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Transcript
2/16/17
+
Progress in
Psychodiagnostics:
DSM-IV-TR
to DSM-5
Tyler Argüello, PhD, DCSW, LCSW
Assistant Professor
CSU, Sacramento
February 15, 2017
Field Education, Division of Social Work
California State University, Sacramento
Thursday,
February 16,
2017
© Tyler Argüello, Ph.D.
AdvancedFieldInstructor
Training
Feb152017
Thursday,February16,2017
©TylerArgüello,Ph.D.
1
2/16/17
FieldEducation
TheHeartofSocialWork
“SignatoryPedagogy”
Thursday,February16,2017
©TylerArgüello,Ph.D.
IReminderofUpcomingEvents
-FieldFaireWed2/229-12
-FocusGroup– directlyafter
II
HolisticCompetency&Complex
PracticeBehavior
III“FieldConnect”
IVDSM5– Competency7
“Assessment”
Thursday,February16,2017
©TylerArgüello,Ph.D.
2
2/16/17
+ For questions and
permissions
Tyler M. Argüello, Ph.D., DCSW
Division of Social Work
California State University, Sacramento
4010 Mariposa, 6000 J Street, Sacramento, CA 95819
+1.206.353.8607
[email protected]
Thursday, February
16, 2017
+
© Tyler Argüello, Ph.D.
Quick Assessment
n
How comfortable are you with the DSM-5?
1.
Totally comfortable (e.g., I’m using it everyday and have been
for over a year)
2.
Somewhat Comfortable (e.g., I’ve opened it up and attempted to
use it)
3.
Neutral (e.g., I have one, or my office has one)
4.
Somewhat Uncomfortable (e.g., I get panicky when I look at it)
5.
Totally Uncomfortable (e.g., If I don’t look at it, it doesn’t exist)
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
3
2/16/17
+
Disclaimers
n
Not representing APA, NASW, BBS, or other professional body
n
In practice, in the classroom
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Learning Objectives
1.
Describe fundamental changes from the DSM-IV-TR to the
DSM-5.
2.
Understand substantive psychodiagnostic, coding, and
recording changes and elements per the DSM-5 for major
and/or common mental illnesses.
3.
Identify crosswalks (from IV-TR to 5) for major and/or
common mental illnesses.
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
4
2/16/17
+
Outline for today…
n
n
n
Part 1
n
Hx & Overview
n
Schizophrenia
n
Depression
n
Bipolar
Break
Part 2
n
Anxiety
n
OCD
n
Trauma
n
Break
n
Part 3
n
Feeding, Eating, Somatic
n
Neurodevelopmental
n
Neurocognitive
n
Gender & Sex
n
Substances
n
Personalities
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
+
www.dsm5.org
•
Online Assessment Measures
•
Quick References
•
DSM-IV-TR to 5 Crosswalk
•
Coding Updates
•
DSM – ICD 10
© Tyler Argüello, Ph.D.
Thursday, February
16, 2017
5
2/16/17
+
Hx & Overview of the DSM
Thursday, February
16, 2017
+
© Tyler Argüello, Ph.D.
Brief h/o DSM
n
(Psychiatric) classification systems have existed in ancient, Medieval,
and modern times
n
1844 – (The future) APA introduces statistical classification of
institutionalized ‘mental patients’
n
n
1880 – 7 categories: mania, melancholia, monomania, paresis, dementia,
dipsomania, epilepsy
1917 – (The future) APA published Statistical Manual for the Use of
Institutions for the Insane
n
22 categories; 10 editions
n
1943 - Medical 203 sets stage for modern nosology (i.e., DSM)
n
1952 – DSM introduced
n
n
n
5 editions, with intermittent text revisions
Issued in conjunction with ICD
$6.5M+ annual sales of DSM
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
6
2/16/17
+
Medical 203
n
1943 – War Department under auspices of the Surgeon
General published a Technical Bulletin entitled Medical 203,
a new classification scheme.
n
Moved the focus away from mental institutions and traditional
clinical perspectives
n
The VA also adopted a slightly modified version
n
WWII saw massive involvement of psychiatrists in selection,
processing, assessment, and treatment of soldiers.
n
1949 – WHO published ICD-6, which for the first time ever,
included a section on mental disorders
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
DSM-I
1952
n
130 pages long and listed 106 mental disorders
n
Focus on “reactions”; designed to figure out why people do what
they do
n
Lengthy assessments
n
Several categories of "personality disturbance", generally
distinguished from "neurosis" (nervousness, egodystonic).
n
Homosexuality listed as a sociopathic personality disturbance
n
“Categorized mental disorders in rubrics similar to those of the
Armed Forces nomenclature”
n
The descriptions were very vague, and based on the
theoretical orientation of a handful of academic psychiatrists
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
7
2/16/17
+
DSM-II
1968
n
180 diagnostic categories
n
Neither DSM-I or DSM-II had much impact on mental health practice.
n
In 1960s, there were many challenges to the concept of “mental illness”
itself
n
n
n
n
n
Myth used to disguise moral conflicts (Szasz)
Another example of how society labels, controls non-conformists (Goffman)
Misguided reliance on unobservable phenomena (behavioral psychologists)
Sexuality is not a disorder (Gay Rights Activists and advocates)
DSM-II viewed as unreliable diagnostic tool (Spitzer & Fleiss, 1974)
n
n
Different practitioners rarely in agreement when diagnosing patients with
similar problems.
Criticized lack of scientific basis and encouragement of negative labeling
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
DSM-III
1980
n
265 diagnoses, 495 pages
n Focused on “categorical model” for diagnosing
n Moved attention away from etiology (and psychodynamic approach)
n Atheoretical principle: Focusing on what is observable
n Introduced use of “criteria sets” and operationalized diagnosis
n Outlined common language for mental illness
n Introduction of PTSD (after strong military advocacy); stressor is external, not a neurosis
n
DSM-III-TR (1987) utilized data from field study trials in efforts to increase reliability
n 292 diagnoses, 567 pages
n Based on Emil Kraepelin’s theory that biology, genetics are integral factors in mental health
n Introducing multi-axial system
n Became a guideline for insurance coverage
n
Questions continued regarding diagnostic reliability and validity
n Mis-diagnoses and ethical issues
n
“Sexual orientation disturbance” removed; largely subsumed by "sexual disorder NOS",
which can be "persistent, marked distress about one’s sexual orientation”
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
8
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+
DSM–IV
1994
n
300 diagnoses, 886 pages; not much change though from III-R
n
n
n
Incorporated…
n
n
n
n
Attempted to address weaknesses of DSM-III and III-TR
Emphasis on evidenced-based diagnostic criteria
Research results of extensive field studies, literature reviews, etc.
