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Dr Caroline Bradley.  Diagnosis  ICD-11  DSM-5  Diagnostic tests  Risk Assessment – HCR v3  Clustering/PbR.

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Presentation on theme: "Dr Caroline Bradley.  Diagnosis  ICD-11  DSM-5  Diagnostic tests  Risk Assessment – HCR v3  Clustering/PbR."— Presentation transcript:

1 Dr Caroline Bradley

2  Diagnosis  ICD-11  DSM-5  Diagnostic tests  Risk Assessment – HCR v3  Clustering/PbR

3  ICD-10 published 1992 (DCR-10: 1993)  DSM-IV published 1994  DSM-IV-TR published 2000  DSM-5 published 2013  ICD-11 to be released in 2015  free to download (paper version for a fee)  Compatible with electronic health records  100 word definition of each entity  Content Model (13 parameters)

4  ICD Entity Title  Classification Properties  Textual Definitions  Terms  Body System/Structure Description  Temporal Properties  Severity of Subtype Properties  Manifestation Properties  Causal Properties

5  Functioning Properties  Specific Condition Properties  Treatment Properties  Diagnostic Criteria

6  ICD-11 may include significant changes to the classification of Personality Disorder  Tyrer,P.,Crawford,M., & Mulder,R. (2011) Reclassification of personality disorder. Lancet, 377,  Tyrer,P. et al Personality and Mental Health 5: (2011) Wiley Online Library

7  Primary classification based on severity:  No PD  Personality Difficulty – some problems in some situations  Personality Disorder - definite well-demarcated problems in a range of situations  Complex Personality Disorder – definite problems in several domains across all situations  Severe Personality Disorder – as above plus significant risk to self or others

8  Secondary Classification of five trait domains  Asocial/schizoid  Dyssocial/antisocial  Obsessional/anankastic  Anxious/dependent  Emotionally unstable Also: possibly no lower age limit

9  No changes from DSM-IV  Cluster A  Paranoid, Schizoid, (Schizotypal)  Cluster B  Antisocial, Borderline, Histrionic, Narcissistic  Cluster C  Avoidant, Dependent, Obsessive-Compulsive

10  Criterion A  Moderate or greater impairment in personality functioning  Self:  Identity  Self-direction  Interpersonal:  Empathy  Intimacy

11  Criterion A  Five levels of impairment  0 = little or no impairment  1 = some impairment  2 = moderate impairment  3 = severe impairment  4 = extreme impairment Rated using Level of Personality Functioning Scale (which uses the four elements – identity, self-direction, empathy, and intimacy)

12  Criterion B  Pathological Personality Traits  5 broad trait domains  Negative Affectivity  Detachment  Antagonism  Disinhibition  Psychoticism

13  25 trait facets  Emotional Lability  Anxiousness  Separation Insecurity  Submissiveness  Hostility ( Negative Affectivity and Antagonism )  Perseveration  Depressivity ( Negative Affectivity and Detachment )  Suspiciousness ( Negative Affectivity and Detachment )  Restricted Affectivity ( Negative Affectivity and Detachment)

14  Withdrawal  Intimacy avoidance  Anhedonia  Manipulativeness  Deceitfulness  Grandiosity  Attention seeking  Callousness  Irresponsibility  Impulsivity

15  Distractability  Rigid perfectionism (lack of)  Unusual beliefs and experiences  Eccentricity  Cognitive and perceptual dysregulation

16 NEGATIVE AFFECTIVITYDETACHMENT  Emotional Lability  Anxiousness  Separation Insecurity  Submissiveness  Hostility  Perseveration  Depressivity  Suspiciousness  Restricted Affectivity (lack of)  Withdrawal  Intimacy Avoidance  Anhedonia  Depressivity  Restricted Affectivity  Suspiciosness 

17 ANTAGONISMDISINHIBITION  Manipulativeness  Deceitfulness  Grandiosity  Attention Seeking  Callousness  Hostility  Irresponsibility  Impulsivity  Distractability  Risk Taking  Rigid Perfectionism  PSYCHOTICISM  Unusual beliefs  Eccentricity  Cognitive/perceptual dysregulation

18  And then:  Antisocial  Avoidant  Borderline  Narcissistic  Obsessive Compulsive  Schizotypal  Personality Disorder – Trait Specified

