from othersRRBs and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress or frustration is apparent when RRB’s are interrupted; difficult to redirect from fixated interestI requires supportWithout supports in place, deficits in social communication cause noticeable impairments. Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRB’s or to be redirected from fixated interest.
25XASD CONCERNSSTIGMA - aspergers made autism respectable! Will it continue to de-stigmatize or re-stigmatizeWill clinicians and insurance companies “control for” the intellectual disability bias?Prior co-morbid estimates with previous classification = 25-75%Drops to negligible with PDD and Aspergers
27Schizophrenia spectrum and other psychotic disorders XThe spectrum seems to emphasize degrees of psychosisChange in criteria for schizophrenia now requires at least one criteria to be either a. Delusions, b. Hallucinations or c. Disorganized speechSubtypes of schizophrenia were eliminatedDimensional measures of symptom severity are now includedSchizoaffective disorder has been reconceptualizedDelusional disorder no longer requires the presence of “non-bizarre" in delusions. There is now specifier for bizarre delusions.Schizotypal personality disorder is now considered part of the spectrum
28Overview of changes from DSM-IV TR to the DSM five 2: schizophrenia and the DSM 5XOverview of changes from DSM-IV TR to the DSM fiveSchizophrenia and other disorders related to schizophrenia are now grouped within a spectrumOverall definition of schizophrenia has not changed that muchRequirements that delusions must be bizarre and hallucinations must be "first rank." (eg. Two or more voices conversing together) have been eliminated.The four subtypes of schizophrenia (paranoid, catatonic, disorganized and chronic undifferentiated) have been eliminated.Rating of symptom severity is most important
29Spectrums‘Spectrum’ as it applies to mental disorder is a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits".In some cases, a spectrum approach joins together conditions that were previously considered separately.(wikipedia)
30Spectrum suggests a progression from Mild or brief Major or lengthyDebilitation DebilitationSeverity severityAttenuatedpsychosisSyndromein conditionsfor furtherstudySchizotypalpersonalityDisorder(Found in PDSection)delusionaldisorderBriefpsychoticdisorderSchizophreniformdisorderSchizophreniaSchizoaffective disorderIn the following areasDelusionsHallucinationsDisorganized thinking/speechDisorganized or abnormal motor behaviorNegative symptoms
31Attenuated psychosis syndrome CRITERIAAt least one of the following symptoms is present in attenuated form and with relatively intact reality testing. It is of sufficient severity or frequency to warrant clinical attentionDelusionsHallucinationsDisorganized speechSymptoms must have been present at least once per week for the last monthSymptoms have begun or worsened in the last yearSymptom is sufficiently distressing or disabling to the individualSymptom is not better explained by another mental disorder including a depressive or bipolar disorder with psychotic features and is not caused by a substanceCriteria for any other psychotic disorder have never been metSymptoms are psychosis like, but below the threshold for a full psychotic disorder. Typically the symptoms are less severe and more transient than in another psychotic disorder. Insight is relatively intact this condition might be stress related. Typically the individual realizes that these changes are taking place and something is wrong. Usually occurs in late adolescence or early adulthoodDIAGNOSTIC FEATURES
32Schizotypal personality disorder (Technically not in the spectrum) CriteriaA pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduce capacity for close relationships as well as by cognitive or perceptual distortions and eccentric cities of behavior beginning by early adulthood and present in a variety of contexts as Indicated by 5 or more of the following:Ideas of reference (excluding delusions of reference)Odd beliefs or magical thinking that influences behavior; i.e. belief in clairvoyance, astral projection telepathy etc.Unusual perceptual experiences, including bodily illusionsOdd thinking and speechSuspicious or paranoid ideationInadequate or constricted affectBehavior or appearance that is odd eccentric or peculiarLack of close friends or confidantsExcessive social anxiety that does not diminishdoes not occur exclusively within the course of schizophrenia a bipolar disorder or depressive disorder with psychotic features or another psychotic disorder or autism spectrum disorderPervasive pattern of social and it interpersonal deficits as well as eccentricities of behavior and cognitive distortions. Such people usually have few close relationships and are considered odd. They may be fascinated or preoccupied with paranormal phenomena and/or superstitions they might believe that they have magical powers. They typically do not fit in and have difficulty matching the norms of consensual social interaction. Typically these people do not become psychotic and any psychotic symptoms are often transient and mild
33Schizophrenia X CRITERION A. DSM-5 Criteria and DSM-IV criteria are same:CRITERION A.2 or more characteristic symptoms present for 1-month period over a 6-month period:DelusionsHallucinationsDisorganized speechdisorganized behaviorNegative symptoms (personality deterioration)Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)“It is a disturbance that lasts for at least 6 months and includes at least 1 month of active phase symptoms (two or more of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms)”WE WILL LOOK AT EACH ONE OF THESE DURING THIS PRESENTATIONPositive symptoms: excess or distortion of normal functions:Delusions—distortions in content of thoughtsHallucinations –distortions in perceptionDisorganized speech –distortions in language and thought processDisorganized or catatonic behavior---distortions in self-monitoring of behaviorNegative symptoms: Loss of normal functions:Flattened affect—restricted range & intensity of emotional expressionAlogia—restricted fluency and productivity of thought and speechAvolition—restricted initiation of goal-directed behavior33
34XExcept forRequirement of “bizarre delusions”and/or schneidnerian 1st rank hallucinations is changed toAt least 1 of the two below need to be from core positive symptoms (delusions, hallucinations, disorganized speech)DelusionsHallucinationsDisorganized speechdisorganized behaviorNegative symptoms (personality
35XB. Level of functioning in one or more areas-work, interpersonal relations, self care, vocation-is markedly below the level of functioning prior to the onset; social/ occupational dysfunction – cant work or relateC. Continuous signs of the disturbance for at least 6 months (at east 1 month with symptoms from category A. Duration is the main factor in differentiating schizophrenia from similar illnessesD. have successfully ruled out schizoaffective disorder and mood disorder (with psychotic symptoms) b/c no evidence of mania or depressionE. not due to substance abuseF. not due to Autism spectrum disorder
36Specifiers X 1st episode, currently in acute stage 1st episode currently in partial remission1st episode in full remissionmultiple episodes, currently in acute episodemultiple episodes currently in partial remissionmultiple episodes currently in full remissioncontinuouswith catatonia
37Schizophrenia X Diagnostic features Other symptoms outside the major diagnostic criteria include mood dysphoria, inappropriate affect sleep disturbance depersonalization, derealization somatic concerns, vocational impairmentsLack of insight or awareness or even denial about the existence of the illness is also a symptom that commonly occurs.Aggression, sometimes associated with delusions is common in males, although not as a ruleAlthough there are many brain and genetic abnormalities that have been identified, there are no “absolute” biological markersSchizophrenia is often overdiagnosed in the poorThere is a high rate of suicide among schizophrenics-6%. With a suicide attempt rate of close to 20%Still thought to be a lifelong illness although the occurrence of "positive symptoms" seem to diminish with ageDepression often shows up over time
38Schizophreniform disorder XDiagnostic features* At least one third of people who receive this diagnosis recover. However the other two thirds will eventually be diagnosed with schizophreniaMeets all the diagnostic criteria for Schizophrenia, except durationDiagnosed when duration is less than six months (Absence of criterion B) (this includes prodromal, active and residual phase)_Make this diagnosis when someone is having an episode longer than one month, but it has not yet lasted 6 months (call it ‘provisional)The 'Tweener' disorder in terms of length. The period of active psychotic symptoms (delusions, hallucinations, disorganized thinking, disorganize motor behavior) is longer than a brief psychotic episode, but not as long as schizophreniaMake this diagnosis when an individual Has already recovered And the episode lasted between 1 and 6 months
39SchizophreniformXDiagnostic criteria –2 or more of the following present for a significant portion of time. At least one of these must be one 2 or 3DelusionsHallucinationsDisorganized speechDisorganized motor behaviorNegative symptomsLasts at least one month but less than 6 months. When diagnosis is made before recovery, specify "provisional“Schizoaffective disorder, depressive disorder or bipolar disorder with psychotic features have been ruled out because either no major mood episodes have occurred with the psychotic symptoms or if they have occurred, their occurrence was infrequentNot attributable to substances or another medical condition
40Schizoaffective disorder XDiagnostic criteria295.70An uninterrupted. period which there is a major mood episode con current with criterion A of schizophreniaDelusionsHallucinationsDisorganized thinkingGrossly abnormal motor behaviorNegative symptoms of schizophreniaIn addition, Delusions or hallucinations must occur for two or more weeks with an absence of a major mood episode during the lifetime duration of the illnessSymptoms that meet criteria for major mood episode be present for the majority of the duration of the Active, and residual portions of the illnessNot attributable to the effects of a substance medication or other medical conditionThe requirement that a major mood disorder must be present for the majorityOf the duration of illness AFTER criterion A is met, makes this alongitudinalIllness or bridge on spectrum
41XSubtypesSpecify whether: bipolar type depressive type Specify if: with catatonia 1st episode currently in acute episode 1st episode currently in partial remission 1st episode currently in full remission multiple episodes currently in acute episode multiple episodes currently in partial remission multiple episodes currently in full remission continuous severity level-use. Clinician related dimensions of psychotic symptoms
443. Bipolar and related disorders summary X3. Bipolar and related disorders summaryDiagnosis must now include both changes in mood and changes in activity/energy levelSome particular conditions can now be diagnosed under "other specified bipolar and related disorders“An "anxiety" specifier has now been includedAttempts made to clarify definition of 'hypomania". However it was not successfulBipolar I mixed episode –no longer requires full criteria for depressed and mania or hypomaniaNew specifier is “mixed features”.