Included information on cultural influences, diagnostic tests, and lab
findings based on extensive field studies.
Not enough to address reliability and validity issues
2000 – DSM-IV-TR released
n
n
Corrected factual errors that surfaced from use of the DSM –IV
e.g., Error in Pervasive Developmental Disorder, NOS had allowed
diagnosis in which there was only pervasive impairment in ONE
developmental area rather than multiple areas (reliability and validity
implications)
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
DSM-IV
Introduced – but did not require – a multi-axial
diagnostic system
n
Axis I
n
n
Axis II
n
n
n
General medical condition, acute medical conditions, and physical disorders
Axis IV
n
n
n
Developmental Disorders
Personality Disorders and mental retardation, defense mechanisms
Axis III
n
n
“Major mental illnesses”
“V-Codes”
Contributing / prominent psychosocial and environmental factors
Axis V
n
n
Global Assessment of Functioning (GAF)
Children’s Global Assessment Scale for those <18 years old
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
9
2/16/17
+
Problems with the DSM-IV’s
Various validity and reliability problems
Problems with frequent comorbidities
n
n
n
anxiety/depression, antisocial/ADHD/substance
abuse, personality disorders
n
Confluence and conflation with legal system
n
Discrete categories vs. spectrum disorders
n
Diagnostic inflation
n
3 False Epidemics among kids (Frances, 2013)
n Bipolar Disorder in children; Autism; Attention Deficit Disorder
Increased use of the Not Otherwise Specified (NOS) category
n
n
n
26% of adults, 21% of children
There are no criteria for an NOS category
© Tyler Argüello, Ph.D.
+
DSM-5
2013
Thursday, February 16, 2017
No more
Roman
numerals
200 Dxs, 1000 pages
• Released May 2013 p 10 yrs devo & 2yrs controversy
Multi-axial system of dx replaced by non-axial documentation
•
•
•
•
•
•
Collapse Axises I, II, III
Have look, feel of medical nosological system (aka, harmonize with ICD)
Axis II not fulfilling its fx; reimbursability problems
Everything is Axis III, aka “medical problem”
Context (Axis IV) epiphenomenonal to dx
GAF is unreliable, inaccurate, suspect validity
Focus on “dimensions” or dimensionality (aka, spectra of pathology)
• Neurobiologic Primacy
• DSM-5 is not atheoretical (more akin, maybe, to I and II?); return to ideology (vs
empiricism)
• Will have micro-revisions (e.g., 5.1) secondary neuro-scientific studies
Reorganization & Focus on Dimensionality
•
•
•
•
Normality relative to culture; lifespan approach; internalizing, externalizing fxs
Dimension / spectrum of pathology
New chapters
Many thresholds lowered
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
10
2/16/17
+
DSM-5 Highlights
Potentially Concerning Diagnostic Changes
n
Disruptive Mood Dysregulation
Disorder
n for temper tantrums
n
Autism
n classifying "introversion" as a
form of autism
n
Major Depressive Disorder
n includes normal grief
n
n
Minor Neurocognitive Disorder
n for normal forgetting in old
age
Substance Use Disorders
n collapsing abuse,
dependence
n
Adult Attention Deficit Disorder
n encouraging psychiatric
prescriptions of stimulants
Behavioral Addictions
n making a "mental disorder of
everything we like to do a lot"
n
Generalized Anxiety Disorder
n includes everyday worries
n
Post-traumatic stress disorder
n opening "the gate even
further” to mis-dx trauma
n
n
Binge Eating Disorder
n for excessive eating
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Organizational Structure
Dimensional Factors & Life Course
Lifespan Perspective
Disorders are clustered along two factors
n
n
Internalizing factors
n Disorders with prominent anxiety,
depressive and somatic symptoms
n Help to develop new diagnostic
approaches such as
dimensional
n Facilitate identification of
biological markers
Externalizing factors
n Disorders with prominent
impulsive, disruptive, antisocial
conduct and substance use
symptoms
n Hope to facilitate advances in
identifying diagnoses, markers
and underlying mechanisms
© Tyler Argüello, Ph.D.
n
Begins with disorders that
reflect developmental processes
manifesting EARLY in Life
n Neurodevelopmental
n Schizophrenia
n
Followed by those that manifest
in adolescence and young
adulthood
n Bipolar, depressive and
anxiety disorders
n
Ends with disorders that emerge
in adulthood and later life
n Neurocognitive disorders
Thursday, February 16, 2017
11
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Organizational Structure
Cultural Formulation
n
Mental d/o’s are defined in relation to cultural, social, and familial
norms and values.
n
n
Culture is an “interpretive framework” that shapes experience and
expression of sxs, signs, bxs that are criteria for dxs.
