Download DSM 5 Changes that May Affect Adolescents

DSM 5
Changes that may affect adolescent care.
DSM-I (1952)
DSM-II (1968)
DSM-III (1980)
DSM-IV (1994)
132 pages
134 pages
494 pp
886 pp
Mental disorders
as “reactions”
“Reaction” terminology
dropped
Descriptive and
neutral
(“atheoretical”)
regarding etiology.
Inclusion of a clinical
significance criterion
Definitions were
simple,
brief paragraphs
with prototypical
descriptions
Users encouraged to
record multiple
psychiatric diagnoses (in
order of importance)
and associated physical
conditions
Coincided with ICD-8
(first time ICD included
mental disorders)
Coincided with ICD-9.
Multiaxial
classification system.
Goal to introduce
reliablilty.
New disorders
introduced (e.g., Acute
Stress Disorder, PTSD,
Bipolar II Disorder,
Asperger’s Disorder),
others deleted (e.g.,
Cluttering, PassiveAggressive Personality
Disorder).
DSM-5 (2013)
947 pages
“5” instead of “V”
Anticipates change
e.g. DSM 5.1 … 5.2 …
Work Groups were to consider:
⃝ Dimensional measures.
◦ e.g. severity scales
◦ or cross-cutting across disorders
⃝ Culture/gender issues.
NOS used in DSM IV = 41
Other/Unspecified used in DSM-5 =65
(To match ICD-10)
Main DSM 5 Categories
 Neurodevelopmental Disorders
 Schizophrenia Spectrum and
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Other Psychotic Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and
Related Disorders
Trauma and Stressor Related
Disorders
Dissociative Disorders
Somatic Symptom Disorders
Feeding and Eating Disorders
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Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse Control, and
Conduct Disorders
Substance Use and Addictive
Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Disorders
New Disorders
⃝ Social (Pragmatic) Communication
Disorder
⃝ Disruptive Mood Dysregulation
Disorder
⃝ Premenstrual Dysphoric Disorder
⃝ Hoarding Disorder
⃝ Excoriation (Skin‐Picking) Disorder
⃝ Disinhibited Social Engagement
Disorder (split from Reactive
Attachment Disorder)
⃝ Binge Eating Disorder
⃝ Central Sleep Apnea
⃝ Sleep-Related Hypoventilation
⃝ Rapid Eye Movement Sleep Behavior
Disorder
⃝ Restless Legs Syndrome
⃝ Caffeine Withdrawal
⃝ Cannabis Withdrawal
⃝ Major Neurocognitive Disorder with Lewy
Body Disease (Dementia Due to Other
Medical Conditions)
⃝ Mild Neurocognitive Disorder
Eliminated
⃝ Sexual Aversion Disorder
⃝ PolysubstanceDependence
Combined
⃝ Language Disorder
◦ Expressive Language Disorder
◦ & Mixed Receptive Expressive Language Disorder
⃝ Autism Spectrum Disorder
◦ Autistic Disorder,
◦ Asperger’s Disorder,
◦ Childhood Disintegrative Disorder,
◦ Rett’s disorder
⃝ Pervasive Developmental Disorder-NOS) Specific Learning Disorder
◦ Reading Disorder,
◦ Math Disorder,
◦ Disorder of Written Expression
⃝ Delusional Disorder
◦ Shared Psychotic Disorder
◦ & Delusional Disorder
Combined
⃝ Panic Disorder
◦ Panic Disorder Without Agoraphobia
◦ Panic Disorder With Agoraphobia
⃝ Dissociative Amnesia
◦ Dissociative Fugue
◦ Dissociative Amnesia
⃝ Somatic Symptom Disorder
◦ Somatization Disorder
◦ Undifferentiated Somatoform Disorder
◦ Pain Disorder
⃝ Insomnia Disorder
◦ Primary Insomnia
◦ Insomnia Related to Another Mental
Disorder
⃝ Hypersomnolence Disorder
◦ Primary Hypersomnia
◦ Hypersomnia Related to Another Mental Disorder
⃝ Non-Rapid Eye Movement Sleep Arousal Disorders
◦ Sleepwalking Disorder
◦ Sleep Terror Disorder
⃝ *Substance* Use Disorder
◦ *Substance* Abuse
◦ *Substance* Dependence
⃝ Stimulant Use Disorder
◦ Cocaine Abuse/Dependence
◦ Amphetamine Abuse/Dependence
Major Changes
Change
Comment
Elimination of multiaxial system and GAF
Clinicians wanted simplified, diagnosis-based