45XSome particular conditions can now be diagnosed under "other specified bipolar and related disorders” These do not meet full criteria for bipolar diagnosisNo history of major depression with hypomanic episode05-2. Short durations. Cyclothymic (less than 24 months).3. Multiple episodes of hypomanic symptoms that do not meet criteria and multiple episodes of depressive symptoms that you might meet criteria4. History of major depressive disorderHypomanic symptoms present but not of sufficient duration (less than 4 days)Insufficient number of hypomanic symptoms
46Problems Severity Criteria are unclear "Severity is based on the number of criterion symptoms, Francis severity of those symptoms and the degree of functional disability." (Page 154)Dimensional measures for both mania and depression exist as level II crosscutting measures. These could be used to measure severity.
47Bipolar I Coding for severity Bipolar I disorderCurrent or most recent episode-manicCurrent or most recent episode-hypomanicCurrent or most recent episode-depressedCurrent or most recent episode-unspecifiedMild296.41Not applicable296.51Moderate296.42296.52Severe296.43296.53Mild = few if any symptoms in excess of those required to meet the diagnostic criteria are present. The intensity is distressing that manageable. Symptoms resulting minor impairment of social and occupational functioningModerate = number of symptoms and intensity and/or functional impairment are between those specified for mild and severeSevere = number of symptoms is substantially in excess of those required to make DX. Intensity of symptoms is seriously distressing and unmanageable. Symptoms interfere markedly with social and occupational functioning.
48The dimensional Alternative assessment of mania and hypomania DSM 5 offer some assistanceSuggests 1st using the level I crosscutting symptoms scale-PP.734 – 735.That the answers to question 9 and 10-increased energy anddecreased need for sleepare positive thenMove to use of the Altman self rating mania scale (ASRM) - See next slide
49Level 2DimensionalMeasure forManiaLevel II measures are more in-depth than level I measures. The level I measure shown in week 1 measured a number of different symptoms. Level II focuses in on only one subgroup. In this case mania
50Instructions for the mania scale Instructions to CliniciansThe DSM-5 Level 2—Mania—Adult measure is the Altman Self-Rating Mania Scale. The ASRM is a 5-item se rating mania scale designed to assess the presence and/or severity of manic symptoms. The measure is completed by the individual prior to a visit with the clinician. If the individual receiving care is of impaired capacity and unable to complete the form (e.g., an individual with dementia), a knowledgeable informant complete the measure. Each item asks the individual (or informant) to rate the severity of the individual’s manic symptoms during the past 7 days.Scoring and InterpretationEach item on the measure is rated on a 5-point scale (i.e., 1 to 5) with the response categories having differ anchors depending on the item. The ASRM score range from 5 to 25 with higher scores indicating greater severity of manic symptoms. The clinician is asked review the score on each item on the measure during th clinical interview and indicate the raw score for each item in the section provided for “Clinician Use”. The r scores on the 5 items should be summed to obtain a total raw score and should be interpreted using the Interpretation Table for the ASRM below:Interpretation Table for the ASRM- A score of 6 or higher indicates a high probability of a manic or hypomanic condition- A score of 6 or higher may indicate a need for treatment and/or further diagnostic workup- A score of 5 or lower is less likely to be associated with significant symptoms of maniaInstructions: for clientOn the DSM-5 Level 1 cross-cutting questionnaire you just completed, you indicated that during the past 2 weeks you (theindividual receiving care) have been bothered by “sleeping less than usual, but still having a lot of energy” and/or “starting lots more projects than usual or doing more risky things than usual” at a mild or greater level of severity. The five statement groups or questions below ask about these feelings in more detail.1. Please read each group of statements/question carefully.2. Choose the one statement in each group that best describes the way you (the individual receiving care) have been feeling for the past week.3. Check the box (P or x) next to the number/statement selected.4. Please note: The word “occasionally” when used here means once or twice; “often” means several times o more and frequently” means most of the time.
51Coding and recording procedures for bipolar one disorder Coding is complicatedMust specify the following in the order presented belowBipolar I disorderType of current episode (manic or depressive)Severity levelCurrent state of most recent episode (active, in partial remission, in full remission, unspecified)Psychotic features presentPresence of other specifiers (uncoded)
52Bipolar I Coding for Current state of episode & psychosis Bipolar I disorderCurrent or most recent episode-manicCurrent or most recent episode-hypomanic*Current or most recent episode-depressedCurrent or most recent episode-unspecified**W/ psychotic features296.44Not applicable296.54In Partial remission296.45296.55In full remission296.46296.56Unspecified296.40296.50Not applicabl*Do not code severity and psychotic features if current or most recent episode is hypomanic. **Do not code severity and psychotic features if current or most recent episode = unspecified.
544. Depressive disorders SUMMARY X4. Depressive disorders SUMMARYNew diagnosis included = "disruptive mood dysregulation disorder-use for children up to age 18New diagnosis included = "premenstrual dysphoric disorder“What used to be called dysthymic disorder is now "persistent depressive disorder“Bereavement is no longer excluded
55MDD: Specifiers X Severity With anxious distress With mixed features Melancholic FeaturesAtypical FeaturesCatatonicPostpartumSeasonalWith Psychotic Features(Mood congruent or incongruent)
56Depression is mainly coded by severity and recurrence Severity/course specifierSingle episodeRecurrent episodeMild296.21296.31Moderate296.22Severe296.23296.33With psychotic features296.24296.34In partial remission296.25296.35In full remission296.26296.36Unspecified296.20296.30Mild = few if any symptoms in excess of those required to meet the diagnostic criteria are present. The intensity is distressing that manageable. Symptoms resulting minor impairment of social and occupational functioningModerate = number of symptoms and intensity and/or functional impairment are between those specified for mild and severeSevere = number of symptoms is substantially in excess of those required to make DX. Intensity of symptoms is seriously distressing and unmanageable. Symptoms interfere markedly with social and occupational functioning.
57Problems with severity Severity Criteria are unclear"Severity is based on the number of criterion symptoms, Francis severity of those symptoms and the degree of functional disability." (Page 154)Dimensional measures for both mania and depression exist as level II crosscutting measures. These could be used to measure severity.
58LEVEL ii CROSS-CUTTING MEASURE FOR DEPRESSION LEVEL ii CROSS-CUTTING MEASURE FOR DEPRESSION. The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking ( or x) one box per row.
59Instructions to Clinicians The DSM-5 Level 2—Depression—Adult measure is the 8-item PROMIS Depression Short Form that assesses the pure domain of depression in individuals age 18 and older. The measure is completed by the individual prior to a visit with the clinician. If the individual receiving care is of impaired capacity and unable to complete the form (e.g., an individual with dementia), a knowledgeable informant may complete the measure as done in the DSM-5 Field Trials. However, the PROMIS Depression Short Form has not been validated as an informant report scale by the PROMIS group. Each item asks the individual receiving care (or informant) to rate the severity of the individual’s depression during the past 7 days.Scoring and InterpretationEach item on the measure is rated on a 5-point scale (1=never; 2=rarely; 3=sometimes; 4=often; and 5=always) with a range in score from 8 to 40 with higher scores indicating greater severity of depression. The clinician is asked to review the score on each item on the measure during the clinical interview and indicate the raw score for each item in the section provided for “Clinician Use.” The raw scores on the 8 items should be summed to obtain a total raw score. Next, the T-score table should be used to identify the T-score associated with the individual’s total raw score and the information entered in the T-score row on the measure.