Culture shapes mental disorders in 3 primary ways
n
n
n
Influences how vulnerabilities to psychopathology are expressed in
symptoms
n In 1800s, ppl presented w “classical hysteria”; in 1900s, “anxiety,
depression”
n Onset of bulimia in recent years, promulgated thru social means
Can increase stress to pre-existing biological vulnerabilities
n Disproportionate rates of psychotic sxs (and dxs) for specific groups, e.g.,
immigrants w Schizophrenia
Shapes unique disorders seen in only one or related cultural groups
n Anorexia Nervosa only found in food-rich populations
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Organizational Structure
Gender Differences & Influences
Gender matters to the DSM-based diagnostic process because…
n
It can exclusively determine risk for a disorder
n
n
It can moderate overall risk for development of a d/o
n
n
n
n
Shown by marked prevalence and incidence rates
Schizophrenia has higher prevalence rates among males
Depression has higher prevalence rates among females
It may influence likelihood of experience of sxs
n
n
e.g., premenstrual dysphoric disorder
e.g., ADHD expressed differently in boys than in girls
It may determine which sxs are reported / endorsed, and
therefore dx’d
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
12
2/16/17
+
Clinical Utility & Significance
n
n
Dx determines prognosis, drives
tx plan, frames tx outcomes
n
Individuals do not have to meet all
sx criterion to dx or to provide tx
n
Does not determine disability nor
need for tx
Separate d/o from disability
n
n
Mental disorder - Sxs causes
clinically significant distress or
impairment in social, occupational
or other important areas of
functioning
Disability - Determined via
WHODAS, medical dx functional /
psychosocial assessment
Need for treatment includes
• Sx severity (eg, mild, moderate, severe)
• Sx salience (eg, suicidality)
• Pt’s distress associated c sx (eg, mental
pain)
• Disability related to sxs (eg, impairment
in ADLs, daily functioning)
• Risks / benefits of tx
• Other factors (e.g., comorbities)
Ways to validate
• Antecedent validators (e.g., family traits,
enviro exposure)
• Concurrent validators (e.g., biomarkers,
cognitive processing)
• Predictive validators (e.g., tx response,
similar clinical course)
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
The Rubric of Diagnosing
The elements of a diagnosis
List order of attention and importance to tx
• If the reason for a treatment is a Mental Disorder due to a Medical Condition,
(ICD/DSM) coding requires that the medical condition be listed first
Principal / Diagnosis
• Subtypes, specifiers
• Per clinical judgment, provide indication of “Principal Dx”
Provisional Diagnosis
• Matter of continued observation / measurement, or of time
• Provide indication of “Provisional Dx”
Contextual Factors
• V-Codes
NB: Make notation if any dx is per hx (reported or archive) or per EMR
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
13
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+
Principal Diagnosis
n
n
Principal Diagnosis
n
Reason for admission to
psychiatric setting
n
Reason for the visit, aka,
typically main focus for
treatment
n
Principal diagnosis is noted by
listing it FIRST
n
Can be followed by
verbiage: “Principal
diagnosis”
For example:
n
296.21 Major Depressive
Disorder, single episode,
mild (principal diagnosis)
n
n
or
Psychotic disorder due to
brain tumor
n
Malignant brain neoplasm
n
296.21 Major Depressive
Disorder, single episode,
mild
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Subtypes
Mutually exclusive and jointly exhaustive
phenomenological subgroups within a dx
n
“Specify whether”
n
e.g.,
n
n
Major Depressive D/O
n
Single Episode
n
Recurrent Episode
Bipolar I D/O
n
Current / recent episode manic
n
Current / recent episode hypomanic
n
Current / recent episode depressed
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
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Specifiers
NOT mutually exclusive or jointly exhaustive
n
Can give more than one
n
“Specify”, “Specify if”, “Specify current severity”
n
Opportunity to form subgrouping – and convey information important to
management of d/o
n
Indicate
n
n
n
n
Course (e.g., partial, full remission)
Severity (e.g., mild, moderate, severe)
n Intensity, frequency, duration, symptom count, or other indicator
Descriptives (e.g., with poor insight)
e.g.,
n
n
n
296.21 – MDD, single episode, mild, with anxious distress (mild)
294.8 – OCD, with poor insight
303.90 – Alcohol Use D/O, severe, with perceptual disturbances
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Provisional Diagnosis
“Provisional”
n
When criteria are not fully met
n
n
Strong evidence or presumption that criteria will be met
n
n
n
Don’t have enough information…yet
042 – HIV Infection
294.11 – Major Neurocognitive D/O due to HIV infection, mild,
with behavioral disturbance (Provisional)
n Still need psychological testing
Differential diagnosis depends on a duration of illness and
that hasn’t been met yet
n
295.40 Schizophreniform Disorder (Provisional)
n Duration of sxs hasn’t met 6 month criteria, but they’ve been
more than 1 (one) month
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
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Coding
Dx Categories, Subtypes, Specifiers
n
Every disorder has a numeric code identified in the first 3
(THREE) numerals
n
Neurodevelopmental Disorders – ADHD
n
n
314.xx
Subtypes and specifiers are coded in the 4th, 5th, and
sometimes 6th digit positions
n
314.01 – ADHD, Combined Presentation
n
314.01 – ADHD, Combined Presentation, partial remission, mild
n
Specify whether…
n
Specify if in partial remission
n
Specify current severity
© Tyler Argüello, Ph.D.
+
“Other” or “Unspecified”
n
NOS (Not
otherwise
specified)
replaced!
Other Specified
n
n
Thursday, February 16, 2017
Communicates specific reasons that cx’s presentation of sxs do
not meet criteria for a specific diagnostic category
n
298.8 – Other Specified Schizophrenia Spectrum & Other
Psychotic D/O, with persistent auditory hallucinations
n
311 – Other Specified Depressive D/O, with depressive episode
c insufficient sxs
Unspecified Disorder
n
Use when unable to further specify or describe the clinical
presentation
n
311 – Unspecified Depressive Disorder
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
16
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Dx Example
Code
Dx
Subtype
296.22 – Major Depressive D/O, single episode, moderate, with
anxious distress (mild) (principal dx)
309.81 – Posttraumatic Stress D/O
Specifier
304.30 – Cannabis Use D/O, moderate
305.70 – Stimulant Use D/O, amphetamine type, mild, in
sustained remission
V15.81 – Nonadherence to medical tx
V60.2 – Insufficient social welfare support (in process SSDI)
995.83 – Adult Sexual Abuse by nonpartner (sexual assault)
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
+ Dx Examples
301.83 – Borderline Personality D/O (principal)
304.30 – Cannabis Use D/O, moderate
304.00 – Opioid Use D/O, moderate
995.83 – Partner Violence, Sexual
V15.41 – Personal h/o partner violence, sexual
V60.89 – Discord w Neighbor
300.7 – Body Dysmorphic Disorder, with poor insight (principal)
300.02 – Generalized Anxiety D/O
307.51 – Bulimia Nervosa, in partial remission, moderate
250.00 – Diabetes Mellitus (Type 1), poorly controlled
995.51 – Child Psychological Abuse, suspected
296.34 – MDD, with psychotic fxs
298.8 – Other Specified Schizophrenia
Spectrum (provisional)
V61.10 – Relationship Distress w Spouse
296.22 – Major Depressive D/O, single episode, moderate, with anxious distress (mild) (principal dx)
309.81 – Posttraumatic Stress D/O
304.30 – Cannabis Use D/O, moderate
305.70 – Stimulant Use D/O, amphetamine type, mild, in sustained remission
V15.81 – Nonadherence to medical tx
V60.2 – Insufficient social welfare support (in process SSDI)
995.83 – Adult Sexual Abuse by nonpartner (sexual assault)
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
17
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Differential Diagnosing
6 Steps…always
1. Rule out malingering and factitious d/o
• Truth; motivation (secondary gain); deception
2. Rule out substance etiology (incl drugs of abuse & Rx’s)
• Psych sxs result from direct effects on CNS
• Substance use is a consequence (or fx) of a psych d/o (eg, self-medication)
• Psych sxs are substance use are independent
3. Rule out a disorder due to a general medication condition
4. Determine the specific primary disorder(s)
5. Differentiate (mal/adpative) adjustment from residual other un- / specified d/o’s
• Maladaptive response to a psychosocial stressor?