system; distinctions between Axis I and Axis II
disorders were never clearly justified; clinicians can
still specify external stressors; new assessment
measures will be introduced
Establishes 20 diagnostic classes or categories of
mental disorders
Categories based on groupings of disorders sharing
similar characteristics; some categories represent
spectrums of related disorders
Introduction of new diagnostic category of
Neurodevelopmental Disorders to include Autism
Spectrum Disorder and ADHD and other disorders
reflecting abnormal brain development
Increasing emphases on neurobiological bases of
mental disorders and the developing understanding
that abnormal brain development underlies many
types of disorders
Major Changes
Change
Comment
Introduces more dimensionality (severity ratings) but
does not restructure personality disorders as some had
proposed
Major changes in personality disorders held over until
next revision, the DSM 5.1 (or maybe 5.2)
Roman numerals dropped: DSM-5, not DSM-V
Allows for easier nomenclature for midcourse revisions,
5.1, 5.2, etc.
Removes obsessive-compulsive disorder from category
of Anxiety Disorders and places it in new category of
Obsessive-Compulsive and Related Disorders
Recognizes a spectrum of obsessive-compulsive type
disorders, including body dysmorphic disorder;
however, anxiety remains the core feature of OCD, so
questions remain about separating it from anxiety
disorders
Major Changes
Change
Comment
Removes ASD and PTSD from Anxiety Disorders and
places them in new category of Trauma and StressorRelated Disorders
Groups all stress-related psychological disorders under
the same umbrella; Adjustment Disorders may now be
coded in context of traumatic stressors
Creates new diagnostic category of Substance-Related
and Addictive Disorders
Now includes Gambling Disorder (previously
Pathological Gambling) but other forms of
nonchemical addiction, such as compulsive Internet
use and compulsive shopping, don’t make it into the
manual and remain under study
Eliminates distinction between substance abuse and
dependence disorders, collapsing them into single
category of substance use disorders
Recognizes that there is no clear line between
substance abuse and dependence disorders; also
brings certain compulsive patterns of behavior into a
spectrum of addictive disorders
Major Changes
Change
Comment
Provides a means of rating severity of symptoms,
such as for ASD
Encourages clinicians to recognize the
dimensionality of disorders
Greater emphasis on comorbidity; e.g., use of
anxiety ratings in diagnosing depressive and bipolar
disorders
Provides more explicit recognition of comorbidity in
having clinicians rate level of anxiety in mood
disorders
Major Changes
Change
Comment
Elimination of term “somatoform disorders” (now
Somatic Symptom and Related Disorders)
Eliminates a term few people understood
(somatoform disorders) and now emphasizes the
psychological reactions to physical symptoms, not
whether they are medically based
Reorganization of mood disorders into two separate
diagnostic categories of Depressive Disorders and
Bipolar and Related Disorders
No major changes anticipated, but no clear basis for
eliminating umbrella construct of mood disorders
Major Changes
Change
Comment
Removal of developmental
trajectory in organizing
classification of disorders:
Eliminates category of “Disorders
Usually First Diagnosed in Infancy,
Childhood, or Adolescence”
May make it easier to diagnose traditional childhood disorders like
ADHD and even separation anxiety disorder in adults. Conversely, it
may also make it easier to diagnose disorders typically seen in adults,
like bipolar disorder, in children.