60Note:This look-up table works only if all items on the form are answered. If 75% or more of the questions have been answered; you are asked to prorate the raw score and then look up the conversion to T-Score. The formula to prorate the partial raw score to Total Raw Score is:(Raw sum x number of items on the short form)Number of items that were actually answeredIf the result is a fraction, round to the nearest whole number. For example, if 6 of 8 items were answered and the sum of those 6 responses was 20, the prorated raw score would be 20 X 8/ 6 = The T-score in this example would be the T-score associated with the rounded whole number raw score (in this case 27, for a T-score of 64.4).The T-scores are interpreted as follows:Less than 55 = None to slight55.0—59.9 = Mild60.0—69.9 = Moderate70 and over = SevereNote: If more than 25% of the total items on the measure are
61Explanation of other specifiers With anxious distress = 1. Tense, 2. Restless 3. Excessive worry 4. Fear of catastrophe 5. Fear of losing controlIf present, Code severity of anxietyMild = 2 symptomsmoderate = 3 symptomsmoderate- severe = 4 or 5 symptomsWith mixed features = prominent dysphoria or depressed mood, diminished interest or pleasure, psychomotor retardation and/or other symptoms found in depressive episodesWith melancholic features = loss of pleasures and all activities, lack of reactivity to pleasurable experiences. 3 or more of the following; depressed mood that is worse in the morning, early-morning awakening mark psychomotor agitation or retardation, significant weight loss, excessive guiltWith atypical features = mood improves in response to positive events (mood reactivity) 2 or more of the following; weight gain or increase in appetite, hypersomnia, heavy feeling in arms or legs heightened sensitivity to interpersonal rejectionMood congruent psychotic features = with depression, delusions and hallucinations are often punitive, self punishing and rejecting. Perhaps delusions of persecution or annihilation.Mood incongruent psychotic features = delusions and hallucinations are not consistent with mood being displayedWith postpartum onset = onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery. Depressive episodes are far more common than manic episodesSeasonal pattern = regular temporal correlation between the onset of manic, hypomanic or depressive episodes and a particular time of year, usually without the presence of psychosocial stressors
62With anxiety anxious distress = 1. Tense 2. RelentlessRestlessness Anxiety is very common with depressionanxious distress =1. Tense2. RelentlessRestlessness3. Excessive worryOr concern that is unwarranted4. Excessive concern regarding the occurrence of a major negative event-5. Fear of losing controlIf present, Code severity of anxietyMild = 2 symptomsmoderate = 3 symptomsmoderate- severe = 4 or 5 symptoms
63Persistent depressive disorder 300 Persistent depressive disorder Formerly known as dysthymic disorderXIn The DSM-IV TR, dysthymia was considered a depressive disorder that that waslong-lasting (chronic) anddid not meet the full criteria for a major depressive episode- a milder form of depressionA less severe type of depression, dysthymia, involves long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives.
64XPersistent depressive disorder in the DSM 5 Combines dysthymia and a chronic form of major depressive disorder (without certain symptomsPersistent depressive disorderChronic major depressive disorder- Must last for 2 or more years with little or no abatement – no suicidal ideation, or anhedoniaChronic depressionmeet full criteria for major depressive episode/DisorderDysthymia-2 or more yearsChronic low-level depressionnever meet full criteria for major depressive episode
65Dysthymia vs MDD X Chronic sense of inadequacy Depression is not as intense as with MDDSymptoms are typically not as “acute” as with MDDMDD = depressed mood, most of day, nearly every day for two weeksDys = depressed mood more days than not over a period of 2 yearsSeems more like a personality disorder “dissatisified personality”N
66Dysthymic Disorder and Chronic major depressive disorder XDysthymic Disorder and Chronic major depressive disorder2 or more of the following associated Symptoms Along with depressed moodChange in appetiteChange in sleepDecreased energyDecreased self worthPoor concentrationHopelessness.Dysthymic disorder, or dysthymia, is a type of depression that lasts for at least 2 years
67XPlease note that there are 3 major symptoms missing from this list that are included in major depressive disorder;1. Absence of pleasure (anhedonia)2. Recurrent thoughts of suicide3. Psychomotor retardation or agitationThis suggests that only a particular type of major depressive disorder-1 without suicidal ideation, anhedonia and lethargy qualify for this diagnosis
68PDD: SpecifiersXSeverityWith anxious distressWith mixed featuresMelancholic FeaturesAtypical FeaturesPsychosis-mild (mood congruent or incongruent)PostpartumPartial remissionFull remissionLate onset-21 or olderEarly onsetWith pure dysthymic syndrome-criteria for major depression is not been metWith persistent major depressive episode-full criteria have been met, excluding anhedonia, psychomotor retardation and suicidal ideationIntermittent major depressive episodes with or without current episode
69X The bereavement exclusion is gone In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons. 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. 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. 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. Finally, the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression.
70Disruptive mood dysregulation disorder 296.99 XDisruptive mood dysregulation disorderThe purpose of this diagnosis was to provide a category for children that created an alternative to the diagnosis of bipolar disorderEvidence for such a diagnosis has long been available. Earlier proposals were "severe mood dysregulation“Evidence suggests that children with this type of mood dysregulation will not go on to be bipolar, but more likely suffer from major depression
71Diagnostic criteriaSevere recurrent temper outburst manifested verbally or behaviorally; grossly out of proportion to the situation to the situationOutbursts are inconsistent with developmental levelOutbursts occur 3 or more times a weekMood between temper outburst is persistently irritable or angry most of the day, nearly every day.Criterion a through D have been present for 12 or more monthsCriteria a through D are present in at least 2 or more settingsInitial Diagnosis can be made between the ages of 6 to 18Age of onset-established her history or observation-must be before the age of 10No presence of manic or hypomanic episodeThese behaviors do not occur during an episode of major depression and are not better explained by another mental disorderSymptoms are not attributable to the effects of a substance, another medical or neurological condition
72XDiagnostic featuresChronic, severe persistent irritability with the following:Frequent temper outbursts in response to frustration over a sustained period of time and are developmentally inappropriateAnger and irritability remains constant even after temper outbursts of stopped
73X Prevalence estimates range between 2% and 5% Affects males more than femalessuch children seem to be extremely temperamental in prodromal manifestationsometimes diagnosed as oppositional defiant disorder
775. Anxiety disordersObsessive-compulsive disorder has been moved out of this categoryPTSD has been moved out of this categoryAcute stress disorder has been moved out of this categoryPanic attacks can now be used as a specifier within any other disorder in the DSMSeparation anxiety disorder has been moved to this groupSelective mutism has been moved to this group
78Other changes and anxiety disorders Criteria for specific phobia, and social anxiety disorder that requires that individuals over 18 recognize that their anxiety is excessive or unreasonable has been deletedI don't know I don't see it in here. I don't know. I had a lot of awareness requirement is now that anxiety must be out of proportion to the actual danger or threat in a situation after a cultural context is considerEDPanic disorder and agoraphobia are unlinked in the DSM 5THE “generalized” specifier for social anxiety disorder has been deleted and replaced with her “performance only” specifier
806. Obsessive-compulsive and related disorders X6. Obsessive-compulsive and related disordersA completely new diagnostic grouping categoryHoarding disorder-new diagnosisExcoriation (skin picking) disorder-new diagnosisSubstance induced obsessive-compulsive disorder-new diagnosisTic specifier has been addedMuscle dysphoria is now a specifier within body dysmorphic disorderObsessive-compulsive disorder-refined to allow distinction between individuals with good to fair poor or “absent/delusional”
81OCD SpecifiersIn DSM-IV TR a requirement for the diagnosis was that the person suffering realized that the worries and behaviors were excessiveNow insight is a specifierWith good or fair insight-individual recognizes that beliefs and behaviors are not true and will not workWith poor insight-individual believes that behaviors and beliefs will helpWith absent insight/delusional beliefs-individual is zealous in thinking that thoughts and behaviors must happen
82Hoarding disorder 300.3XPersistent difficulty discarding her, parting with possessions, regardless of their actual valueDifficulty is due to perceived need to save the items and due to distress associated with discarding themTo difficulty discarding results in the accumulation of possessions that congest and clutter active living areas and compromise their intended useCauses clinically significant distress or impairment in social, occupational or other Areas of functioningNot attributable to another medical conditionNot better accounted for by….With excessive acquisition-in addition to keeping things, this type actively seeks out more(80 to 90% of all hoarders)With good or fair insightWith poor insightWith absent insight and delusional beliefs – this would trump delusional disorderSpecifiers
83Excoriation (skin picking) disorder 698.4 Recurrent skin picking resulting in lesionsRepeated attempts to stop or decrease behaviorCauses clinically significant distress or impairment in social, occupational…Not attributable to the effects of a substance or medicationNot better explained by…
84Substance/medication induced obsessive-compulsive and related disorder XSubstance/medication induced obsessive-compulsive and related disorderObsessions, compulsions, skin picking, hair pulling or other body focused repetitive behaviors occurEvidence that symptoms began during or soon after substance use, withdrawal or medication exposure. Substance or medication is capable of producing obsessive-compulsive symptomsNot better accounted for by OCD that is not substance/medication inducedDoes not occur exclusively during deliriumCauses clinically significant distress