6. Differentiate cultural bounds and significance
• Cultural relativity
• Clinical significance
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
NB
Forensic Use of the DSM-5
n
Dx criterion not developed to meet needs of courts and legal
system
n
n
Still, DSM is used by attorneys, legal personnel, courts
Psychiatric dx does not equal confirmation of legal criteria
for presence of a mental disorder
n
Competence
n
Criminal responsibility
n
Insanity plea
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
18
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+
Schizophrenia Spectrum
Thursday, February
16, 2017
© Tyler Argüello, Ph.D.
+ Schizophrenia Spectrum
and Other Psychotic Disorders
SS&OPD
n
n
n
n
n
n
n
n
n
n
n
n
n
Schizotypal Personality D/O
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophrenia
Schizoaffective Disorder
Substance/Medication-Induced Psychotic Disorder
Psychotic Disorder Due to Another Medical Condition
Catatonia Associated with Another Mental Disorder
Catatonia D/O due to another Medical Condition
Unspecified Catatonia
Other Specified SS&OPD
Unspecified SS&OPD
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
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Schizophrenia & Other Psychotic D/O’s
Changes from DSM IV-TR to DSM 5
(DSM-IV-TR) Schizophrenia & other Psychotic D/O’s
(DSM-5) Schizophrenia Spectrum & other Psychotic D/O’s
n
Reorganized in DSM-5 from least to most severe d/o’s
n
Change to sx threshold: 2+ sxs
n
Elimination of subtypes
n
Elimination of Shared Psychotic D/O (Folie à Deux)
n
Inclusion of Schizoptypal Personality Disorder
n
Inclusion of Catatonia specifier
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Psychosis
Core Concept of
Diagnostic Group
Psychosis
1. Delusions
2.
Hallucinations
3. Disorganized
Thinking
(Speech)
4. Grossly
Disorganized
Bx
5. Negative Sxs
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
20
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+
1. Delusions
False and fixed beliefs not amenable to change in light of
conflicting evidence (note: degree of conviction)
n
Types
n
n
n
n
n
n
n
Grandiose – person is special, famous, exceptional, wealthy
Persecutory – intend to harm the person; very common
Referential – person is the object of gestures, comments, environmental cues;
very common
Erotomanic – person is object of desire by another
Nihilistic – conviction that catastrophe will happen
Somatic – preoccupation with health and organ functioning
Specify
n
n
Nonbizarre - plausible
Bizarre – implausible, not culturally understood, not ordinary
n Thought broadcasting
n Thought insertion
n Thought withdrawal
n Delusions of control
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
2. Hallucinations
Perception-like experiences w/o external stimulus
n
Vivid, clear, full sensory perception, not under control
n
Types
n
Auditory – most common; e.g., talk about / to individual
n
Must be in clear sensorium (awake)
n
Tactile (touch)
n
Gustatory (taste)
n
Visual (sight)
n
Olfactory (smell)
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
21
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+
3. Disorganized Thinking (Speech)
Thought d/o inferred by way of speaking
(note: cultural/linguistic differences do not qualify)
n
Echolalia – copy tone, words, or fragments of overheard conversations
n
Neologism – condensing or combining words or inventing new words or
sentence
n “Arachno-squisher”
n
Perseveration – continuously repeat same words or sentence
n
Clanging – use of rhymes or puns
n “My wife, she’s the wife of my life, no strife”
n
Derailment / tangential – random leap from topic to topic
n
Circumstantial / Loose Associations - circuitous but to the point
n
Incoherence / Word Salad
n “Shovel…it wasn’t the…best hatred….lifetime”
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
4. Grossly Disorganized Bx
Problems w (non-)goal directed bx
n
Catatonia - Marked decrease in reactivity to environment
n
Negativism – resistance to instructions
n
Mutism, Stupor – Rigid, inappropriate, bizarre posture, or lack of
verbal / motor response
n
Excitement – Excessive purposeless motor activity (w/o obvious
cause)
n
Other – stereotyped movement, staring, grimacing, mutism,
echoing
n
Nonspecific
n
May occur in other disorders
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Thursday, February 16, 2017
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5. Negative Symptoms
n
Positive symptoms - Those outward psychotic signs present in
a person with schizophrenia and absent in a person without
psychosis
n
n
Delusions, Hallucinations, Disorganized Thinking, Grossly
Disorganized Bx
Negative symptoms - Are notably absent in the person without
Schizophrenia but normally present in those diagnosed
n
n
n
n
n
Diminished emotional expression – reduction in expression of eyes
(contact), face (flat affect), intonation (prosody), hand gestures, head
Asociality – reduced interest in socializing (incl opportunities)
Anhedonia – loss of pleasure; inability to experience such things
Alogia – poverty of speech (diminished speech output)
Avolition – withdrawal, loss of motivation or goal directed behavior
(e.g., hygiene)
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Schizophrenia
From DSM IV-TR to DSM-5
DSM IV-TR
n
Schizophrenia subtypes
n Paranoid Type
n Disorganized Type
n Catatonic Type
n Undifferentiated Type
n Residual Type
n
Criterion A: Any two sxs
n Delusions
n Hallucinations
n Disorganized speech
n Grossly disorganized bx or
catatonia
n Negative sxs (affect flattening,
alogia, avolition)
© Tyler Argüello, Ph.D.