19  For example – for Antisocial PD:  Moderate or greater impairment in 2 + of the 4 areas (identity, self-direction, empathy, intimacy)  6 or more out of 7 pathological personality traits:  Manipulativeness  Callousness  Deceitfulness  Hostility  Risk Taking  Impulsivity  Irresponsibility

20  Compared with:  Three or more out of the following 7 :  Failure to conform to social norms  Deceitfulness  Impulsivity  Irritability and aggressiveness  Reckless disregard for safety of self/others  Irresponsibility  Lack of remorse

21  15 new mental disorders (1-8):  Social (Pragmatic) Communication Disorder  Disruptive Mood Dysregulation Disorder (u18)  Premenstrual Dysphoric Disorder  Hoarding Disorder  Caffeine Withdrawal  Cannabis Withdrawal  Excoriation (skin-picking) Disorder  Binge Eating Disorder

22  15 new mental disorders (9-15):  REM Sleep Disorder  Restless Legs Syndrome (not really new)  Major Neurocognitive Disorder (replaces dementia)  Mild Neurocognitive Disorder  Disinhibited Social Engagement Disorder (children)  Central Sleep Apnea  Sleep-related hypoventilation

23  One or more of:  Affective lability (mood swings etc)  Marked irritability/anger/interpersonal conflict  Marked depressed mood  Marked anxiety/tension  PLUS: one or more of the following to a total of 5:  Decreased interest in activities; difficulty concentrating; lethargy; hypersomnia/insomnia; change in appetite; feeling overwhelmed; physical symptoms such as “bloating”.

24  Difficulty getting rid of possessions  Due to a perceived need to save them and distress associated with discarding  Resulting in the accumulation of items that clutter living areas and compromise their use  Causes distress or impairment Note to self: could be time to confront partner about 37 years’ worth of football programmes

25  No subtypes  No Schneiderian special attribution (running commentary; voices conversing)  No special attribution for bizarre delusions  Two or more of the following present for a significant period during a month:  Delusions, hallucinations, disorganized speech, grossly disorganised or catatonic behaviour, and negative symptoms

26  Autistic Spectrum Disorder replaces four previously separate disorders (autism, Asperger’s, childhood disintegrative disorder, and pervasive developmental disorder NOS)  ASD is characterised by:  1. deficits in social communication and social interaction  2. restricted repetitive behaviours, interests, or activities (RRBs) Note: if 1. but not 2. diagnosis is Social (Pragmatic) Communication Disorder

27  Intellectual Disability replaces Mental Retardation  Panic Disorder and Agoraphobia “unlinked”  Removal of the requirement (in phobic disorders) that adults recognise that their anxiety is unreasonable or excessive  New separate chapters for OCD and Trauma/Stress related disorders  Distinction between Paraphilia and Paraphilic Disorder and addition of “controlled environment” and “in remission”

28  Philip J Benson, Sara A Beedie, Elizabeth Shephard, Ina Giegling, Dan Rujescu, David St Clair Biological Psychiatry Vol 72 Issue 9, pp November 2012  Case Control study  Eye movement tests (gaze, following, viewing and image)  Total 298 assessments (whole data set)  Near perfect accuracy (discriminating between people with SCZ and those without)

29  Pharmacogenetics may lead to a way to identify those patients more likely to respond to Clozapine and those more likely to suffer Clozapine-induced Agranulocytosis  Use of bone marrow stimulating factors to treat the neutropenia caused by Clozapine

30  Stephen D. Hart, Christine Michie, David J. Cooke BJP 2007, 190:s60s65  Precision of actuarial risk assessment instruments: Evaluating the ‘margins of error’ of group v individual predictions of violence  Yang M, Wong SC, Coid J. Psychol Bull 2010 Sept; 136(5):  The efficacy of violence prediction: a meta-analytic comparison of nine risk assessment tools

31  Coid J et al The Journal of Forensic Psychiatry & Psychology Vol22, No. 1, February  Most items in structured risk assessment instruments do not predict violence  Alec Buchanan; Renee Binder; Michael Norko; Martin Swartz Am J Psychiatry 2012; 169:  Psychiatric Violence Risk Assessment

32  Primary Changes from HCR-20 v2:  Changes to names of Basic Risk Factors  Changes to content of some Basic Risk Factors  Addition of Sub-Items for complex risk factors  Addition of Indicators (examples) to Risk Factor Definitions  Elaboration of administration procedure (7 steps)