The new category of Neurodevelopmental Disorders includes many
disorders previously classified as childhood onset disorders, however it
excludes disorders involving abnormal emotional development, such as
separation anxiety disorder and selective mutism.
Where does this new classification leave the study of child
psychopathology?
Elimination of bereavement
exclusion from major depression
Recognizes that a major depressive episode may overlay a normal
reaction to loss; critics claim it may pathologize bereavement
Major Changes
Change
Comment
Hypochondriasis dropped as distinct disorder
Eliminates the pejorative term “hypochondriasis”;
people formerly diagnosed with hypochondriasis may
now be diagnosed with Somatic Symptom Disorder if
their physical symptoms are significant or with Illness
Anxiety Disorder if their symptoms are minor or mild
Factitious Disorder moved to Somatic Symptom and
Related Disorders
Associated with other somatic symptom disorders, but
is distinguished by intentional fabrication of symptoms
for no apparent gain other than assuming medical
patient role
A brief History of Substance Use Diagnostics
Over time the definition of the problem has changed…
In the 1930’s the APA
called substance
abuse a “mentally
altered state deemed
inappropriate,
undesirable, harmful,
threatening, or, at
minimum, culturealien."
In the 1960’s the
terms ‘misuse’ and
‘abuse’ emerged as
distinctly different,
and dependence
was considered a
part of ‘abuse’.
In the 1970’s and
1980’s the terms
‘dependence’ and
‘drug-induced’ were
included in official
definitions of the
problem as
separate entities.
A few Definitions…
Clinically Significant Impairment
Decreased
functioning in
one or more
life area
(school, work)
Legal
problems
Recurrent
social/
interpersonal
problems
A few Definitions…
Substance Abuse
Excessive
Clinically
Use in spite risk taking/
Significant
of problems ignoring
Impairment
risk
A few Definitions…
Substance Dependence
(Addiction)
Physical
Clinically
symptoms of
Significant
tolerance/
Impairment
withdrawal
Lifestyle
centers
around use
Current diagnostics…
Substance Abuse
At least 1 of 4
symptoms
Dependence
At least 3 of 7
symptoms
Either one or the other,
maximum number of
problems anyone can
experience is 7.
Future Diagnosis: Substance Use Disorder
No disorder: 0-1
Symptom
Mild: 2-3
symptoms
Moderate: 4-5
symptoms
Severe: 6 or
more
11 Symptom continuum that ranks Substance Use
Disorder from mild to severe.
Prevalence
Prevalence
• NIAAA estimates that alcohol and drug abuse are associated with
100,000 deaths per year and cost society $180 billion per year.
• The overall cost of drug abuse rose 5.3 percent annually between
1992 and 2002, increasing from $107.5 to $180.9 billion. The most
rapid growth in drug costs came from increases in criminal justice
system activities, including productivity losses associated with growth
in the population imprisoned due to drug abuse.
Drug use by age Group…
31.5% of young people
have used in the past
month
Source: NSDUH 2011
Alcohol use by age…
39.8% Of
young
people aged
18-25 were
bingeing
Source: NSDUH 2011
All other drugs…
20.6%
increase in
MJ use
since 2007
Source: NSDUH 2011
Adolescent use is on the rise…
65-87%
increase in
MJ use
since 1990
Source: NSDUH 2009
Most commonly Abused
Drugs…
1
Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically.
Perception of risk by
Adolescents…
Risk
perception
decreases
with age for
ETOH and MJ
Perceived risk among
clinicians
Alcohol by far
outranks most
perceptions of
harm
CAREERS OF USE LAST DECADES…
80%
70%
60%
0-9*
Careers are
shorter the
sooner they
get to
treatment
10-19*
Percent in Recovery
50%
40%
20+
Years to 1st Tx Groups
100%
90%
30%
20%
10%
0%
0
5
10
15
20
Years from first use to 1+ years abstinence
25
30
* p<.05 (different
from 20+)
Source: Dennis et
al302005 (n=1,271)
Careers of use last decades…
100%
90%
80%
70%
60%
Median
duration of 9
years
and 3 to 4
episodes of
care
Percent in Recovery
50%
40%
30%
20%
10%
0% 0
5
10
15
Years from first Tx to 1+ years abstinence
20
25
Source: Dennis et
al312005 (n=1,271)
Relapse Rates of chronic illnesses
50% to
70%
ASTHMA
50% to
70%
HYPERTENSION
40% to
60%
DRUG ADDIC TION
30% to
50%
TYPE I DIABETES
0%
10%
20% 30% 40% 50% 60%
Source: McLellan, et al., 2000
70%
80%
Lapse vs. relapse
Lapse
Relapse
Impulsive

Short

duration
Accompanied by guilt
Small amount/duration of
use
Relatively low
consequence
Desire to return to change
process



Planned
Longer duration
High defensiveness
Large amount/duration of
use
Uncertain about desire to
return to change process
Median Length of Stay in Days
The Majority Stay in Tx
Less90 than 90 days
60
52
42
33
20
30
0
Outpatient
Intensive
Outpatient
Short Term
Residential
Long Term
Residential
Level of Care
Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY)
as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS
Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from
http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .
34
DEPRESSIVE DISORDERS
⃝DISRUPTIVE MOOD DISREGULATION
◦ Severe, age inappropriate temper outbursts 3+x weekly
◦ Daily irritable, angry mood 12 months, not asymptomatic 3 months; 2/3 settings
◦ Dx between 6-18 years; onset <10 years
◦ Not meeting criteria for manic/hypomanic for full day or ODD or IED
◦ (Purpose: Prevent Manic dx & subsequent antipsychotic medication)
⃝ MAJOR DEPRESSIVE DISORDER
◦ “Bereavement exclusion” removed
◦ Includes “note”: significant loss may result in some Criterion A symptoms. MDD
may also be considered in context of clinical judgment, history, and cultural norms.
⃝ PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA)
◦ MDD may be present 2 years (previously excluded)
DEPRESSIVE DISORDERS
⃝ PREMENSTRUAL DYSPHORIC DISORDER
◦ 5 of4+7 symptoms appear in final week before onset of most menses, then
improve (lability, irritability, anxiety, depressive, etc. )
⃝ SUBSTANCE/MEDICATION-INDUCED DEPRESSIVE DISORDER
◦ Removed Criterion A2:elevated, expansive or irritable mood
⃝ OTHER SPECIFIED DEPRESSIVE DISORDER
◦ Lists a few examples
⃝ UNSPECIFIED DEPRESSIVE DISORDER
◦ e.g. insufficient information
ANXIETY DISORDERS
⃝ “The anxiety must be out of proportion to the actual danger or
threat in the situation”
⃝ This chapter no longer includes OCD and PTSD
◦ DSM 5 creates new chapters for OCD and PTSD
⃝ Chapter is arranged developmentally.
◦ Sequenced by age of onset
◦ Now includes Separation Anxiety and
◦ Selective Mutism
ANXIETY DISORDERS
⃝ Panic Attacks and Agoraphobia are “unlinked” in DSM- 5
⃝ DSM- IV terminology describing different types of
Panic Attacks replaced in DSM-5 with the terms
“expected” or “unexpected” panic attack
⃝ Social Anxiety Disorder :
◦ “Generalized” specifier in DSM-IV has been deleted
◦ Replaced with “performance only” specifier
OBSESSIVE COMPULSIVE AND RELATED DISORDERS
⃝New chapter created for DSM 5
⃝Rationale for this chapter grouping:
◦ Increasing evidence that these disorders are related to each other
⃝New disorders in chapter :
◦ Hoarding disorder
◦ Excoriation (skin picking) disorder
◦ Substance /Medication–induced OCD
◦ OCD due to another medical condition
OBSESSIVE COMPULSIVE AND RELATED DISORDERS
⃝Trichotillomania, now termed trichotillomania disorder (hair pulling), moved
to OCD chapter
◦ No longer classified as an impulse control disorder.