DSM 5
n
Schizophrenia Spectrum
n Dimensional approach to rating sx
severity of the core symptoms
n Clinician Rated Dimensions of
Psychosis Symptom Severity (pp.
743-744)
n
Criterion A: 2+ with at least one
being 1 to 3
1.
Delusions
2.
Hallucinations
3.
Disorganized Speech
4.
Grossly disorganized or
catatonic behavior
5.
Negative symptoms (restricted
affect, avolition, apathy)
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Previous 5 Subtypes of Schizophrenia
Eliminated with DSM-5
n
Paranoid type – where the affected person experiences hallucinations
with persecutory or grandiose content and delusions of persecution,
while speech, motor, and emotional behavior remains relatively
unimpaired
n
Catatonic type – characterized by unusual posturing, mutism or
incoherent chatter, and/or facial grimacing
n
Disorganized type – a condition whose features include disrupted
speech and behavior, fragmented delusions and hallucinations, and flat
or silly affect
n
Undifferentiated type – characterized by the major features of
schizophrenia without meeting full assessment distinctions for the
paranoid, disorganized, or catatonic types of schizophrenia
n
Residual type – a category reserved for individuals who have had at
least one episode of schizophrenia but no longer display schizophrenic
features; some evidence of bizarre thoughts and/or social withdrawal
remain
© Tyler Argüello, Ph.D.
+
Schizophrenia
Phases and Criterion
n
Prodromal phase
n
Before sxs become apparent
and person’s functioning
begins to deteriorate
Thursday, February 16, 2017
Criteria A: 2+ with at least one being 1 to 3
•
•
•
•
•
1. Delusions
2. Hallucinations
3. Disorganized Speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (restricted affect, avolition,
apathy)
Criteria B
• Marked decrease in functioning; or failure to do so
n
Active or Acute phase
n
n
See criterion to right
Residual phase
n
Prevailing features are in
remission
Criteria C
• Lasts for 6 months and include 1+month active phase
sxs
Criteria D
• R/O mood episode
Criteria E
• Criteria E: R/O substances and medical conditions
Criteria F
• Differential w Autism Spectrum D/O
© Tyler Argüello, Ph.D.
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CRDPSF :: pp 743-744
Clinician-Rated Dimensions of Psychosis Symptom Severity
Name:________________________________
Age: _______
Sex: [
] Male
[
] Female
Date:________________
Instructions: Based on all the information you have on the individual and using your clinical judgment, please rate (with checkmark) the
presence and severity of the following symptoms as experienced by the individual in the past seven (7) days.
Domain
0
3
4
I. Hallucinations
Not
present
Equivocal (severity or
Present, but mild
duration not sufficient
(little pressure to act
to be considered
upon voices, not very
psychosis)
bothered by voices)
Present and moderate
(some pressure to
respond to voices, or is
somewhat bothered by
voices)
Present and severe
(severe pressure to
respond to voices, or
is very bothered by
voices)
II. Delusions
Not
present
Equivocal (severity or
Present, but mild
duration not sufficient
(little pressure to act
to be considered
upon delusional beliefs,
psychosis)
not very bothered by
beliefs)
Present and moderate
(some pressure to act
upon beliefs, or is
somewhat bothered by
beliefs)
Present and severe
(severe pressure to
act upon beliefs, or is
very bothered by
beliefs)
III. Disorganized
speech
Not
present
Equivocal (severity or
Present, but mild
duration not sufficient
(some difficulty
to be considered
following speech)
disorganization)
Present and moderate
Present and severe
(speech often difficult to (speech almost
follow)
impossible to follow)
IV. Abnormal
psychomotor
behavior
Not
present
Equivocal (severity or
Present, but mild
duration not sufficient
(occasional abnormal or
to be considered
bizarre motor behavior
abnormal psychomotor or catatonia)
behavior)
Present and moderate
Present and severe
(frequent abnormal or
(abnormal or bizarre
bizarre motor behavior
motor behavior or
or catatonia)
catatonia almost
constant)
V. Negative
symptoms
(restricted
emotional
expression or
avolition)
Not
present
Equivocal decrease in
Present, but mild
facial expressivity,
decrease in facial
prosody, gestures, or
expressivity, prosody,
self-initiated behavior
gestures, or
self-initiated behavior
Present and moderate
decrease in facial
expressivity, prosody,
gestures, or self-initiated
behavior
Present and severe
decrease in facial
expressivity, prosody,
gestures, or
self-initiated behavior
Equivocal (cognitive
function not clearly
outside the range
expected for age or
SES; i.e., within 0.5 SD
of mean)
Present, but mild
(some reduction in
cognitive function;
below expected for age
and SES, 0.5–1 SD from
mean)
Present and moderate
(clear reduction in
cognitive function;
below expected for age
and SES, 1–2 SD from
mean)
Present andThursday,
severe
(severe reduction in
cognitive function;
below expected for
age and SES, > 2 SD
from mean)
Present, but mild
(frequent periods of
feeling very sad, down,
moderately depressed,
or hopeless; concerned
about having failed
someone or at
something, with some
preoccupation)
Present and moderate
(frequent periods of
deep depression or
hopelessness;
preoccupation with guilt,
having done wrong)
Present and severe
(deeply depressed or
hopeless daily;
delusional guilt or
unreasonable
self-reproach grossly
out of proportion to
circumstances)
Present and moderate
(frequent periods of
extensively elevated,
expansive, or irritable
mood or restlessness)
Present and severe
(daily and extensively
elevated, expansive,
or irritable mood or
restlessness)
Impaired Ph.D. Not
© TylerVI.Argüello,
+
1
2
cognition
present
VII. Depression
Not
present
Equivocal
(occasionally feels sad,
down, depressed, or
hopeless; concerned
about having failed
someone or at
something but not
preoccupied)
VIII. Mania
Not
present
Equivocal (occasional
Present, but mild
elevated, expansive, or (frequent periods of
irritable mood or some somewhat elevated,
restlessness)
expansive, or irritable
mood or restlessness)
Schizophrenia
Score
February 16, 2017
Note. SD = standard deviation; SES = socioeconomic status.