85OCD due to another medical condition 294.8 Obsessions, compulsions, skin picking, hair pulling or other body focused repetitive behaviors occurEvidence that symptoms began during or soon after Another medical condition that could cause the symptomsNot better accounted for by OCD that is not substance/medication inducedDoes not occur exclusively during deliriumCauses clinically significant distressSpecify ifWith the possessive compulsive disorder like symptomsWith appearance. PreoccupationWith hoarding symptomsWith hair pulling symptomsWith skin picking symptoms
86Other specified obsessive-compulsive and related disorder 300.3 Use when OCD symptoms are there and cause clinically significant distress, but do not meet full criteria for an OCD related diagnosesSpecifyBody dysmorphia with actual flawsBody dysmorphia without repetitive behaviorsBody dysmorphia with repetitive behaviorsobsessional jealousy
88Substance-Related Disorders XSubstance-Related Disorders:The distinction between Dependence and abuse disorders has been eliminated in the DSM 5Substance Use DisordersSubstance DependenceSubstance AbuseSubstance-Induced DisordersSubstance IntoxicationSubstance WithdrawalSubstance induced mental disorder
89Must have at least 2 of the following11: XSubstance use disorders maladaptive pattern leading to clinically significant impairment or distress for at least 12 monthsMust have at least 2 of the following11:Substance taken in larger amount (need more for increased effect)Persistent desire or efforts to quitTime spent to obtain, use, recover from effectsCravings Or urges to useFailure to fulfill significant rolesContinued use despite persistent and recurrent problemsImportant social/occupational activities are reducedRecurrent use in physically hazardous situationsUse continues despite knowledge of impact of the problemTolerance, as defined by a. Increased amounts needed to achieve intoxication or b. Diminished effectWithdrawal
90Substance-related disorders XSubstance-related disordersSubstance induced dis.Substance use dis.Pathological pattern of behaviors related to use of the substanceImpaired controlSocial impairmentRisky use4. Pharmacological effectsIncreased toleranceSubstanceWithdrawalPhysiological and psychological symptoms due to decreased use or cessationSubstanceInducedMental disorder.Recent ingestion followed by symptoms of another M.D.SubstanceIntoxicationRecent ingestion.Reversible symptoms related to ingestion== does occur alsoDelirium; persisting dementia; persisting amnesia;Psychotic disorder; mood dis; anxiety dis; sexual dys; sleep dis.
9111 criteria four areas – USE Dx Substance taken in larger amount (need more for increased effect)Persistent desire or efforts to quitTime spent to obtain, use, recover from effectsCravings Or urge to useFailure to fulfill significant rolesContinued use despite persistent and recurrent problemsImportant social/occupational activities are reducedRecurrent use in physically hazardous situationsUse continues despite knowledge of impact of the problemTolerance, as defined by a. Increased amounts needed to achieve intoxication or b. Diminished effectWithdrawalImpairedControlsocialImpairmentRiskyusePharmacologicaleffects
921. Criteria for Substance Use disorder XA maladaptive pattern of substance use leading to impairment or distress, as seen in 2 of the following in the same 12-mo. period:Substance taken in larger amount (need more for increased effect)Persistent desire or efforts to quitTime spent to obtain, use, recover from effectsCravings Or urges to useFailure to fulfill significant rolesContinued use despite persistent and recurrent problemsImportant social/occupational activities are reducedRecurrent use in physically hazardous situationsUse continues despite knowledge of impact of the problemTolerance, as defined by a. Increased amounts needed to achieve intoxication or b. Diminished effectWithdrawal92
93DSM 5 use = 2 or more crit. DSM IV Abuse = 1 or more 1Failure to fulfill major role obligations at work, school, home such as repeated absences or poor work performance related to substance use;#5 DSM 52. Frequent use of substances in situation which iis physically hazardous #8 dsm 53Frequent legal problems (e.g. arrests, disorderly conduct) for substance abuse removed 4. Continued use despite having persistent or recurrent social or interpersonal problems #6 dsm 5Dependence = 3 or more5. Tolerance or markedly increased amounts of the substance to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount of substance #10 DSM 56 Withdrawal symptoms or the use of certain substances to avoid withdrawal symptoms #11 DSM Use of a substance in larger amounts or over a longer period than was intended #1 DSM 5 8.persistent desire or unsuccessful efforts to cut down or control substance use #2 DSM Involvement in chronic behavior to obtain the substance, use the substance, or recover from its effects #3 DSM 510. .Reduction or abandonment of social, occupational or recreational activities because of substance use #7 DSM 511. Use of substances even though there is a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance #9 DSM 5Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month periodSubstance taken in larger amount (need more for increased effect) dsm4Persistent desire or efforts to quit Using dsm4Time spent to obtain, use, recover from effects dsm4Cravings Or urges to use Substance NEWFailure to fulfill significant rolesdsm4Continued use Alcohol despite persistent and recurrent problemsdsm4Important social/occupational activities reduceddsm4Recurrent use Of Substance in physically hazardous situations NEWUse Of Substance continues despite knowledge of impact of the problem dsm4Tolerance, as defined by a. Increased amounts needed to achieve intoxication or b. Diminished effect Of Substancedsm4Withdrawal From Substancedsm4
94Specifiers for use disorders XSpecifiers for use disordersSeverity Mild = presence of 2-3 symptoms moderate = presence of four – five symptoms severe = presence of six or more symptoms Course specifiers In early remission = after full criteria were previously met none of the criteria have been met for at least three months but less than 12 (with the exception of craving) In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
95XCan also diagnose intoxication, withdrawal and induced mental disordersSimple substance dxMental disorders that can be induced by substancesI/WI/WI
977. Trauma and stress related disorders X7. Trauma and stress related disordersFor diagnosis of acute stress disorder, it must be specified whether the traumatic events were experienced directly or indirectlyAdjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stressMajor changes in the criteria for the diagnosis of PTSD
98XDiagnostic criteria has gotten more detailed and specific = more complicated diagnosisThe basicsExposure to trauma-direct or indirectPresence of intrusive thoughts, memories, flashbacks, dreams, triggers that cause distress, or other external cues that remind one of the traumaAvoidance of stimuli associated with the traumatic eventChanges (usually increased sensitivity) in thought processes and emotions associatedIncreased arousal or reactivity associated with the traumatic event with the traumatic eventTraumaticeventsSubsequentreactions
99XPTSD changesCriterion A - the stressor criterion is more explicit with regard to how an individual experienced “traumatic” events.Criterion A2 (subjective reaction) has been eliminated.Three major symptom clusters in DSM-IV—reexperiencing, avoidance/numbing, and arousal—Now four symptom clusters in DSM-5, because the avoidance/numbing cluster is divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood. This latter category, which retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as persistent negative emotional states. The final cluster—alterations in arousal and reactivity—retains most of the DSM-IV arousal symptoms. It also includes irritable or aggressive behavior and reckless or self-destructive behavior. Posttraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder.Reactive Attachment
100XPTSDA . Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways 1. Directly experiencing the traumatic events 2. Witnessing in person. The event is it occurred to others 3. Learning that the traumatic events occurred to a close family member or close friend 4. Experiencing repeated or extreme exposure to aversive details of the traumatic events; a form of Vicarious exposure experienced by police officers or 1st responders B. Presence ofone or more of the following intrusion symptoms associated with the traumatic events beginning after the event occurred 1. Recurrent, involuntary and intrusive distressing memories of the event 2. Recurrent distressing dreams in which the content is related to the event 3. Dissociative reactions (flashbacks) where individual feels or acts as if the event were recurring 4 intense-prolonged psychological distress when exposed to internal or external cues 5. Marked physiological reactions to internal or external cues C. Persistence avoidance of stimuli associated with the traumatic events beginning after the event occurred 1. Avoidance or efforts to avoid distressing memories, thoughts or feelings associated with the event 2. Avoidance or efforts to avoid external reminders-people, places, conversations that might arouse distressing memory starts her feelings associated with the event D. Negative alterations in cognitions and mood associated with the events beginning or worsening after the events 1. Inability to remember an important aspect of the traumatic event. This is not caused by a head injury help call or drugs, but dissociative amnesia related to the event 2. Persistent exaggerated negative beliefs or expectations about oneself, Others and the world-I am bad, No one can be trusted, the world sucks 3. Distorted cognitions that lead to self blame where the blame of others. 4. Persistent negative emotional state 5. Diminished interest or participation in significant activities 6. Feelings of detachment or estrangement from others 7. Persistent inability to experience positive emotions
101PTSD 309.81-Continued X Specifiers Specify whether: E. Significant alterations in arousal and reactivity associated with the traumatic event 1. Irritable behavior in angry outbursts with little or no provocation-started after the event, usually directed toward people or objects 2. Reckless or self-destructive behavior 3. Hypervigilance 4. Exaggerated startle response 5. Problems with concentration 6. Sleep disturbance F. Duration of the disturbance is longer than one month G. Causes clinically significant distress or impairment H. The disturbance is not attributable to the physiological effects of a substance or another medical conditionSpecifiersSpecify whether:Dissociative symptoms are presentDepersonalization = experience of feeling detached from, and disconnected from one self. Often described as feeling as if one were outside observing oneself or as though in a dream.A sense or feeling of unreality regarding oneself-with the knowledge that this is not trueDerealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her distorted. However, one realizes this is not trueSpecify ifExpression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or more after the eventPlease note the presence of anxiety, fear and avoidance. 3 conditions that we find in generalized anxiety disorder