⃝Specifiers listed for each OCD disorder
◦ Specifier “with poor insight” in DSM- IV has been expanded in DSM- 5
◦ New Specifiers are
1.
“with good or fair insight”
2. “with poor insight”
3. “with absent insight/delusional beliefs”
◦ Intent of these specifiers is to improve differential diagnoses
OBSESSIVE COMPULSIVE AND RELATED DISORDERS
⃝Body Dysmorphic Disorder
◦ A criterion added: “Preoccupation with one or more perceived defects or
flaws in physical appearance that are not observable or appear slight to
others”
⃝Hoarding Disorder added to DSM-5
◦ Due to evidence that it is not a variant of OCD;
◦ Evidence that it is a separate diagnosis
⃝Excoriation Disorder added to DSM-5
◦ Based on strong evidence of diagnostic validity and clinical utility
OTHER SPECIFIED AND UNSPECIFIED OBSESSIVE-COMPULSIVE
AND RELATED DISORDERS
DSM-5 includes conditions in this chapter such as:
⃝ Body-focused repetitive behavior disorder
◦ - other than excoriation and trichotillomania
i.e. nail biting, lip chewing
⃝ Obsessional jealousy
TRAUMA- AND STRESSOR-RELATED DISORDERS
New chapter in DSM-5 brings together anxiety disorders that are
preceded by a distressing or traumatic event:
⃝Reactive Attachment Disorder
⃝Disinhibited Social Engagement Disorder (new)
⃝PTSD (includes PTSD for children 6 years and younger)
⃝Acute Stress Disorder
⃝Adjustment Disorders
Disinhibited Social Engagement Disorder:
“The essential feature of disorder is a pattern of behavior that
involves culturally inappropriate, overly familiar behavior with
relative strangers. This behavior violates the social boundaries of the
culture.” DSM-5, p. 269
TRAUMA- AND STRESSOR-RELATED DISORDERS
Acute Stress Disorder
⃝Stressor criterion in DSM -5 is changed:
◦ Criterion requires being explicit whether qualifying traumatic
events were experienced directly, witnessed, or experienced
indirectly.
◦ DSM-IV Criterion A2 regarding reaction to the event- “the
person’s response involved intense fear, helplessness, or
horror” –has been eliminated
TRAUMA- AND STRESSOR-RELATED DISORDERS
Changes in PTSD Criteria
⃝Four symptom clusters, rather than three:
◦ Re-experiencing
◦ Avoidance
◦ Persistent negative alterations in mood and cognition
◦ Arousal: describes behavioral symptoms
⃝DSM-5 more clearly defines what constitutes a traumatic event:
◦ Sexual assault is specifically included
◦ Recurring exposure, that could apply to first responders
DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS
Oppositional Defiant Disorder
⃝ Criteria exhibited “with at least one individual who is not a sibling”
⃝ “Spiteful or vindictive twice in 6 months”
⃝ Severity: Mild, moderate, severe
⃝ <5years most days for 6 months; >5 years, weekly
Conduct Disorder
⃝ Adds specifier “With limited prosocial emotions”
⃝ Persistently in 12 months (2 of 4)
◦
◦
◦
◦
Lack of Remorse/ guilt
Callous—lack of empathy
Unconcerned about performance
Shallow or deficient affect
DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS
Intermittent Explosive Disorder
⃝ Verbal aggression 2x weekly for 3 months
⃝ Destruction or assault: 3x in 12 months
⃝ 6 years +
⃝ Not premeditated
AntiSocial Personality Disorder (criteria in PD chapter) “Dual coded”
⃝ Pyromania
⃝ Kleptomania
⃝ Other DICCD
⃝ Unspecified DICCD