33  Historical Scale:  H1 – History of Problems with Violence  3 age ranges  H2 – History of Problems with Other Antisocial Behaviour  Incorporates information that in v2 was rated under H8 Early maladjustment, H10 Supervision Failure, and C2 Negative Attitudes  3 age ranges  H3 – History of Problems with Relationships  Broadened to include general social relationships

34  H4 – History of Problems with Employment  No substantive changes  H5 – History of Problems with Substance Use  No substantive changes  H6 – History of Problems with Major Mental Disorder  No substantive changes  H7 – History of Problems with Personality Disorder  Broadened from Psychopathy: PCL-R not needed

35  H8 – History of Problems with Traumatic Experiences  Narrowed in respect of focus on trauma experiences  Broadened to include adult experiences  H9 – History of problems with Violent Attitudes  Includes information rated in C2 in v2  H10 – History of Problems with Treatment or Supervision Response  Broadened to include treatment as well as supervision

36  C1 – Recent problems with Insight  No substantive changes  C2 – Recent Problems with Violent Ideation or Intent  Narrowed to focus on thoughts/plans concerning perpetration of violence  C3 – Recent Problems with Symptoms of Major Mental Disorder  No substantive changes

37  C4 – Recent Problems with Instability  No substantive changes  C5 – Recent Problems with Treatment or Supervision Response  Broadened to include problems with response to institutional or community supervision  R1 – Future Problems with Professional Services and Plans  Narrowed to focus on difficulties implementing professional services and making adequate plans

38  R2 – Future Problems with Living Situation  Narrowed to focus on difficulties finding a living situation that would help avoid potential destabilising influences  R3 – Future problems with Personal Support  No substantive changes  R4 – Future problems with Treatment or Supervision Response  Broadened to include treatment refractoriness  R5 – Future problems with Stress or Coping  No substantive changes

39  Change in coding from to N P Y  NB: rating is a mean to an end; not an end  The 7 Steps:  Gather information  Presence of Risk Factors  Relevance (to risk management strategies)  Formulation (theoretical basis; 4 P’s etc)  Scenarios  Management  Final Opinions (case prioritization etc)

40  Mental Health Clustering Tool (MHCT)  Groups service users according to level of need  Developed from HoNOS and SARN  Additional items for forensic services  Five Forensic Pathways (FFP)

41  Suicide  Substance Misuse  Cognitive Problems  Physical Illness  Hallucinations + Delusions  Depressed Mood  Other Symptoms  Relationships  Activities of Daily Living  Living Conditions  Occupation/Activities  Strong Unreasonable Beliefs  Mental Capacity  Carer Needs  Cultural/communicatio n  Physical Security

42  Agitated behaviour/expansive mood  Repeat Self-harm  Safeguarding  Engagement  Vulnerability  Interpersonal Dynamics  Drink/Drug Taking  Antisocial Attitudes

43  0 – no cluster but in need of care and will get a service  1Common MH Problems (low severity)  2 Common MH Problems (low severity; greater need)  3 Non Psychotic (moderate severity)  4Non-Psychotic (severe)  5Non-Psychotic (very severe)  6Non Psychotic Disorder of Overvalued Ideas

44  7Enduring Non-psychotic (high disability)  8Non-Psychotic Chaotic and Challenging  8b Non-Psychotic challenging and antisocial  8c Non-Psychotic socially avoidant, disaffected  10 First Episode Psychosis  11 Ongoing recurrent psychosis (low symptoms)  12 Ongoing or Recurrent Psychosis (high disability)

45  13 Ongoing or Recurrent Psychosis (high symptom and disability)  14 Psychotic Crisis  15 Severe Psychotic Depression  16 Dual Diagnosis  17 Psychosis and Affective Disorder – Difficult to Engage  18 – 21 Cognitive Impairment and Dementia

46  Each cluster has:  Indicative episode of care - e.g. 3+ years  A defined frequency of review – e.g. annually  Step-Down criteria  Step-up criteria  Description of which transitions are most likely, possible, rare, and clinically impossible  Discharge Criteria

47  I Treatment Responsive Group  II Treatment Resistant – challenging behaviour  III Treatment Resistant - continuing care  IV Personality Disorder – prison transfer  V Personality Disorder – co-morbidity


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