102PTSD In children-6 or younger Avoidance and alterations in cognition collapsed into one criterion groupXA . Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways 1. Directly experiencing the traumatic events 2. Witnessing in person. The event is it occurred to others 3. Learning that the traumatic events occurred to a close family member or close friend B. Presence ofone or more of the following intrusion symptoms associated with the traumatic events beginning after the event occurred 1. Recurrent, involuntary and intrusive distressing memories of the event 2. Recurrent distressing dreams in which the content is related to the event 3. Dissociative reactions (flashbacks) where individual feels or acts as if the event were recurring 4 intense-prolonged psychological distress when exposed to internal or external cues 5. Marked physiological reactions to internal or external cues C. One or more of the following symptoms involving either avoidance or negative alterations in cognition are made - must be Present 1. Avoidance or efforts to avoid distressing memories, thoughts or feelings associated with the event 2. Avoidance or efforts to avoid external reminders-people, places, conversations that might arouse distressing memory starts her feelings associated with the event 3. Increase of negative emotional states 4. Diminished interest or participation in significant activities 5. Socially withdrawn Behavior 6. Reduction in expression of positive emotions D. alterations in arousal and reactivity associated with the traumatic event 1. Irritable behavior in angry outbursts with little or no provocation- 2. Hypervigilance 3. Exaggerated startle response 4. Problems with concentration 5. Sleep disturbance E.. Duration of the disturbance is longer than one month F. Causes clinically significant distress or impairment G.. The disturbance is not attributable to the physiological effects of a substance or another medical condition
103PTSD 309.81-Children X Specifiers are the same Specifiers Specify whether:Dissociative symptoms are presentDepersonalization = experience of feeling detached from, and disconnected from one self. Often described as feeling as if one were outside observing oneself or as though in a dream.A sense or feeling of unreality regarding oneself-with the knowledge that this is not trueDerealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her distorted. However, one realizes this is not trueSpecify ifExpression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or more after the event
104In DSM-IV RAD was divided into subtypes Subtypes = inhibited type and disinhibited type (criterion A),Inhibited = Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g. the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit "frozen watchfulness", hypervigilance while keeping an impassive and still demeanor). Such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain "proximity", an essential element of attachment behaviorDisinhibited = Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures). There is therefore a lack of "specificity" of attachment figure
105Disinhibited = 313.89 disinhibited social engagement disorder A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of the followingReduced or absent reticence in approaching and interacting with unfamiliar adultsOverly familiar verbal or physical behavior that is not consistent with age-appropriate social boundariesDiminished or absent "checking back" behaviorsWillingness to go with an unfamiliar adult with minimal or no hesitationBehaviors in criterion a are not limited to impulsivity such as that seen in ADHDThe child has experienced a pattern of extremes of insufficient care, as evidenced by at least one of the followingSocial neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort stimulation and affectation met by caregiversRepeated changes of primary caregivers that limit opportunities for stable attachmentRearing in unusual settingsThe criterion C is presumed to be responsible for the disturbed behavior in criterion AThe child has a developmental age of at least 9 months
106RADA consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers manifested by both of the followingThe child rarely or minimally seeks comfort when distressedThe child rarely or minimally responds to comfort. When distressedA persistent social and emotional disturbance characterized by at least 2 of the followingMinimal social and emotional responsiveness to othersLimited positive affectEpisodes of unexplained irritability, sadness or fearfulness that are evident even during nonthreatening interactions with caregiversThe child has experienced the pattern of extremes or insufficient care, as evidenced by at least one of the followingSocial neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort stimulation and affection met by caregiving adultsRepeated changes a primary caregivers that limit opportunities to form stable attachmentRearing in unusual settings that severely limit opportunities to form attachmentsTo carry in criterion C is presumed to be responsible for the disturbed behavior in criterion aCriterion are not met for autism spectrum disorderDisturbance is evident before age 5Child has a developmental age of at least 9 months
107Adjustment DisordersIn DSM-5, adjustment disorders are reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event, rather than as a residual category for individuals who exhibit clinically significant distress without meeting criteria for a more discrete disorder (as in DSM-IV ). DSM-IV subtypes marked by depressed mood, anxious symptoms, or disturbances in conduct have been retained, unchanged.Stressor can be of any severity or type (unlike PTSD Criterion A)Much more flexible diagnosis then PTSD or acute stress disorderDiagnose adjustment disorder when:PTSD criteria are not metCriterion A for PTSD stressors not metSubthreshold for acute stress disorder & PTSDSymptoms do not last longer than 6 months after stressor.-A transitional state that is longer than acute stress disorder, but typically not as intense
1098. Dissociative disorders SUMMARY Depersonalization disorder has been relabeled “Depersonalization/Derealization disorder“Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of "dissociative amnesia“Changes in criteria for the diagnosis of "dissociative identity disorder"
110DIDCriterion A has been expanded to include certain possession-form phenomena and functional neurological symptoms to account for more diverse presentations of the disorder.Criterion A now specifically states that transitions in identity may be observable by others or self-reported.Criterion B, individuals with dissociative identity disorder may have recurrent gaps in recall for everyday events, not just for traumatic experiences. Other text modifications clarify the nature and course of identity disruptions.
111Diagnostic criteria – DSM 5 300.14 Presence of two or more distinct Personality states, which may be described in some cultures as an experience of possession. This disruption and identity involves marked discontinuity in sense of self and personal agency. This is accompanied by alterations (often sudden) in affect, behavior, consciousness, memory, perception and/or sensorimotor functioning. These signs and symptoms may be observed by others or reported by the individualInability to recall important personal information Or gaps in recall of everyday events. Important personal information or traumatic events. AKA dissociative amnesiaCause clinically significant distress , And/or impairmentNot a part of broadly accepted cultural or religious practiceNot due to a substance or general medical condition
112Note the difference in the Diagnostic criteria –IV TR Presence of two or more distinct identities, each with its own relatively stable pattern of personality traitsAt least two of these ‘alters’ take control of the person’s behaviorInability to recall important personal information that is too extensive to be explained by ordinary forgetfulnessNot due to a substance or general medical condition
1149. Somatic symptom and related disorders X9. Somatic symptom and related disordersThis is a new name for what was previously called "somatoform disorders“The number of diagnoses in this category has been reduced. The diagnoses of somatization disorder, hypochondriasis, pain disorder and undifferentiated somatoform disorder have all been removed"Illness anxiety disorder" has been an added diagnosis and replaces hypochondriasisFactitious disorder is now included in this group
115XSome definitionsFactitious disorder: conscious and intentional feigning or production of symptoms, because of a psychological need to assume the sick role to obtain emotional gainMalingering: conscious and intentional production or exaggeration of symptoms for material gain, such as money, lodging, food, drugs, avoidance of military service, or escape from punishmentSomatization: recurrent and multiple symptoms (eg, pain, GI, sexual, pseudoneurological) with no organic basis, believed to be due to unconscious expressions of suppressed emotional conflict or stress; unlike factitious disorders, the symptoms are not created by voluntary, conscious behaviorHypochondriasis: obsession with fears that one has a serious, undiagnosed disease, presumably based on misinterpretation of bodily sensations - See more at:
116Somatic Symptom Disorder XIndividuals with somatic symptoms plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed medical condition.The relationship between somatic symptoms and psychopathology exists along a spectrum.high symptom count required for DSM-IV somatization disorder did not accommodate this spectrum.The diagnosis of somatization disorder was essentially based on a long and complex symptom count of medically unexplained symptoms.Individuals previously diagnosed with somatization disorder will usually meet DSM-5 criteria for somatic symptom disorder, but only if they have the maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to their somatic symptoms.In DSM-IV, the distinction between “undifferentiated somatoform disorder” had been created in recognition that “somatization disorder” would only describe a small minority of “somatizing” individuals, but this disorder did not prove to be a useful clinical diagnosis.They are merged in DSM-5 under somatic symptom disorder, and no specific number of somatic symptoms is required.