Specifiers
n
Copyright © 2013 American Psychiatric Association. All Rights Reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.
Episode
n
1st episode, acute
n
1st episode, partial remission
n
1st episode, full remission
n
Multiple episodes, acute
n
Multiple episodes, partial remission
n
Multiple episodes, full remission
n
Continuous
n
With Catatonia
n
Severity and which sxs (clinician rating scale)
© Tyler Argüello, Ph.D.
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Schizophrenia
Common Differentials to Be Made / Ruled-Out
n
Psychiatric
n
n
n
n
n
n
n
n
Medical
n
n
MDD w psychotic features
Bipolar I (mania)
OCD
Delirium, Dementia
Substance-induced d/o
Personality d/o (schizotypal)
Factitious
AIDS, B12 Deficiency, CO poisoning
Neuro
n
Epilepsy, cerebrovascular disease, head trauma, herpes encephalitis,
neurosyphilis
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Other Psychotic Disorders
n
Schizotypal Personality D/O
n
n
Schizophreniform D/O
n
n
Pervasive pattern of social / interpersonal deficits (incl reduced
capacity for close relationships); cognitive, perceptual distortions;
eccentricities beginning in early adulthood; below threshold of
other psychotic d/o
Sxs similar to but less severe than those found in schizophrenia;
2+ Criterion A sxs for 1+ month but less than 6 months; and must
have prodromal, active, and residual phases; less functionally
impairing
Schizoaffective D/O
n
Period of concurrent schizophrenia (criterion A) and a major
mood episode (depressive or manic); 2+ weeks of delusions or
hallucinations w/o mood sxs
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Other Psychotic Disorders
n
Brief Psychotic D/O
n
n
Delusional D/O
n
n
Hallucinations, delusions; sxs physiologically produced; remit after removal of
substance
Catatonia related to Substances or Medications
n
n
1+ month of delusions, but no other psychotic sxs
Psychotic D/Os related to Substances or Medications
n
n
Includes 1+ positive sxs of schizophrenia (from 1-3 of Criterion A); lasting more
than 1 day but less than 1 month; often occurs following a severe life stressor
3+ sxs of stupor, catalepsy, waxy flexibility, mutism, negativism, posturing,
mannerism, sterotypy, agitation, grimacing, echolalia, echopraxia
Other Specified or Unspecified
n
Psychotic presentation but do not meet criterion for other SS&OPD
or contradictory information
n Inadequate
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
+
Depressive Disorders
Thursday, February
16, 2017
© Tyler Argüello, Ph.D.
27
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Depressive Disorders
Differences among d/o’s are duration, timing, etiology
n
Disruptive Mood Dysregulation Disorder
n
Major Depressive Disorder
n
Persistent Depressive Disorder (previously Dysthymia)
n
Premenstrual Dysphoric Disorder
n
Substance/Medication-induced Depressive Disorder
n
Depressive Disorder due to Another Medical Condition
n
Other Specified, and Unspecified Depressive D/O
© Tyler Argüello, Ph.D.
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Thursday, February 16, 2017
Depressive Disorders
From the DSM-IV-TR to DSM-5
DSM-IV-TR
n
n
“Mood Disorders”
(Dep+BiPolar)
Premenstrual Dysphoric D/O
n
Item for further study
DSM-5
n
n
n
n
n
Dysthymia
n
Bereavement exclusion
n
Refrain from diagnosing
MDD within first 2 months
© Tyler Argüello, Ph.D.
n
“Depressive Disorders”
Disruptive Mood Dysregulation D/O
n Attempt to correct over-dx of
Bipolar D/O in children
Premenstral Dysphoric D/O
n Formal Dx
Persistent Depressive Disorder
n Includes dysthymia & chronic
major depressive disorder
n Redirects focus on chronicity of
depression (both major & minor)
Remove Bereavement Exclusion
n No evidence of difference in tx
response b/w grief and non-grief
n Grief does not end p 2 months
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Major Depressive Disorder
Note: Criterion A, B, C = Major Depressive Episode
Criterion A: 5 of 9 over 2 weeks; noted change from previous functioning; one sx has to be
either depressed mood or anhedonia
Despondent mood most of the day nearly every day
Diminished interests or pleasure (anhedonia)
3. Changes in weight
4. Insomnia or hypersomnia nearly Qd
5. Psychomotor agitation or retardation
6. Fatigue and/or loss of energy
7. Feeling worthless or having excessive guilt
8. Unable to concentrate or think
9. Recurrent thoughts of suicide
1.
2.
Criterion B: Distressed or impaired functioning
Criterion C: Not attributable to medical condition or substances
Criterion D: Not better explained by schizoaffective, schizophrenia, schizophreniform,
delusional or other schizophrenia spectrum & other psychotic
Criterion E: Never been a manic or hypomanic episode
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Differentiating Grief from MDE
Grief
n
n
Predominant affect: emptiness &
loss
Dysphoria likely to decrease in
intensity over days/weeks
n
n
n
n
n
n
n
Comes in waves / pangs
Associated with thoughts/memories
Accompanied by capability of
positive emotion & humor
n Enjoyment returns
Preoccupation: memories &
thoughts of deceased
Self esteem is generally preserved
If derogatory ideation-related to
deceased
Thoughts of death & dying related
to “joining” deceased
© Tyler Argüello, Ph.D.
MDE
n
n
n
n
n
n
Persistent depressed mood &
anhedonia
Mood is pervasive & not tied
to specific thoughts or
preoccupations
Pervasive misery & unhappy
Self-critical and pessimistic
ruminations
Worthlessness, self loathing,
low self esteem
Suicidal ideation
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Coding MDD
Considerations
n
Single or recurrent episode
n
n
n
n
n
n
Recurrent: Must be an interval of at least 2 consecutive months
between separate episodes in which criteria for MDD are not met
What are the individual’s particular sxs?
What are the duration and intensity of the depressive features?
Is the individual’s mood “reactive” to changes in life?
n Those with MDE do not perk up with something good happens
Is there a family history of major depression?
Only indicate if full criteria of major depressive episode are met
n Current level of severity
n Presence of psychotic features
n Remission
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Severity and Course
Severity/Course
Specifier
Single Episode
Recurrent episode
Mild
296.21
296.31
Moderate
296.22
296.32
Severe
296.23
296.33
With Psychotic
features
296.24
296.34
In partial remission
296.25
296.35
In full remission
296.26
296.36
Unspecified
296.20
296.30
© Tyler Argüello, Ph.D.
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Specifiers for Depressive Disorders
Note: Be sure to double check features
n
n
n
n
n
n
n
With anxious distress
With mixed features
With melancholic features
With atypical features
With mood congruent psychotic features
With mood incongruent psychotic features (non depressive
themes)
With catatonia:
n
n
n
n
Use additional code 293.89
See Schizophrenia Spectrum
With peripartum onset
With seasonal pattern
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Other Depressive D/O’s
DMDD, PDD, PMDD
n
n
Disruptive Mood Dysregulation D/O
n
Core feature is chronic, severe, persistent irritability, angry mood,
and outbursts (verbal, bx) for 12+ months
n
Differential w Bipolar, ASD, PTSD, Separation Anxiety, ADHD,
Intermittent Explosive D/O, Conduct, SUD
Persistent Depressive D/O (Dysthymia)
n
n
Depressed mood most of day, for more days than not for 2+ years;
need only 2 sxs (see MDD)
Premenstrual Dysphoric D/O
n
5 sxs in week prior to menses; improvement w onset;
minimal/absent post menses
n
1+ (marked affect lability, irritability, depressed mood, anxiety);
1+ (MDD sxs, sense of out of control, physical sxs)
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Other Depressive D/O’s
Substance & Others
n
Substance/Medication-Induced Depressive D/O
n
n
Depressive D/O due to Medical Condition
n
n
Mood disturbance co-located with physiologic change
Other Specified Depressive D/O
n
n
n
Mood disturbance sxs co-located with substance ingestion,
intoxication, w/drawal
Do not meet full criterion
Can include “Recurrent Brief Depression” (mood plus 4+ sxs, 2-13
dys / mo., 12+ consecutive months); “Short-Duration Depressive
Episode” (mood plus 4+ sxs, 4-13 days, never had mood d/o);
“Depressive Episode w Insufficient Sxs” (mood plus 1 sx).
Unspecified Depressive D/O
n
Characteristic sxs, but do not meet full criterion
© Tyler Argüello, Ph.D.
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Thursday, February 16, 2017
Differential Diagnosis
n
n
n
n
Bipolar I Disorders
n Current or previous sxs of
mania or hypomania
Uncomplicated Bereavement
n Depressive sxs are expected
manifestation of normal grief
Depressive Disorder Due to
another medical condition
n Consider this especially
among elders
Substance-induced mood
disorder
n Drug use among younger and
medications among older
© Tyler Argüello, Ph.D.
n
n
n
Persistent Depressive
Disorder
n Depressive sxs are milder
and persist for years
Schizophrenia,
Schizoaffective, or
Delusional Disorder
n Psychotic features present in
absence of mood symptoms
Brief Psychotic Disorder
n Sxs occur w/o clear episode
of depression, psychotic sxs
resolve quickly, may occur
in response to stress
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Bipolar & Related Disorders
Thursday, February
16, 2017
+
© Tyler Argüello, Ph.D.
Bipolar and Related Disorders
n
Bipolar I Disorder
n
Bipolar II Disorder
n
Cyclothymia Disorder
n
Substance/Medication-Induced Bipolar and Related Disorder
n
Bipolar & Related Disorder Due to another Medical
Condition
n
Other Specified Bipolar and Related Disorder
n
Unspecified Bipolar and Related Disorder
© Tyler Argüello, Ph.D.
No longer a “Mood D/O”,
rather a disorder of energy
and activity
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Bipolar and Related Disorder
DSM-IV-TR
n
n
Grouped within Mood
Disorders
Separated out from Mood Disorders
n
Criterion A for Manic & Hypomanic
emphasis on changes in activity, energy
& mood
n
New specifier, with mixed features
n Can be applied to episodes of mania
or hypomania when depressive
features present
n Bipolar when mania/ hypomania
present & to episodes of depression
in context of major depressive
disorder
n
Anxious Distress specifier
n Anxiety symptoms not part of BD
diagnostic criteria
Criterion A
n
n
DSM-5
n
Noted mood and duration
Bipolar Disorder, Mixed
episode
n
Full criteria for mania &
major depression
© Tyler Argüello, Ph.D.
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Thursday, February 16, 2017
Bipolar – Mania
Manic Episode: Criteria A thru D
NB: May be preceded or proceeded by period of hypomania or MDD
n
Criteria A
n
n
Criteria B – 3+ sxs (4 if mood is irritable)
n
n
n
n
n
n
n
n
n
Distinct period of abnormally, persistent elevated, expansive, irritable mood
plus ab/persis increased goal-directed activity for at least 1 week, present
most day, nearly everyday
Inflated self-esteem, grandiosity
Decreased need for sleep
More talkative
Flight of Ideas
Distractability
Increased goal-directed activity
Excessive involvement in activities with high potential for painful
consequences
Criteria C – Marked functional impairment, or hospitalization
Criteria D – Not physiologic or substance etiology
© Tyler Argüello, Ph.D.
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Bipolar – Hypomania
Hypomanic Episode: Criteria A thru F
Common in Bipolar I, but not mandatory
n
Criteria A
n
n
Criteria B – 3+ sxs (4 if mood is irritable)
n
n
n
n
n
n
n
n
n
n
n
Distinct period of abnormally, persistent elevated, expansive, irritable mood plus
ab/persis activity or energy for 4 consecutive days, present most day, nearly everyday
Inflated self-esteem, grandiosity
Decreased need for sleep
More talkative
Flight of Ideas
Distractability
Increased goal-directed activity
Excessive involvement in activities with high potential for painful consequences
Criteria C – Change in functionality (uncharacteristic)
Criteria D – Observable change by others
Criteria E – No impairment in functionality
Criteria F – Not physiologic or substance etiology
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Bipolar – MDD
Major Depressive Episode: Criterion A thru C
Common in Bipolar I, but not mandatory
Criterion A
n 5 of 9 over 2 weeks; noted change from previous functioning; one sx has to be either
depressed mood or anhedonia
1. Despondent mood most of the day nearly every day
2. Diminished interests or pleasure (anhedonia)
3. Changes in weight
4. Insomnia or hypersomnia nearly Qd
5. Psychomotor agitation or retardation
6. Fatigue and/or loss of energy
7. Feeling worthless or having excessive guilt
8. Unable to concentrate or think
9. Recurrent thoughts of suicide
Criterion B: Distressed or impaired functioning
Criterion C: Not attributable to medical condition or substances
Criterion D: Not better explained by schizoaffective, schizophrenia, schizophreniform, delusional
or other schizophrenia spectrum & other psychotic
Criterion E: Never been a manic or hypomanic episode
© Tyler Argüello, Ph.D.
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Bipolar I D/O
Criterion
n
Criteria A
n
n
1+ manic episode (Criterion A – D)
n See previous slide
Criteria B
n
Mania, Depression not better explained by Schizo Spectrum &
Other Psychotic D/O’s
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Bipolar I Disorder
Typically over time, interepisodic periods shorter in
time / years
Specifiers
Current or most recent episode
Manic
Hypomanic
Depressed
Unspecified
Mild
296.41
n/a
296.51
n/a
Moderate
296.42
n/a
296.52
n/a
Severe
296.43
n/a
296.53
n/a
W Psychotic
Fx’s
296.44
n/a
296.54
n/a
In Partial
Remission
296.45
296.45
296.55
n/a
In Full
Remission
296.46
296.46
296.56
n/a
Unspecified
© Tyler
Argüello, Ph.D.
296.40
296.40
296.50
n/a February 16, 2017
Thursday,
36
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+
Specifiers for Bipolar I
NB: Be sure to double check features (pp.149-154)
n
Bipolar I D/O, [type of current or most recent episode],
[severity/psychotic/remission specifier], [other specifiers]
n
n
n
n
n
n
n
n
n
n
With anxious distress
With mixed features
With rapid cycling
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia
With peripartum onset
With seasonal pattern
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Bipolar II Disorder
296.89 – One diagnostic code
n
Criteria A
n
Meet criteria for 1+ hypomanic episode
n
n
Differential
much longer
and
involved…
why?
See previous slide; Criteria A – F
Meet criteria for 1+ major depressive episode
n
See previous slide; Criteria A – C
n
Criteria B – No h/o manic episode
n
Criteria C – R/O Schizo spectrum & other psychotic d/o’s
n
Criteria D – Functional impairment & distress
© Tyler Argüello, Ph.D.
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Specifiers for Bipolar II
NB: Be sure to double check features (pp.149-154)
n
Specify current or most recent
episode
n Hypomanic
n Depressed
n
Specify if
n With anxious distress
n With mixed features
n With rapid cycling
n With melancholic features
n With atypical features
n With mood-congruent
psychotic features
n With mood-incongruent
psychotic features
n With catatonia
n With peripartum onset
n With seasonal pattern
n
n
Specify course if full criteria
for a mood episode are not
currently met
n
In partial remission
n
In full remission
Specify if full criteria for a
mood episode are currently
met
n
Mild
n
Moderate
n
Severe
© Tyler Argüello, Ph.D.
+
Cyclothymic Disorder
Chronic, fluctuating mood disturbance
n
R/o schizo spectrum & other psychotic d/o’s
Criteria E
n
n
Criteria never met for major depressive, manic, hypomanic episodes
Criteria D
n
n
During above period, sxs present at least half time & person has not been
w/o sxs for 2+ months at a time
Criteria C
n
n
2+ years (1+ in kids) w hypomanic & depressive sxs that do not meet
criteria
Criteria B
n
n
What might this
be a good
differential with
– or “stand in”?
Criteria A
n
n
Thursday, February 16, 2017
R/o drugs & medical
Criteria F
n
Sxs cause distress and functional impairment
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
38
2/16/17
+
Other Bipolar Disorders
n
Substance-Induced Bipolar & Related D/O
n
n
Bipolar & Related D/O due to Another Medical Condition
n
n
n
See specifiers for most recent episode
Include name of medical condition & list in diagnostic scheme
Other Specified
n
n
n
n
n
See coding on pp 142 – 143; to match w ICD-10
Short-duration hypomanic (2-3 days) & depressive episodes – Meet
criteria for major dep episode, but not hypo/mania; cycles do not
overlap
Hypomanic episodes w insufficient sxs and major depressive episodes
(4+ consecutive days)
Hypomanic w/o prior major depressive episode
Short-duration cyclothymia (< 24 months)
Unspecified
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Bipolar I Disorder R/O
(More Mania)
n
Mood & Other Bipolar D/O’s
n
n
n
n
n
n
Teens: Disruptive Mood
Dysregulation D/O
Major Depressive Disorder - Never had mania or hypomania
Bipolar II Disorder - Hypomania but never full manic episode
Cyclothymic Disorder
Bipolar D/O due to another medical condition – Renal failure, Vit B3 or B12 deficiency, stroke,
hyperthyroidism, Rx induced (eg, antidepressant), CNS infection, head trauma, epilepsy
Substance Induced Bipolar Disorder – eg, amphetamines, PCP
“Positive” End of Emotions/Cognitions/Bx’s
n
n
n
Anxieties – GAD, Panic, PTSD, etc.
ADHD
Other disorders w prominent irritability
n
Personality – