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Diagnostic groupings in the DSM 5.  In DSM-IV TR, the diagnostic groupings had a separate category for children and adolescents.  DSM 5 does not make.

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Presentation on theme: "Diagnostic groupings in the DSM 5.  In DSM-IV TR, the diagnostic groupings had a separate category for children and adolescents.  DSM 5 does not make."— Presentation transcript:

1 Diagnostic groupings in the DSM 5

2  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 adolescents  In DSM-IV TR some of the categories had names that made no sense-such as somatoform disorders  DSM 5 attempts to simplify diagnostic category names  DSM 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 Diagnostic groupings in IV-TR and 5

3  Attention to severity assessment and specification of severity for each diagnosis  Inclusion 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 Changes throughout DSM X

4  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 DSM 5 changes in classification

5 Neuro develop mental Bipolar SchizophreniaDepr essiv e Anxiety Obsessiv e- compuls ive and related Trauma related Dissocia tive Somatic symptom related Feeding and eating disorders Sexual dysfuncti ons Sleep wake disorders Eliminatio n disorders Substance related and addictive disorders Disruptive, impulse control disorders Neurocog nitive disorders Personality disorder Gender dysphoria Paraphilia disorders Others Younger Older The 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

6 1. Neurodevelopmental disorders 2. schizophrenia spectrum and other psychotic disorders 3. bipolar and related disorders 4. depressive disorders 5. anxiety disorders 6. obsessive-compulsive and related disorders 7. Trauma and related disorders 8. dissociative disorders 9. Somatic symptom and related disorders 10. feeding and eating disorders 11. elimination disorders 12. sleep wake disorders 13. sexual dysfunctions 14. gender dysphoria 15. disruptive, impulse control, and conduct disorders 16. neurocognitive disorders 17. paraphilia disorders Which are your top 7 or 8

7  Neurodevelopmental disorders- 1.mental retardation is removed intellectual disability is put in. 2.Autism spectrum disorder is the new DSM 5 diagnosis encompassing autistic disorder. Aspergers and childhood disintegrative disorder as well as pervasive developmental disorder. 3.Several changes have been made to ADHD- specifiers = combined; inattententive type; hyperactive/impulsive type Changes in the groupings: 1. Neurodevelopmental disorders SUMMARY

8 Severity level Conceptual domainSocial domainPractical domain Mild Preschool = 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 thinking Immaturity 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 assessment Personal 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 management Moderate Conceptual 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-making Marked 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 decisions Personal care is okay in adulthood. Adults typically can participate in all household tasks with teaching. Can work with considerable support in the workplace Severe Limited attainment of conceptual skills. Little or no understanding of written language math, time and money. Extensive support for problem solving is needed Spoken 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 limited Profound No 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 activities Dependent 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 participation MENTAL RETARDATION = INTELLECTUAL DISABILITY Severity level for intellectual disability SEVERITY DETERMINED BY ADAPTIVE FUNCTIONING NOT IQ

9 1. Expressive language disorder 2. Receptive-expressive language disorder 3. Phonological (articulation) disorder= speech sound disorder (315.39) In DSM 5 4. Stuttering AKA Childhood onset fluency disorder (315.35) In DSM 5 Combined into "language disorder" (315.39) in DSM 5 Includes deficits in language speech and communication

10 A.Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following; deficits in using communication for searching purposes A.impairments of the ability to change communications to match the context or needs of the listener B.difficulties following rules for conversation and storytelling such as taking turns in conversation, rephrasing and knowing how to use verbal and nonverbal to regulate interaction C.Difficulties in understanding what is not explicitly stated B.Deficits result in functional limitations and effective communications. The onset is in the early developmental. (But deficits aren't fully noticeable until later in life) C.Not attributable to another medical condition or neurological condition and not better explained by other neurodevelopmental disorders Social pragmatic communication disorder Differential 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 communication social anxiety disorder and social phobia can often appear with similar symptoms and again mild intellectual developmental disorder might also mask symptoms

11  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 INTELLIGENCE  DSM IV  Dyslexia – reading disorder  Dyscalculia – math disorder  Dysgraphia – written expression disorder LEARNING DISORDERS

12 A.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. 1.Inaccurate or slow and effortful word reading 2.Difficulty understanding the meaning of what is read 3.Difficulties with spelling 4.Difficulties with written expression 5.Difficulties mastering number sense, number facts, or calculation 6.Difficulty with mathematical reasoning B.Affected academic skills are substantially and quantifiably below those expected for the individual's chronological age causing significant interference with performance (quantifiable suggest testing) C.The learning difficulties begin during school way cheers but might not become apparent until those faculties require more regular use D.Not better accounted for by intellectual disabilities visual or auditory deficits other mental or neurological disorders etc. DSM 5 criteria – no separation

13  In 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 disorders  DSM-IV TR separated ADHD into 2 subtypes:  predominantly attention deficit  predominantly hyperactivity impulsivity  DSM 5 has moved these two sub-types to specifiers ADHD X

14  Must occur before age 7 years  Present for at least 6 months  Causes impairment in at least 2 settings  Meets 6 of 9 symptoms of inattention  AND/OR 6 of 9 symptoms of hyperactivity/impulsivity  – Must be developmentally inappropriate levels Diagnostic Criteria for ADHD (DSM-IV) DSM 5 has moved onset age limit to 12! Now requires “SEVERAL SYMPTOMS” across settings X

15 A.Persistent pattern of inattention and or hyperactivity-impulsivity that interferes with functioning or development as characterized by inattention and or hyperactivity/impulsivity 1.Inattention: 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 activities A.Often fails to give close attention to details or makes careless mistakes in schoolwork B.Has difficulty sustaining attention in tasks or play activitiesAnd remaining focused C.Often does notseem to listen when spoken to directly D.Does not follow through on instructions and fails to finish schoolwork chores or duties E.Has difficulty organizing tasks and activities F.Avoids dislikes or is reluctant to engage in tasks that require sustained mental effort G.Loses things necessary for tasks or activities H.Is easily distracted I.Is forgetful in daily activities DSM 5 criteria X

16  – combined presentation  predominantly inattentive presentation  predominantly hyperactive impulsive  In partial remission  Severity level (mild moderate severe) Specifiers

17  ADHD can now be co-morbid with Autism spectrum  Symptom threshold has been specified for adults  Adults require a minimum of 5 symptoms – not 6  Developmentally appropriate example of symptoms are offered Other important changes ADHD X