117Somatic Symptom Disorder300.82 XDiagnostic Criteria:One or more somatic symptoms that are distressing and result in significant disruption of daily lifeExcessive thoughts, feelings or behaviors related to the symptoms or associated health concerns, as manifested by at least one of the following:Disproportionate and persistent thoughts about the seriousness of symptomsPersistently high level of anxiety about health or symptomsExcessive time and energy devoted to the symptoms or health concernsThe state of being symptomatic is persistent (typically more than 6 months)
118Specifiers Specify if: with predominant pain (previously classified as pain disorder and DSM-IV)persistent: severe symptoms lasting longer than 6 monthsSpecify current severity:mild = only one of the symptoms specified in criterion B is the filledmoderate = 2 or more of the symptoms in criterion beer for filledSevere = 2 or more of the symptoms are fulfilled. Plus, there are multiple other somatic complaints
119300. 7 Illness anxiety disorder criteria Previously hypochondriasis Preoccupation with having or acquiring a serious illnessNo evidence of somatic symptoms or extremely mild symptoms presentHigh anxiety about health and health statusExcessive health related behaviors or avoidant health related behaviorsIllness preoccupation present for at least 6 monthsnot better explained by another disorderSpecify whether:care seeking type: medical care, including physician visits frequently usedcare avoidant type: medical care is rarely if ever used
120Pain Disorder removed from DSM 5 XPain Disorder removed from DSM 5DSM-IVpain disorder diagnoses assume that some pains are associated solely with psychological factors, some with medical diseases or injuries, and some with both.lack of evidence that such distinctions can be made with reliability and validity, and a large body of research has demonstrated that psychological factors influence all forms of pain.individuals with chronic pain attribute pain to a combination of factors, including somatic, psychological, and environmental influences-not either/orDSM-5 some individuals with chronic pain could be DXdhaving somatic symptom disorder, with predominant pain316.0psychological factors affecting other medical conditionsadjustment disorder
121Psychological Factors Affecting Other Medical Conditions Psychological factors affecting other medical conditions is a new mental disorder in DSM-5, having formerly been included in the DSM-IV chapter “Other Conditions That May Be a Focus of Clinical Attention.” This disorder and factitious disorder are placed among the somatic symptom and related disorders because somatic symptoms are predominant in both disorders, and both are most often encountered in medical settings. The variants of psychological factors affecting other medical conditions are removed in favor of the stem diagnosis.
122Psychological Factors Affecting Other Medical Conditions A. Medical symptom or condition is presentB. psychological or behavioral factors adversely affect the medical condition in one of the following waysThe factors that influence the course of the medical condition as shown by a close temporal association between a psychological factors and the development or exacerbation of medical conditionThe factors interfere with the treatment of the medical conditionThe factors constitute additional well-established health risk for the individual The factors influence the underlying psychopathology precipitating or exacerbating symptoms or necessitating medical attentionC. psychological and behavioral factors in criterion B are not better explained by another mental disorder
123300.19 Factitious disorder criteria XSelf-imposedFalsification of physical or psychological signs or symptoms or induction of injury or disease. In order to deceiveIndividual present self to others, as if impaired or injuredNo apparent or obvious external rewards, Not better accounted for by…Imposed on othersIndividual presents another individual to others as you know, impaired or injuredNo apparent external rewardsNot better accounted for by…When imposed on others. Diagnosis is given to the perpSpecify ifsingle episoderecurrent episodes
124XSomatic symptoms – major focus on symptoms experienced as well as anxiety- symptoms can have a physical cause, but the pt. experiences no reliefIllness anxiety – major focus on anxiety and what “might” happen. Symptoms might or might not be present- but are mild if there.Conversion disorder – symptoms present. Of a neuro-perceptual type; blindness paralysisFactitious – symptoms intentionally produced – no apparent gain-assess motivationMalingering (v code)– intentional gain can be documented-assess motivation
125Somatic symptoms Inauthentic –authentic illnesses XSomatic symptoms Inauthentic –authentic illnessesPsychogenic illness – the mind causes symptoms that are experienced by the patient but have no “real” presenceUnconsciousSomatic symptomIllness anxietyconversionConsciousFactitiousmalingeringDiagnosed in part by LACK of evidenceDiagnosed by evidence
126When to suspect factitious disorder XWhen to suspect factitious disorderThe person's medical history doesn't make senseNo believable reason exists for the presence of an illness or injuryThe illness does not follow the usual courseThere is a lack of healing for no apparent reason, despite appropriate treatmentThere are contradictory or inconsistent symptoms or lab test resultsThe person is caught in the act of lying or causing his or her injury
127X http://www.psychiatrictimes.com) The Case of Factitious Disorder Versus Malingering(2009] Courtney B. Worley,MPH ; Marc D. Feldman, MD and James C. Hamilton, PhD
128XWithout detailing the full DSM diagnostic criteria sets for these disorders and their relations, thefollowing is a summary of how DSM instructs psychiatrists to diagnose cases of inauthentic illnessbehavior:1. In the absence of overwhelming affirmative evidence of intentional medical deception (eg, caughton video, evidence from a room search), diagnose a somatoform disorder.2. If there is traditional forensic evidence of overt medical deception, diagnose malingering orfactitious disorder.3. If there is any significant material or instrumental benefit from the intentional medical deception(eg, financial settlement, disability determination, access to narcotic medicine), diagnose malingering.The Case of Factitious Disorder Versus Malingering(2009] Courtney B. Worley,MPH ; Marc D. Feldman, MD and James C. Hamilton, PhD
13010. Feeding and eating disorders "Binge eating disorder' is now included as a separate diagnosisalso includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter "disorders usually 1st diagnosed during infancy childhood and adolescence“.Pica and rumination disorder are 2 examples
13211. Elimination disorders Originally classified in chapters on childhood and infancy. Now have separate classificationPrimary insomnia renamed "insomnia disorder«Narcolepsy now distinguished from other forms of hypersomniaBreathing related sleep disorders have been broken into 3 separate diagnosesRapid eye movement disorder and restless leg syndrome are now independent diagnoses within this category12. Sleep wake disorders
13413. Sexual dysfunctionsSome gender related sexual dysfunctions have been outedNow only 2 subtypes-acquired versus lifelong and generalized versus situationalNew diagnostic class and the DSM 5Include separate classifications for children adolescents and adultsThe construct of gender has replaced the construct of sex
13614. GENDER DYSPHORIA DSM 5Attempted to eliminate the stigma involved in the previous diagnosis of gender identity disorderLikely that more research is needed. Prevalence is remarkably low
137Gender Dysphoria in Adolescents and adults Mark incongruence between one's experienced/expressed gender and assigned gender. At least 6 months duration, as manifested by at least 2 of the followingMarked incongruence between one's experienced/expressed gender and primary and/orsecondary sex characteristicsStrong desire to be rid of one's primary and/or secondary sex characteristics because of marked incongruence with one's experienced/expressed genderStrong desire for the primary and/or secondary sex characteristics of the other genderStrong desire to be of the other genderStrong desire to be treated as the other genderStrong conviction that one has the typical feelings and reactions of the other genderCondition is associated with clinically significant distress or impairmentSpecify if "post-transition“ = the individual has transition to full-time living in the desired gender (with or without legalization of gender change), and has undergone or is preparing to have at least one cross-section medical procedure or treatment regimen
139Disruptive, impulse control and conduct disorders XDisruptive, impulse control and conduct disordersNew diagnostic grouping and DSM 5Combines a group of disorders previously included in disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classifiedOppositional defiant disorder now has 3 subtypesIntermittent explosive disorder no longer requires physical violence but can include verbal aggression
141Major dynamic in all ICDs ImpulsiveactImmediate release in tension,Experience of pleasureor gratificationSpike (steep rise)In tension immediatelyBefore the actTension and stressBegins to build
142ODD 313.81 X Changes from DSM IV Pattern of angry/irritable mood, argumentative/defiant behavior, Vindictiveness, lasting at least 6 months; evidenced by at least 4 symptoms for many of the following categories and exhibited during interaction with at least one individual, not a sibling.Angry, irritable mood1. Often loses temper2. Is often touchy or easily annoyed.3. Often angry and resentfulArgumentative, defiant behavior4. Often argues with authority figures.5. Actively defies or refuses to comply with requests from authority figures.6. Deliberately annoys others.7. Blames others for his or her mistakesVindictive behavior8. Has been spiteful or vindictive at least twice within the past 6 monthsB Causes distress in person, and othersDoes not occur during the course of another disorderChanges from DSM IVODD & conduct disorder are not mutually exclusive3 symptom type groupingsguidance re: how to distinguish from developmental normsseverity measure included
143Specifiers X Mild Moderate Severe Severity can be measured through intensity, frequency, or pervasiveness. For example, if the behavior occurs in more than one setting, it is more pervasive and thus more severe. Usually occurs in the home and not across settings
144Dimensional severity assessment for ODD XDimensional severity assessment for ODDInstructions to clinicians for ODDThe Clinician-Rated Severity of Oppositional Defiant Disorder assesses the severity of the OPPOSITIONAL DEFIANT symptoms for the individual based on their pervasiveness across settings. The measure is intended to capture meaningful variation in the severity of symptoms, which may help with treatment planning and prognostic decision-making. The measure is completed by the clinician at the time of the clinical assessment. The clinician is asked to rate the severity of oppositional defiant problems as experienced by the individual in the past seven days.Scoring and interpretation for ODD scaleThe Clinician-Rated Severity of Oppositional Defiant Disorder is rated on a 4-point scale (Level 0=None; 1=Mild; 2=Moderate; and 3=Severe). The clinician is asked to review all available information for the individual and, based on his or her clinical judgment, select ( ) the level that most accurately describes the severity of the individual’s condition.Frequency of use for ODD scaleTo track changes in the individual’s symptom severity over time, the measure may be completed at regular intervals as clinically indicated, depending on the stability of the individual’s symptoms and treatment status. Consistently high scores on a particular domain may indicate significant and problematic areas for the individual that might warrant further assessment, treatment, and follow-up. Your clinical judgment should guide your decision.
146Problems with diagnosis XProblems with diagnosisDifferentiating this from developmental and/or environmental stress related behaviorDifferentiating from other diagnoses such as bipolar 2Biased reporting or reporting based on reputationExpectation induced disruptive behaviorsBehavior is often confined to one way one setting (for example, the home)Little or no insight is present on the part of the suffer. See self is victim
147Conduct disorder unchanged Diagnostic criteria XConduct disorder unchanged Diagnostic criteriaRepetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms and rules are violated, as manifested by the presence of at least 3 of the following 15 criteria in the past 12 months. For many of the categories below, with at least one criteria present in the last 6 monthsAggression to people or animals1 bullies, threatens or intimidates2 often initiates physical fights3 used weapons that can cause serious physical harm4. been physically cruel to people5. Been physically cruel to animals6. Has stolen while confronting a victim7. Forced someone into sexual activitydestruction of property8. Has deliberately engaged in fire setting with intent of causing damage9. Deliberately destroyed others propertydeceitfulness or theft10. Broken into someone else's home building car11. lies or deceives to obtain goods or favors12. Has stolen nontrivial items without confronting victim – shoplifting etc.serious violation of rules13. Stays out at night. Despite parental prohibitions. Begins before 1314. Has run away from home at least twice15. Often truant, beginning before age 13B Causes clinically significant impairmentC If age 18 or over, not attributable to antisocial personality disorder
14916. Neuro-cognitive disorders X16. Neuro-cognitive disordersNew diagnostic groupDementia and amnestic disorder are included in this new groupMild NCD is a new diagnosis
150X Term "dementia" has been deemphasized done to lessen stigmaDeemphasize irreversibilityBroadens category in a more neutral way (see The following points below)Mild neurocognitive disorder has been addedDistinguished from Major (severe) neurocognitive disorder
151Diagnostic criteria for delirium unchanged XDiagnostic criteria for delirium unchangedA. disturbance Inattention (reduced ability to direct, focused, sustain and shift attention and awareness); reduced orientation to environmentB. . develops over a short period of time and fluctuates during the dayC. Add a disturbance in cognition (usually marked) – such as memory deficit, disorientation, agitation, language or perceptual disturbanceD. The criteria from A&C are Not better explained by a preestablished neurocognitive disorder or evolving neurocognitive disorderE. evidence from the history, physical examination or lab findings thate disturbances are direct consequence of another medical condition, substance, intox or w/drawal
152SpecifiersSubstance intoxication delirium = when criteria in A and C predominate during a period of intoxicationSubstance withdrawal delirium = should be made it instead of substance withdrawal when the symptoms in criterion a and C predominate in the clinical pictureMedication induced delirium = should be made when the symptoms in criteria a and C arises a side effect of the medication taken as prescribedDelirium due to another medical condition = evidence that the disturbance is attributable to the physiological consequences of another medical conditionDelirium due to multiple etiologies = evidence that the delirium has more than one cause or causal conditionCourse =acute: lasting a few hours or dayspersistent: lasting weeks or months
153Diagnostic criteria for Major NCD AKA DEMENTIA XDiagnostic criteria for Major NCD AKA DEMENTIAA. Evidence of significant decline from her previous level of performance in one or more cognitive domains.: (Cognitive attention, Memory impairment, Learning, attention, recognition (Aphasia, agnosia), apraxia , Language, perceptual/motor problems , Social cognition and/or other disturbance of executive functions)B. cause significant impairment in social, vocational functioning; is a marked decline from previous functioning And require assistance, and activities. If daily living, because they interfere with independence in every day activitiesC. Are not caused or related to by deliriumD. Not better explained by…
154Mild neurocognitive disorder XMild neurocognitive disorderEvidence of modest cognitive decline for previous data performance in one or more cognitive domains-cognitive attention, executive function, learning and memory, language, perceptual motor or social cognition. Evidence based onConcern of individual, a knowledgeable informant or the clinician that there is been a mild decline in cognitive function andModest impairment in cognitive performance preferably documented by standardized neuropsychological testing or another quantified clinical assessmentThe cognitive deficits do not interfere for capacity with independence in every day activities, but greater effort compensatory strategies or accommodations may be requiredThe cognitive deficits do not occur exclusively in the context of a deliriumNot better accounted for by another mental disorder (major depression, schizophrenia
155XSpecifiers whether (Sub-types) of Mild NCD (dementia) are classified by etiology in DSMAlzheimer’s typeFrontotemporal deteriorationLewy body diseaseVascular (multi-infarct) dementiaRelated to HIVHead trauma Or TBISubstance medication inducedHuntington’s diseaseParkinson’s diseasesPick’s diseasePrions diseaseMultiple etiologiesUnspecifiedUsually the result of generalized brain deterioration due to aging or degenerative disease like AD.Onset is often slow.General, gradual declineAlzheimer’s disease (at least 50% of all dementia)Vascular (multi-infarct) dementia (8-30%)Pick’s diseaseRare; similar sx to ADCreutzfeldt-Jakob diseaseViral; spasmodic movementsHuntington’s disease
15617. Difference between paraphilia's and paraphilia disorders Paraphilia describes the experience of intense Sexual arousal to atypical objects, situations, or individuals.Paraphilic behavior (such as Pedophilia, zoophilia, voyeurism and exhibitionism and may be illegal in some jurisdictions, but may also be tolerated.A paraphilia is NOT a paraphilic disorderParaphilia disorder requires the generation of clinically significant distress, impairment or acting them out with the nonconsenting person. (Criterion B)
159DSM 5 promised major changes in criteria XDSM 5 promised major changes in criteriaPromised dimensional focusPromised reduction in number of personaliity disorders to fiveChanges did not occurDimensional focus for personality disorders was moved to section 3
160Primary Criteria in DSM 5 (Unchanged from DSM-IV TR) XPrimary Criteria in DSM 5 (Unchanged from DSM-IV TR)Enduring pattern of inner experience & behavior that deviates markedly from expectations of the culture. This pattern is manifested in 2 or more of the following areasCognition;Affect;Interpersonal;Impulse controlInflexible & pervasive across situationDistress or impairment in social, occupational interpersonal..…Long-standing (back to adolescence or early adulthood)The criteria for diagnosing PDs are very much within the realm of common human experience.Every one of us at times has been: hypervigilant, destructive, suspicious, shy, bossy, vain, striving for perfection, dramatic, afraid to be alone, fearful of rejection, too needy, critical of others, resentful of authority, bored, seductive, or have been happy one minute and irritated the next.This is normal! It begins to warrant a diagnosis when clusters of these behaviors exist over a long period of time and interfere with our interpersonal functioning.