18  Represents a new classification of several disorders that were considered different forms of autism  Previously, these were separate diagnoses.  Autistic disorder  Retts disorder  Childhood disintegrative disorder  Aspergers  PDD NOS Autism Spectrum disorder X

19  Autistic disorder  Retts disorder  Childhood disintegrative disorder  Aspergers  PDD NOS PDDs in DSM IV TR All characterized by severe deficits and pervasive impairment in multiple areas of development Reciprocal social interaction Communication impaired Stereotyped behavior, interests and activities

20 With the new DSM 5. Those separate disorders have now been consolidated and ASD is evaluated in terms of severity rather than separate diagnosis RETTS Disorder removed because it has been established as a physical disease X

21 Three domains from the DSM IV-TR became two: 1Social interaction; 2 communication deficits; 3 repetitive behavior/fixated interest = 1) Social interaction/communication deficits 2) Fixated interests and repetitive behaviors  Deficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms with contextual and environmental specificities  Delays 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 diagnosis  Requiring both criteria to be completely fulfilled improves specificity of diagnosis without impairing sensitivity  Providing 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 domains  Decision 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 major changes for ASD X

22 A. 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 people B. 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 DSM 5 criteria for all ASD X

23  With or without accompanying intellectual impairment  With her without accompanying language impairment  Associated with a known medical or genetic condition or environmental factor  With catatonia  Specify severity level Specifiers X

24 severity Severity level ASD Social communication and interaction Restricted interests and repetitive behaviors 3.Requires very substantial support Severe 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 quickly 2 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 others RRBs 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 interest I 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. X

25  STIGMA - aspergers made autism respectable! Will it continue to de-stigmatize or re-stigmatize  Will 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 ASD CONCERNS X

26 2. Schizophrenia spectrum

27 Schizophrenia spectrum and other psychotic disorders 1.The spectrum seems to emphasize degrees of psychosis 2.Change in criteria for schizophrenia now requires at least one criteria to be either a. Delusions, b. Hallucinations or c. Disorganized speech 3.Subtypes of schizophrenia were eliminated 4.Dimensional measures of symptom severity are now included 5.Schizoaffective disorder has been reconceptualized 6.Delusional disorder no longer requires the presence of “non- bizarre" in delusions. There is now specifier for bizarre delusions. 7.Schizotypal personality disorder is now considered part of the spectrum X

28  Schizophrenia and other disorders related to schizophrenia are now grouped within a spectrum  Overall definition of schizophrenia has not changed that much  Requirements 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 Overview of changes from DSM-IV TR to the DSM five 2: schizophrenia and the DSM 5 X

29  ‘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". [1]mental disordertraitssyndromemental disordersdeficits [1]  In some cases, a spectrum approach joins together conditions that were previously considered separately.(wikipedia) Spectrums

30 Spectrum suggests a progression from Attenuated psychosis Syndrome in conditions for further study Schizotypal personality Disorder (Found in PD Section) delusional disorder Brief psychotic disorder Schizophreniform disorder Schizoaffective disorder Schizophrenia Mild or brief Major or lengthy Debilitation Severity severity In the following areas 1.Delusions 2.Hallucinations 3.Disorganized thinking/speech 4.Disorganized or abnormal motor behavior 5.Negative symptoms

31 Attenuated psychosis syndrome A.At 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 attention 1.Delusions 2.Hallucinations 3.Disorganized speech B.Symptoms must have been present at least once per week for the last month C.Symptoms have begun or worsened in the last year D.Symptom is sufficiently distressing or disabling to the individual E.Symptom is not better explained by another mental disorder including a depressive or bipolar disorder with psychotic features and is not caused by a substance F.Criteria for any other psychotic disorder have never been met Symptoms 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 adulthood CRITERIA DIAGNOSTIC FEATURES

32 Schizotypal personality disorder (Technically not in the spectrum) A.A 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: 1.Ideas of reference (excluding delusions of reference) 2.Odd beliefs or magical thinking that influences behavior; i.e. belief in clairvoyance, astral projection telepathy etc. 3.Unusual perceptual experiences, including bodily illusions 4.Odd thinking and speech 5.Suspicious or paranoid ideation 6.Inadequate or constricted affect 7.Behavior or appearance that is odd eccentric or peculiar 8.Lack of close friends or confidants 9.Excessive social anxiety that does not diminish B.does not occur exclusively within the course of schizophrenia a bipolar disorder or depressive disorder with psychotic features or another psychotic disorder or autism spectrum disorder Pervasive 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 Criteria

33 Schizophrenia 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: 1. Delusions 2.Hallucinations 3.Disorganized speech 4.disorganized behavior 5.Negative symptoms (personality deterioration) X

34  Requirement of “bizarre delusions”and/or schneidnerian 1 st rank hallucinations is changed to  At least 1 of the two below need to be from core positive symptoms (delusions, hallucinations, disorganized speech) 1.Delusions 2.Hallucinations 3.Disorganized speech 4.disorganized behavior 5.Negative symptoms (personality Except for X

35  B. 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 relate  C. 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 illnesses  D. have successfully ruled out schizoaffective disorder and mood disorder (with psychotic symptoms) b/c no evidence of mania or depression  E. not due to substance abuse  F. not due to Autism spectrum disorder X

36 Specifiers  1st episode, currently in acute stage  1st episode currently in partial remission  1st episode in full remission  multiple episodes, currently in acute episode  multiple episodes currently in partial remission  multiple episodes currently in full remission  continuous  with catatonia X

37 Schizophrenia  Other symptoms outside the major diagnostic criteria include mood dysphoria, inappropriate affect sleep disturbance depersonalization, derealization somatic concerns, vocational impairments  Lack 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 rule  Although there are many brain and genetic abnormalities that have been identified, there are no “absolute” biological markers  Schizophrenia is often overdiagnosed in the poor  There 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 age  Depression often shows up over time Diagnostic features X

38 Schizophreniform disorder  * At least one third of people who receive this diagnosis recover. However the other two thirds will eventually be diagnosed with schizophrenia  Meets all the diagnostic criteria for Schizophrenia, except duration  Diagnosed 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 schizophrenia  Make this diagnosis when an individual Has already recovered And the episode lasted between 1 and 6 months Diagnostic features X

39 Schizophreniform A.2 or more of the following present for a significant portion of time. At least one of these must be one 2 or 3 1.Delusions 2.Hallucinations 3.Disorganized speech 4.Disorganized motor behavior 5.Negative symptoms B.Lasts at least one month but less than 6 months. When diagnosis is made before recovery, specify "provisional“ C.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 infrequent D.Not attributable to substances or another medical condition Diagnostic criteria – X

40 Schizoaffective disorder A.An uninterrupted. period which there is a major mood episode con current with criterion A of schizophrenia 1.Delusions 2.Hallucinations 3.Disorganized thinking 4.Grossly abnormal motor behavior 5.Negative symptoms of schizophrenia B.In 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 illness C.Symptoms that meet criteria for major mood episode be present for the majority of the duration of the Active, and residual portions of the illness D.Not attributable to the effects of a substance medication or other medical condition Diagnostic criteria The requirement that a major mood disorder must be present for the majority Of the duration of illness AFTER criterion A is met, makes this alongitudinal Illness or bridge on spectrum X

41 Specify 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 Subtypes X

42 PSYCHOTICISM AFFECTAFFECT HIGH NONE MOOD DISORDER MOOD DISORDERWITH PSYCHOTIC FEATURES SCHIZOPHRENIA ACUTE SCHIZOPHRENIA PARTIAL REMISSION SCHIZO- AFFECTIVE X

43

44  Diagnosis must now include both changes in mood and changes in activity/energy level  Some particular conditions can now be diagnosed under "other specified bipolar and related disorders“  An "anxiety" specifier has now been included  Attempts made to clarify definition of 'hypomania". However it was not successful  Bipolar I mixed episode –no longer requires full criteria for depressed and mania or hypomania  New specifier is “mixed features”. 3. Bipolar and related disorders summary X

45 Some particular conditions can now be diagnosed under "other specified bipolar and related disorders” These do not meet full criteria for bipolar diagnosis 1.No history of major depression with hypomanic episode 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 criteria 4. History of major depressive disorder Hypomanic symptoms present but not of sufficient duration (less than 4 days) Insufficient number of hypomanic symptoms X

46  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. Problems

47 Bipolar I Coding for severity Bipolar I disorder Current or most recent episode-manic Current or most recent episode- hypomanic Current or most recent episode- depressed Current or most recent episode- unspecified Mild Not applicable Not applicable Moderate Not applicable Not applicable Severe Not applicable Not applicable Mild = 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 functioning Moderate = number of symptoms and intensity and/or functional impairment are between those specified for mild and severe Severe = 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.

48 The dimensional Alternative assessment of mania and hypomania  DSM 5 offer some assistance  Suggests 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 then  Move to use of the Altman self rating mania scale (ASRM) - See next slide

49 Level 2 Dimensional Measure for Mania Level 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

50 Instructions for the mania scale Instructions: for client On the DSM-5 Level 1 cross-cutting questionnaire you just completed, you indicated that during the past 2 weeks you (the individual 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.  Instructions to Clinicians The 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 Interpretation Each 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 mania

51 Coding and recording procedures for bipolar one disorder  Coding is complicated  Must specify the following in the order presented below 1.Bipolar I disorder 2.Type of current episode (manic or depressive) 3.Severity level 4.Current state of most recent episode (active, in partial remission, in full remission, unspecified) 5.Psychotic features present 6.Presence of other specifiers (uncoded)

52 Bipolar I Coding for Current state of episode & psychosis Bipolar I disorderCurrent or most recent episode- manic Current or most recent episode- hypomanic* Current or most recent episode- depressed Current or most recent episode- unspecified** W/ psychotic features Not applicable Not applicable In Partial remission Not applicable In full remission Not applicable Unspecified Not 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.

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54  New diagnosis included = "disruptive mood dysregulation disorder-use for children up to age 18  New diagnosis included = "premenstrual dysphoric disorder“  What used to be called dysthymic disorder is now "persistent depressive disorder“  Bereavement is no longer excluded 4. Depressive disorders SUMMARY X

55 MDD: Specifiers  Severity  With anxious distress  With mixed features  Melancholic Features  Atypical Features  Catatonic  Postpartum  Seasonal  With Psychotic Features(Mood congruent or incongruent) X

56 Depression is mainly coded by severity and recurrence Severity/course specifierSingle episodeRecurrent episode Mild Moderate Severe With psychotic features In partial remission In full remission Unspecified Mild = 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 functioning Moderate = number of symptoms and intensity and/or functional impairment are between those specified for mild and severe Severe = 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.

57  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. Problems with severity

58 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.

59 Instructions 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 Interpretation Each 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.

60 Note: 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 answered If 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 slight 55.0—59.9 = Mild 60.0—69.9 = Moderate 70 and over = Severe Note: If more than 25% of the total items on the measure are

61 Explanation of other specifiers  With anxious distress = 1. Tense, 2. Restless 3. Excessive worry 4. Fear of catastrophe 5. Fear of losing control  If present, Code severity of anxiety  Mild = 2 symptoms  moderate = 3 symptoms  moderate- severe = 4 or 5 symptoms  With mixed features = prominent dysphoria or depressed mood, diminished interest or pleasure, psychomotor retardation and/or other symptoms found in depressive episodes  With 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 guilt  With 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 rejection  Mood 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 displayed  With postpartum onset = onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery. Depressive episodes are far more common than manic episodes  Seasonal 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

62 With anxiety  Anxiety is very common with depression  anxious distress =  1. Tense  2. RelentlessRestlessness  3. Excessive worryOr concern that is unwarranted  4. Excessive concern regarding the occurrence of a major negative event-  5. Fear of losing control  If present, Code severity of anxiety  Mild = 2 symptoms  moderate = 3 symptoms  moderate- severe = 4 or 5 symptoms

63 Persistent depressive disorder Formerly known as dysthymic disorder In The DSM-IV TR, dysthymia was considered a depressive disorder that that was A.long-lasting (chronic) and B.did not meet the full criteria for a major depressive episode- a milder form of depression X

64 Persistent depressive disorder in the DSM 5 Combines dysthymia and a chronic form of major depressive disorder (without certain symptoms Persistent depressive disorder X

65 Dysthymia vs MDD  Chronic sense of inadequacy  Depression is not as intense as with MDD  Symptoms are typically not as “acute” as with MDD  MDD = depressed mood, most of day, nearly every day for two weeks  Dys = depressed mood more days than not over a period of 2 years  Seems more like a personality disorder “dissatisified personality” N X

66 Dysthymic Disorder and Chronic major depressive disorder  2 or more of the following associated Symptoms Along with depressed mood 1.Change in appetite 2.Change in sleep 3.Decreased energy 4. Decreased self worth 5.Poor concentration 6. Hopelessness . X

67  Please 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 suicide  3. Psychomotor retardation or agitation This suggests that only a particular type of major depressive disorder-1 without suicidal ideation, anhedonia and lethargy qualify for this diagnosis X

68 PDD: Specifiers  Severity  With anxious distress  With mixed features  Melancholic Features  Atypical Features  Psychosis-mild (mood congruent or incongruent)  Postpartum  Partial remission  Full remission  Late onset-21 or older  Early onset  With pure dysthymic syndrome-criteria for major depression is not been met  With persistent major depressive episode-full criteria have been met, excluding anhedonia, psychomotor retardation and suicidal ideation  Intermittent major depressive episodes with or without current episode X

69 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. The bereavement exclusion is gone X

70 Disruptive mood dysregulation disorder  The purpose of this diagnosis was to provide a category for children that created an alternative to the diagnosis of bipolar disorder  Evidence 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 X

71 Diagnostic criteria A.Severe recurrent temper outburst manifested verbally or behaviorally; grossly out of proportion to the situation to the situation B.Outbursts are inconsistent with developmental level C.Outbursts occur 3 or more times a week D.Mood between temper outburst is persistently irritable or angry most of the day, nearly every day. E.Criterion a through D have been present for 12 or more months F.Criteria a through D are present in at least 2 or more settings G.Initial Diagnosis can be made between the ages of 6 to 18 H.Age of onset-established her history or observation-must be before the age of 10 I.No presence of manic or hypomanic episode J.These behaviors do not occur during an episode of major depression and are not better explained by another mental disorder K.Symptoms are not attributable to the effects of a substance, another medical or neurological condition

72 Diagnostic features  Chronic, severe persistent irritability with the following:  Frequent temper outbursts in response to frustration over a sustained period of time and are developmentally inappropriate  Anger and irritability remains constant even after temper outbursts of stopped X

73  Prevalence estimates range between 2% and 5%  Affects males more than females  such children seem to be extremely temperamental in prodromal manifestation  sometimes diagnosed as oppositional defiant disorder X

74

75 5. Anxiety disorders, 6. obsessive- compulsive disorder and 7. trauma- related disorders SUMMARY

76 Anxiety disorders Panic disorder Agoraphobia Generalized anxiety disorder Social phobia Specific phobia PTSD Acute Stress disorder Stress and trauma related disorders Adjustment disorders PTSD Acute stress disorder Reactive attachment disorder Disinhibited social engagement dis. Reactive attachment disorder Specified anxiety disorder Unspecified anxiety disorder Obsessive-compulsive related disorders Obsessive compulsive disorder ocd w/ poor insight Hoarding disorder Hair-pulling disorder Skin-picking disorder Body dysmorphic disorder Medication-induced ocd Other specified/unspecified ocd Obsessive compulsive disorder Separation anxiety disorder selectivemutism

77  Obsessive-compulsive disorder has been moved out of this category  PTSD has been moved out of this category  Acute stress disorder has been moved out of this category  Panic attacks can now be used as a specifier within any other disorder in the DSM  Separation anxiety disorder has been moved to this group  Selective mutism has been moved to this group 5. Anxiety disorders

78  Criteria for specific phobia, and social anxiety disorder that requires that individuals over 18 recognize that their anxiety is excessive or unreasonable has been deleted  I 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 considerED  Panic disorder and agoraphobia are unlinked in the DSM 5  THE “generalized” specifier for social anxiety disorder has been deleted and replaced with her “performance only” specifier Other changes and anxiety disorders

79

80  A completely new diagnostic grouping category  Hoarding disorder-new diagnosis  Excoriation (skin picking) disorder-new diagnosis  Substance induced obsessive-compulsive disorder-new diagnosis  Tic specifier has been added  Muscle dysphoria is now a specifier within body dysmorphic disorder  Obsessive-compulsive disorder-refined to allow distinction between individuals with good to fair poor or “absent/delusional” 6. Obsessive-compulsive and related disorders X

81 OCD Specifiers  In DSM-IV TR a requirement for the diagnosis was that the person suffering realized that the worries and behaviors were excessive  Now insight is a specifier  With good or fair insight-individual recognizes that beliefs and behaviors are not true and will not work  With poor insight-individual believes that behaviors and beliefs will help  With absent insight/delusional beliefs-individual is zealous in thinking that thoughts and behaviors must happen

82 Hoarding disorder A.Persistent difficulty discarding her, parting with possessions, regardless of their actual value B.Difficulty is due to perceived need to save the items and due to distress associated with discarding them C.To difficulty discarding results in the accumulation of possessions that congest and clutter active living areas and compromise their intended use D.Causes clinically significant distress or impairment in social, occupational or other Areas of functioning E.Not attributable to another medical condition F.Not 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 insight  With poor insight  With absent insight and delusional beliefs – this would trump delusional disorder Specifiers X

83 Excoriation (skin picking) disorder A.Recurrent skin picking resulting in lesions B.Repeated attempts to stop or decrease behavior C.Causes clinically significant distress or impairment in social, occupational… D.Not attributable to the effects of a substance or medication E.Not better explained by…

84 Substance/medication induced obsessive-compulsive and related disorder A.Obsessions, compulsions, skin picking, hair pulling or other body focused repetitive behaviors occur B.Evidence that symptoms began during or soon after substance use, withdrawal or medication exposure. Substance or medication is capable of producing obsessive-compulsive symptoms C.Not better accounted for by OCD that is not substance/medication induced D.Does not occur exclusively during delirium E.Causes clinically significant distress X

85 OCD due to another medical condition A.Obsessions, compulsions, skin picking, hair pulling or other body focused repetitive behaviors occur B.Evidence 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 induced C.Does not occur exclusively during delirium D.Causes clinically significant distress Specify if With the possessive compulsive disorder like symptoms With appearance. Preoccupation With hoarding symptoms With hair pulling symptoms With skin picking symptoms

86 Other specified obsessive-compulsive and related disorder  Use when OCD symptoms are there and cause clinically significant distress, but do not meet full criteria for an OCD related diagnoses  Specify  Body dysmorphia with actual flaws  Body dysmorphia without repetitive behaviors  Body dysmorphia with repetitive behaviors  obsessional jealousy

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88  Substance Use Disorders  Substance Dependence  Substance Abuse  Substance-Induced Disorders  Substance Intoxication  Substance Withdrawal  Substance induced mental disorder Substance-Related Disorders : The distinction between Dependence and abuse disorders has been eliminated in the DSM 5 X

89 Substance use disorders maladaptive pattern leading to clinically significant impairment or distress for at least 12 months Must have at least 2 of the following11: 1.Substance taken in larger amount (need more for increased effect) 2.Persistent desire or efforts to quit 3.Time spent to obtain, use, recover from effects 4.Cravings Or urges to use 5.Failure to fulfill significant roles 6.Continued use despite persistent and recurrent problems 7.Important social/occupational activities are reduced 8.Recurrent use in physically hazardous situations 9.Use continues despite knowledge of impact of the problem 10.Tolerance, as defined by a. Increased amounts needed to achieve intoxication or b. Diminished effect 11.Withdrawal X

90 Substance-related disorders Substance use dis. Substance induced dis. Pathological pattern of behaviors related to use of the substance 1.Impaired control 2.Social impairment 3.Risky use 4. Pharmacological effects Increased tolerance Substance Intoxication Recent ingestion. Reversible symptoms related to ingestion Substance Withdrawal Physiological and psychological symptoms due to decreased use or cessation Delirium; persisting dementia; persisting amnesia; Psychotic disorder; mood dis; anxiety dis; sexual dys; sleep dis. = does occur also = Substance Induced Mental disorder. Recent ingestion followed by symptoms of another M.D. X

91 1.Substance taken in larger amount (need more for increased effect) 2.Persistent desire or efforts to quit 3.Time spent to obtain, use, recover from effects 4.Cravings Or urge to use 5.Failure to fulfill significant roles 6.Continued use despite persistent and recurrent problems 7.Important social/occupational activities are reduced 8.Recurrent use in physically hazardous situations 9.Use continues despite knowledge of impact of the problem 10.Tolerance, as defined by a. Increased amounts needed to achieve intoxication or b. Diminished effect 11.Withdrawal 11 criteria four areas – USE Dx Impaired Control social Impairment Risky use Pharmacological effects X

92 A.A maladaptive pattern of substance use leading to impairment or distress, as seen in 2 of the following in the same 12-mo. period: 1.Substance taken in larger amount (need more for increased effect) 2.Persistent desire or efforts to quit 3.Time spent to obtain, use, recover from effects 4.Cravings Or urges to use 5.Failure to fulfill significant roles 6.Continued use despite persistent and recurrent problems 7.Important social/occupational activities are reduced 8.Recurrent use in physically hazardous situations 9.Use continues despite knowledge of impact of the problem 10.Tolerance, as defined by a. Increased amounts needed to achieve intoxication or b. Diminished effect 11.Withdrawal 1. Criteria for Substance Use disorder X

93 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 5 2. Frequent use of substances in situation which iis physically hazardous #8 dsm 5 3Frequent 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 5 Dependence = 3 or more 5. 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 5 6 Withdrawal symptoms or the use of certain substances to avoid withdrawal symptoms #11 DSM 5 7. 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 5 9. Involvement in chronic behavior to obtain the substance, use the substance, or recover from its effects #3 DSM Reduction or abandonment of social, occupational or recreational activities because of substance use #7 DSM 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 5 DSM 5 use = 2 or more crit.

94 Severity 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 Specifiers for use disorders X

95 Simple substance dx Mental disorders that can be induced by substances I/W I Can also diagnose intoxication, withdrawal and induced mental disorders X

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97  For diagnosis of acute stress disorder, it must be specified whether the traumatic events were experienced directly or indirectly  Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress  Major changes in the criteria for the diagnosis of PTSD 7. Trauma and stress related disorders X

98 Diagnostic criteria has gotten more detailed and specific = more complicated diagnosis  The basics A.Exposure to trauma-direct or indirect B.Presence of intrusive thoughts, memories, flashbacks, dreams, triggers that cause distress, or other external cues that remind one of the trauma C.Avoidance of stimuli associated with the traumatic event D.Changes (usually increased sensitivity) in thought processes and emotions associated E.Increased arousal or reactivity associated with the traumatic event with the traumatic event Traumatic events Subsequent reactions X

99  Criterion 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 PTSD changes X

100 PTSD A. 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 X

101 PTSD Continued 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 condition Please note the presence of anxiety, fear and avoidance. 3 conditions that we find in generalized anxiety disorder Specifiers Specify whether: Dissociative symptoms are present Depersonalization = 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 true Derealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her distorted. However, one realizes this is not true Specify if Expression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or more after the event X

102 PTSD In children-6 or younger Avoidance and alterations in cognition collapsed into one criterion group A. 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 X

103 PTSD Children Specifiers Specify whether: Dissociative symptoms are present Depersonalization = 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 true Derealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her distorted. However, one realizes this is not true Specify if Expression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or more after the event Specifiers are the same X

104 In 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 behavior  Disinhibited = 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

105 Disinhibited = disinhibited social engagement disorder A.A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of the following 1.Reduced or absent reticence in approaching and interacting with unfamiliar adults 2.Overly familiar verbal or physical behavior that is not consistent with age-appropriate social boundaries 3.Diminished or absent "checking back" behaviors 4.Willingness to go with an unfamiliar adult with minimal or no hesitation B.Behaviors in criterion a are not limited to impulsivity such as that seen in ADHD C.The child has experienced a pattern of extremes of insufficient care, as evidenced by at least one of the following 1.Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort stimulation and affectation met by caregivers 2.Repeated changes of primary caregivers that limit opportunities for stable attachment 3.Rearing in unusual settings D.The criterion C is presumed to be responsible for the disturbed behavior in criterion A E.The child has a developmental age of at least 9 months

106 RAD A.A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers manifested by both of the following 1.The child rarely or minimally seeks comfort when distressed 2.The child rarely or minimally responds to comfort. When distressed B.A persistent social and emotional disturbance characterized by at least 2 of the following 1.Minimal social and emotional responsiveness to others 2.Limited positive affect 3.Episodes of unexplained irritability, sadness or fearfulness that are evident even during nonthreatening interactions with caregivers C.The child has experienced the pattern of extremes or insufficient care, as evidenced by at least one of the following 1.Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort stimulation and affection met by caregiving adults 2.Repeated changes a primary caregivers that limit opportunities to form stable attachment 3.Rearing in unusual settings that severely limit opportunities to form attachments D.To carry in criterion C is presumed to be responsible for the disturbed behavior in criterion a E.Criterion are not met for autism spectrum disorder F.Disturbance is evident before age 5 G.Child has a developmental age of at least 9 months

107 Adjustment Disorders In 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 disorder Diagnose adjustment disorder when: PTSD criteria are not met Criterion A for PTSD stressors not met Subthreshold for acute stress disorder & PTSD Symptoms do not last longer than 6 months after stressor.- A transitional state that is longer than acute stress disorder, but typically not as intense

108

109  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" 8. Dissociative disorders SUMMARY

110  Criterion 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. DID

111 Diagnostic criteria – DSM A.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 individual B.Inability to recall important personal information Or gaps in recall of everyday events. Important personal information or traumatic events. AKA dissociative amnesia C.Cause clinically significant distress, And/or impairment D.Not a part of broadly accepted cultural or religious practice E.Not due to a substance or general medical condition

112 Note the difference in the Diagnostic criteria –IV TR A.Presence of two or more distinct identities, each with its own relatively stable pattern of personality traits B.At least two of these ‘alters’ take control of the person’s behavior C.Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness D.Not due to a substance or general medical condition

113

114  This 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 hypochondriasis  Factitious disorder is now included in this group 9. Somatic symptom and related disorders X

115  Factitious disorder: conscious and intentional feigning or production of symptoms, because of a psychological need to assume the sick role to obtain emotional gain  Malingering: conscious and intentional production or exaggeration of symptoms for material gain, such as money, lodging, food, drugs, avoidance of military service, or escape from punishment  Somatization: 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 behavior  Hypochondriasis: obsession with fears that one has a serious, undiagnosed disease, presumably based on misinterpretation of bodily sensations - See more at: detection-diagnosis-and-forensic-implications#sthash.trRTuLQM.dpuf Some definitions X

116  Individuals 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. Somatic Symptom Disorder X

117 Somatic Symptom Disorder Diagnostic Criteria: A.One or more somatic symptoms that are distressing and result in significant disruption of daily life B.Excessive thoughts, feelings or behaviors related to the symptoms or associated health concerns, as manifested by at least one of the following: 1.Disproportionate and persistent thoughts about the seriousness of symptoms 2.Persistently high level of anxiety about health or symptoms 3.Excessive time and energy devoted to the symptoms or health concerns C.The state of being symptomatic is persistent (typically more than 6 months) X

118 Specifiers  Specify if:  with predominant pain (previously classified as pain disorder and DSM-IV)  Specify if:  persistent: severe symptoms lasting longer than 6 months  Specify current severity:  mild = only one of the symptoms specified in criterion B is the filled  moderate = 2 or more of the symptoms in criterion beer for filled  Severe = 2 or more of the symptoms are fulfilled. Plus, there are multiple other somatic complaints

119 Illness anxiety disorder criteria Previously hypochondriasis A.Preoccupation with having or acquiring a serious illness B.No evidence of somatic symptoms or extremely mild symptoms present C.High anxiety about health and health status D.Excessive health related behaviors or avoidant health related behaviors E.Illness preoccupation present for at least 6 months F.not better explained by another disorder Specify whether: care seeking type: medical care, including physician visits frequently used care avoidant type: medical care is rarely if ever used X

120  DSM-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/or  DSM-5 some individuals with chronic pain could be DXd  having somatic symptom disorder, with predominant pain  316.0psychological factors affecting other medical conditions  adjustment disorder Pain Disorder removed from DSM 5 X

121  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. Psychological Factors Affecting Other Medical Conditions

122  A. Medical symptom or condition is present  B. psychological or behavioral factors adversely affect the medical condition in one of the following ways  The 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 condition  The factors interfere with the treatment of the medical condition  The factors constitute additional well-established health risk for the individual The factors influence the underlying psychopathology precipitating or exacerbating symptoms or necessitating medical attention  C. psychological and behavioral factors in criterion B are not better explained by another mental disorder Psychological Factors Affecting Other Medical Conditions

123 Factitious disorder criteria Self-imposed A. Falsification of physical or psychological signs or symptoms or induction of injury or disease. In order to deceive B.Individual present self to others, as if impaired or injured C.No apparent or obvious external rewards D., Not better accounted for by… Imposed on others A. Falsification of physical or psychological signs or symptoms or induction of injury or disease. In order to deceive B.Individual presents another individual to others as you know, impaired or injured C.No apparent external rewards D.Not better accounted for by… E.When imposed on others. Diagnosis is given to the perp Specify if single episode recurrent episodes X

124  Somatic symptoms – major focus on symptoms experienced as well as anxiety- symptoms can have a physical cause, but the pt. experiences no relief  Illness 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 paralysis  Factitious – symptoms intentionally produced – no apparent gain-assess motivation  Malingering (v code)– intentional gain can be documented- assess motivation X

125 Somatic symptoms Inauthentic –authentic illnesses  Psychogenic illness – the mind causes symptoms that are experienced by the patient but have no “real” presence  Unconscious  Somatic symptom  Illness anxiety  conversion  Conscious  Factitious  malingering Diagnosed in part by LACK of evidence Diagnosed by evidence X

126  The person's medical history doesn't make sense  No believable reason exists for the presence of an illness or injury  The illness does not follow the usual course  There is a lack of healing for no apparent reason, despite appropriate treatment  There are contradictory or inconsistent symptoms or lab test results  The person is caught in the act of lying or causing his or her injury When to suspect factitious disorder X

127 The Case of Factitious Disorder Versus Malingering (2009] Courtney B. Worley, MPH ; Marc D. Feldman, MD and James C. Hamilton, PhD X

128 Without detailing the full DSM diagnostic criteria sets for these disorders and their relations, the following is a summary of how DSM instructs psychiatrists to diagnose cases of inauthentic illness behavior: 1. In the absence of overwhelming affirmative evidence of intentional medical deception (eg, caught on video, evidence from a room search), diagnose a somatoform disorder. 2. If there is traditional forensic evidence of overt medical deception, diagnose malingering or factitious 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 X

129

130  "Binge eating disorder' is now included as a separate diagnosis  also 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 10. Feeding and eating disorders

131

132  Originally classified in chapters on childhood and infancy. Now have separate classification  Primary insomnia renamed "insomnia disorder«  Narcolepsy now distinguished from other forms of hypersomnia  Breathing related sleep disorders have been broken into 3 separate diagnoses  Rapid eye movement disorder and restless leg syndrome are now independent diagnoses within this category 11. Elimination disorders 12. Sleep wake disorders

133

134  Some gender related sexual dysfunctions have been outed  Now only 2 subtypes-acquired versus lifelong and generalized versus situational  New diagnostic class and the DSM 5  Include separate classifications for children adolescents and adults  The construct of gender has replaced the construct of sex 13. Sexual dysfunctions

135

136 14. GENDER DYSPHORIA DSM 5  Attempted to eliminate the stigma involved in the previous diagnosis of gender identity disorder  Likely that more research is needed. Prevalence is remarkably low

137 Gender Dysphoria in Adolescents and adults A.Mark incongruence between one's experienced/expressed gender and assigned gender. At least 6 months duration, as manifested by at least 2 of the following 1.Marked incongruence between one's experienced/expressed gender and primary and/orsecondary sex characteristics 2.Strong desire to be rid of one's primary and/or secondary sex characteristics because of marked incongruence with one's experienced/expressed gender 3.Strong desire for the primary and/or secondary sex characteristics of the other gender 4.Strong desire to be of the other gender 5.Strong desire to be treated as the other gender 6.Strong conviction that one has the typical feelings and reactions of the other gender B.Condition is associated with clinically significant distress or impairment Specify 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

138

139  New diagnostic grouping and DSM 5  Combines 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 classified  Oppositional defiant disorder now has 3 subtypes  Intermittent explosive disorder no longer requires physical violence but can include verbal aggression Disruptive, impulse control and conduct disorders X

140 15. Disruptive, impulse control, and conduct disorders Disruptive ones oppositional defiant disorder conduct disorder Intermittent explosive disorder Impulsive ones Intermittent explosive disorder pyromania kleptomania Gambling disorder X

141 Major dynamic in all ICDs Tension and stress Begins to build Spike (steep rise) In tension immediately Before the act Impulsive act Immediate release in tension, Experience of pleasure or gratification

142 ODD A.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 mood 1. Often loses temper 2. Is often touchy or easily annoyed. 3. Often angry and resentful Argumentative, defiant behavior 4. 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 mistakes Vindictive behavior 8. Has been spiteful or vindictive at least twice within the past 6 months B. Causes distress in person, and others C.Does not occur during the course of another disorder X Changes from DSM IV ODD & conduct disorder are not mutually exclusive 3 symptom type groupings guidance re: how to distinguish from developmental norms severity measure included

143 Specifiers  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 X

144 Dimensional severity assessment for ODD Instructions to clinicians for ODD The 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 scale The 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 scale To 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. X

145 ODD dimensional assessment X

146 Problems with diagnosis  Differentiating this from developmental and/or environmental stress related behavior  Differentiating from other diagnoses such as bipolar 2  Biased reporting or reporting based on reputation  Expectation induced disruptive behaviors  Behavior 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 X

147 Conduct disorder unchanged Diagnostic criteria A.Repetitive 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 months Aggression to people or animals 1 bullies, threatens or intimidates 2 often initiates physical fights 3 used weapons that can cause serious physical harm 4. been physically cruel to people 5. Been physically cruel to animals 6. Has stolen while confronting a victim 7. Forced someone into sexual activity destruction of property 8. Has deliberately engaged in fire setting with intent of causing damage 9. Deliberately destroyed others property deceitfulness or theft 10. Broken into someone else's home building car 11. lies or deceives to obtain goods or favors 12. Has stolen nontrivial items without confronting victim – shoplifting etc. serious violation of rules 13. Stays out at night. Despite parental prohibitions. Begins before Has run away from home at least twice 15. Often truant, beginning before age 13 B. Causes clinically significant impairment C. If age 18 or over, not attributable to antisocial personality disorder X

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149  New diagnostic group  Dementia and amnestic disorder are included in this new group  Mild NCD is a new diagnosis 16. Neuro-cognitive disorders X

150  Term "dementia" has been deemphasized  done to lessen stigma  Deemphasize irreversibility  Broadens category in a more neutral way (see The following points below)  Mild neurocognitive disorder has been added  Distinguished from Major (severe) neurocognitive disorder X

151 Diagnostic criteria for delirium unchanged  A. disturbance Inattention (reduced ability to direct, focused, sustain and shift attention and awareness); reduced orientation to environment  B.. develops over a short period of time and fluctuates during the day  C. Add a disturbance in cognition (usually marked) – such as memory deficit, disorientation, agitation, language or perceptual disturbance  D. The criteria from A&C are Not better explained by a preestablished neurocognitive disorder or evolving neurocognitive disorder  E. evidence from the history, physical examination or lab findings thate disturbances are direct consequence of another medical condition, substance, intox or w/drawal X

152 Specifiers  Substance intoxication delirium = when criteria in A and C predominate during a period of intoxication  Substance withdrawal delirium = should be made it instead of substance withdrawal when the symptoms in criterion a and C predominate in the clinical picture  Medication induced delirium = should be made when the symptoms in criteria a and C arises a side effect of the medication taken as prescribed  Delirium due to another medical condition = evidence that the disturbance is attributable to the physiological consequences of another medical condition  Delirium due to multiple etiologies = evidence that the delirium has more than one cause or causal condition Course = acute: lasting a few hours or days persistent: lasting weeks or months

153 Diagnostic criteria for Major NCD AKA DEMENTIA  A. 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 activities  C. Are not caused or related to by delirium  D. Not better explained by… X

154 Mild neurocognitive disorder A.Evidence 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 on 1.Concern of individual, a knowledgeable informant or the clinician that there is been a mild decline in cognitive function and 2.Modest impairment in cognitive performance preferably documented by standardized neuropsychological testing or another quantified clinical assessment B.The cognitive deficits do not interfere for capacity with independence in every day activities, but greater effort compensatory strategies or accommodations may be required C.The cognitive deficits do not occur exclusively in the context of a delirium D.Not better accounted for by another mental disorder (major depression, schizophrenia X

155 Specifiers whether (Sub-types) of Mild NCD (dementia) are classified by etiology in DSM  Alzheimer’s type  Frontotemporal deterioration  Lewy body disease  Vascular (multi-infarct) dementia  Related to HIV  Head trauma Or TBI  Substance medication induced  Huntington’s disease  Parkinson’s diseases  Pick’s disease  Prions disease  Multiple etiologies  Unspecified X

156 17. 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 disorder  Paraphilia disorder requires the generation of clinically significant distress, impairment or acting them out with the nonconsenting person. (Criterion B)

157

158 Personality disorders Nothing changes X

159 DSM 5 promised major changes in criteria  Promised dimensional focus  Promised reduction in number of personaliity disorders to five  Changes did not occur  Dimensional focus for personality disorders was moved to section 3 X

160 Primary Criteria in DSM 5 (Unchanged from DSM-IV TR) A.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 areas A.Cognition; B.Affect; C.Interpersonal; D.Impulse control B.Inflexible & pervasive across situation C.Distress or impairment in social, occupational interpersonal..… D.Long-standing (back to adolescence or early adulthood) X

161 DSM IV & 5 and personality clusters Cluster A Odd/eccentric Paranoid Schizoid schizotypal Cluster B Dramatic, erratic Self-involved Anti-social Histrionic Narcissistic Borderline Cluster C Anxious/fearful Dependent Avoidant Obsessive-compulsive X

162 Dimensional classification of personality disorders  Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders  They plan to reduce personality disorders from 10 to 5  This changed in a closed-door meeting  Dimensional measures are now in section 3 X

163 ANTI_SOCIAL  A) 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;norms 2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;deceptionlying 3. impulsiveness or failure to plan ahead;impulsiveness 4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;irritabilityaggressiveness 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;remorserationalizing  B) The individual is at least age 18 years.  C) There is evidence of conduct disorder with onset before age 15 years.conduct disorder  D) The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.schizophreniamanic episode X

164 OR Mnemonic: “CALLOUS MAN” Diagnostic Criteria for Antisocial PD  Conduct disorder before age 15; current age at least 18  Antisocial activities; commits acts that are grounds for arrest  Lies frequently  Lacunae—lacks a superego  Obligations not honored (financial, occupational etc.)  Unstable—can’t plan ahead  Safety of self and others is ignored  Money– recklessness with money; spouse and children are not supported because he bought a motorcycle  Aggressive, Assaultive  Not occurring during schizophrenia or mania X

165 Antisocial signs  Glibness, shallow emotion  Requires constant stimulation  Criminal versatility  Promiscuity  Poor impulse control  Avoids responsibility for actions X

166  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.paranoid  reputation-defending antisocial – including narcissistic features narcissistic  risk-taking antisocial – including histrionic featureshistrionic  nomadic antisocial – including schizoid, avoidant featuresschizoidavoidant  malevolent antisocial – including sadistic, paranoid features.sadisticparanoid X

167 BORDERLINE PD A. 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:interpersonal relationshipsself-image affectsimpulsivity 1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self- injuring behavior covered in Criterion 5 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.interpersonal relationshipsidealization and devaluation 3. Identity disturbance: markedly and persistently unstable self-image or sense of self.Identityself-imagesense 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 5Impulsivitypromiscuous sexeating disordersbinge eatingsubstance abusereckless driving 5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars or picking at oneself (excoriation).suicidal behaviorself-injuring behavior 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).Affectivemooddysphoriaanxiety 7. Chronic feelings of emptinessemptiness 8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).anger 9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptomsstressparanoiddelusionsdissociative X

168 OR Mnemonic for Diagnostic Criteria: “I RAISED A PAIN”  Identity disturbance  Relationships are unstable  Abandonment is frantically avoided  Impulsive  Self-mutilation, suicidal threats/attempts; splitting - as a predominant defense mechanism is used  Emptiness is a description of their inner selves  Dissociative symptoms  Affective instability  Paranoid instability  Anger is poorly controlled  Idealization of others, followed by devaluation (splitting – person is either all good or all bad)  Negativistic—undermine their own efforts and those of others X

169  First called “as if” personality because or changes in direction or interest  Term “borderline” is unfortunate. Originally referred to being on the ‘border’ between psychotic and neurotic  Label is often used pejoratively among mental health professionals  Misunderstood and mis-labeled as “manipulative” X

170 Borderline Themes  Parental neglect and abuse  Impulsivity  Fears of abandonment  Frequent suicide ideation or gestures  Substance abuse or dependence  Legal difficulties  Disrupted education relationships, vocations, vacations X

171 Propose general criteria for personality disorder A.Moderate or greater impairment in personality (self interpersonal functioning) B.One or more pathological personality traits C.The impairments in personality functioning are inflexible and pervasive across a broad range of personal and social situations D.The impairments in personality functioning are relatively stable across time E.The impairments in personality function are not better explained by another medical condition or substance F.Impairments in personality functioning are not better understood as normal for individuals developmental stage, or sociocultural environment X

172 Dimensional classification of personality disorders  Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders  They plan to reduce personality disorders from 10 to 5  This changed in a closed-door meeting  Dimensional measures are now in section 3 X

173 Proposed changes in assessment Two broad dimensions Overall personality functioning 5 Broad Pathological Trait Domains self Interpersonal Identity Self direction Empathy Intimacy Negative affectivity Detachment Antagonism Disinhibition Psychoticism X

174 How to deal with uncertainty

175 2 dimensions required for all DSM diagnosis 1.Clarity of symptoms 2.Specified length of time for symptoms

176 4 basic levels of diagnostic warrant Symptomclarity symptom pattern over time High low Clear stable Unclear unstable Diagnostic certainty Diagnostic uncertainty or Diagnostic confusion Diagnostic plausibility Diagnostic possibility

177 Diagnostic certainty  The likelihood that a “plausible” diagnosis is “probable”  Clinicians often diagnoses based on “clinical hunches”, which are a form of bias  They 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”.

178 Easy 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 this  Probability = the statistical likelihood of an event; researchers focus on this Kahneman, 2011

179 2 conditions necessary for Diagnostic certainty  When symptoms are clear and stable over time  When the relationship between plausibility and probability has been considered Plausibility- these symptoms represent X Probability – the likelihood of X occurring

180 Symptomclarity symptom pattern over time High low Clear stable Unclear unstable Diagnostic certainty Diagnostic uncertainty or Diagnostic confusion Diagnostic plausibility Diagnostic possibility probability

181 Progression of domains of diagnostic certainty over time Diagnostic uncertainty Diagnostic possibilities Diagnostic probabilities Diagnostic certainty Ethical issues arise here when: Clinician unknowingly or unwittingly is in the wrong domain (incompetence) Clinician knowingly chooses the wrong domain Diagnostic plausibility

182 Progression of diagnostic certainty over time Diagnostic uncertainty Diagnostic possibilities Diagnostic probabilities Diagnostic certainty Documentation can help What leads me to be unsure? Do I know What don’t I Know? Why are these The possibilities ? How do I know that other DXs are not poss. Why am I certain? How do I know that I know? What makes this a probability and others not? Where is my prevalence data? Diagnostic plausibility What am I seeing that is so compelling? What am I missing? Why am I missing?

183 Progression of diagnostic certainty over time Diagnostic uncertainty Diagnostic plausibility Diagnostic probabilities Diagnostic certainty The more uncommon or unusual a diagnosis is, the more time and care one must take in differentiating or excluding other – more common - (statistically) diagnoses Diagnostic possibilities


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