161DSM IV & 5 and personality clusters XDSM IV & 5 and personality clustersCluster CAnxious/fearfulDependentAvoidantObsessive-compulsiveCluster AOdd/eccentricParanoidSchizoidschizotypalCluster BDramatic, erraticSelf-involvedAnti-socialHistrionicNarcissisticBorderline
162Dimensional classification of personality disorders XDimensional classification of personality disordersAuthors of DSM 5 had planned to use dimensional measures to diagnose personality disordersThey plan to reduce personality disorders from 10 to 5This changed in a closed-door meetingDimensional measures are now in section 3
163XANTI_SOCIALA) There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three or more of the following:1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;3. impulsiveness or failure to plan ahead;4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;5. reckless disregard for safety of self or others;6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another;B) The individual is at least age 18 years.C) There is evidence of conduct disorder with onset before age 15 years.D) The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.
164OR Mnemonic: “CALLOUS MAN” Diagnostic Criteria for Antisocial PD XOR Mnemonic: “CALLOUS MAN” Diagnostic Criteria for Antisocial PDConduct disorder before age 15; current age at least 18Antisocial activities; commits acts that are grounds for arrestLies frequentlyLacunae—lacks a superegoObligations not honored (financial, occupational etc.)Unstable—can’t plan aheadSafety of self and others is ignoredMoney– recklessness with money; spouse and children are not supported because he bought a motorcycleAggressive, AssaultiveNot occurring during schizophrenia or mania
165Antisocial signs X Glibness, shallow emotion Requires constant stimulationCriminal versatilityPromiscuityPoor impulse controlAvoids responsibility for actionsBecause of poor impulse control and avoiding responsibility, these individuals are sometimes social “parasites,” and may have several sources of financial assistance, “under the table” cash, or profit from stolen property or drugs.
166X Millon identified five subtypes of Anti-Social Personality Disorder covetous antisocial – variant of the pure pattern where individuals feel that life has not given them their due – including paranoid features.reputation-defending antisocial – including narcissistic featuresrisk-taking antisocial – including histrionic featuresnomadic antisocial – including schizoid, avoidant featuresmalevolent antisocial – including sadistic, paranoid features.
167XBORDERLINE PDA. A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-injuring behavior covered in Criterion 52. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.3. Identity disturbance: markedly and persistently unstable self-image or sense of self.4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, excessive spending, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 55. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars or picking at oneself (excoriation) .6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).7. Chronic feelings of emptiness8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms
168OR Mnemonic for Diagnostic Criteria: “I RAISED A PAIN” XOR Mnemonic for Diagnostic Criteria: “I RAISED A PAIN”Identity disturbanceRelationships are unstableAbandonment is frantically avoidedImpulsiveSelf-mutilation, suicidal threats/attempts; splitting - as a predominant defense mechanism is usedEmptiness is a description of their inner selvesDissociative symptomsAffective instabilityParanoid instabilityAnger is poorly controlledIdealization of others, followed by devaluation (splitting – person is either all good or all bad)Negativistic—undermine their own efforts and those of othersPBD in its more florid forms is not hard to diagnose. These clients frequently present at emergency rooms, day programs and outpatient clinics in a state of turmoil, usually brought on by a psychosocial crisis that threatens a r’ship. In response to this, borderline individuals become overwhelmed and regress to the point of being lost in a crisis. They get admitted to a hospital by a suicidal gesture or attempt. An inpatient stay is often required because the individual feels that she can’t trust her impulses, and this forces caregivers into a protective, “parental” role.As outpatients, they remain “stably unstable” and often make demands for ongoing therapy. In this form, BPD people can present a real diagnostic and treatment challenge.
169XFirst called “as if” personality because or changes in direction or interestTerm “borderline” is unfortunate. Originally referred to being on the ‘border’ between psychotic and neuroticLabel is often used pejoratively among mental health professionalsMisunderstood and mis-labeled as “manipulative”
170Borderline Themes X Parental neglect and abuse Impulsivity Fears of abandonmentFrequent suicide ideation or gesturesSubstance abuse or dependenceLegal difficultiesDisrupted education relationships, vocations, vacationsThey report chaotic childhoods. Abuse and neglect are usually reported; not always confirmed.They often report sexual abuse; early onset of sexual activity; promiscuityThey are intensely fearful of abandonment; they seem to maintain self-destructive r’shipsThey fail to achieve their potential or their long-term goalsThey have poor ego boundaries; they’re unduly influenced by those around them
171Propose general criteria for personality disorder XModerate or greater impairment in personality (self interpersonal functioning)One or more pathological personality traitsThe impairments in personality functioning are inflexible and pervasive across a broad range of personal and social situationsThe impairments in personality functioning are relatively stable across timeThe impairments in personality function are not better explained by another medical condition or substanceImpairments in personality functioning are not better understood as normal for individuals developmental stage, or sociocultural environment
172Dimensional classification of personality disorders XDimensional classification of personality disordersAuthors of DSM 5 had planned to use dimensional measures to diagnose personality disordersThey plan to reduce personality disorders from 10 to 5This changed in a closed-door meetingDimensional measures are now in section 3
173Proposed changes in assessment Two broad dimensions XProposed changes in assessment Two broad dimensionsOverallpersonalityfunctioning5 BroadPathological Trait DomainsselfInterpersonalNegativeaffectivityDetachmentAntagonismDisinhibitionPsychoticismSelfdirectionEmpathyIdentityIntimacy
1752 dimensions required for all DSM diagnosis Clarity of symptomsSpecified length of time for symptoms
1764 basic levels of diagnostic warrant HighSymptom clarityDiagnostic plausibilityDiagnostic certaintysymptom pattern over timeUnclearunstableClearstableDiagnostic uncertainty orDiagnostic confusionDiagnostic possibilitylow
177Diagnostic certaintyThe likelihood that a “plausible” diagnosis is “probable”Clinicians often diagnoses based on “clinical hunches”, which are a form of biasThey select one or 2 salient characteristics –rather than the complete 7 to 9- and make assumptions (Paris, 2013)This is a form of “fast thinking” or quick judgment that leads to “framing effects” (Kahneman, 2011) sometimes called the “clinicians illusion”.
178Easy for clinicians to conflate probability with plausibility Plausibility = the likelihood that an event or events are representative of something more; clinicians tend to focus on thisProbability = the statistical likelihood of an event; researchers focus on thisKahneman, 2011
1792 conditions necessary for Diagnostic certainty When symptoms are clear and stable over timeWhen the relationship between plausibility and probability has been consideredPlausibility- these symptoms represent XProbability – the likelihood of X occurring
181Progression of domains of diagnostic certainty over time uncertaintyDiagnosticpossibilitiesDiagnosticplausibilityDiagnosticprobabilitiesDiagnosticcertaintyEthical issues arise here when:Clinician unknowingly or unwittingly is in the wrong domain (incompetence)Clinician knowingly chooses the wrong domain
182Progression of diagnostic certainty over time Documentation can helpDiagnosticuncertaintyDiagnosticprobabilitiesDiagnosticpossibilitiesDiagnosticplausibilityDiagnosticcertaintyWhat leadsme to be unsure?Do I know What don’t IKnow?What makes this a probability and others not?Where is my prevalence data?Why are theseThe possibilities?How do I know that other DXs are not poss.Why am I certain?How do I know that I know?What am I seeing that is so compelling?What am I missing? Why am I missing?
183Progression of diagnostic certainty over time uncertaintyDiagnosticpossibilitiesDiagnosticplausibilityDiagnosticprobabilitiesDiagnosticcertaintyThe more uncommon orunusual a diagnosis is, the more timeand care one must take indifferentiating or excludingother – more common - (statistically) diagnoses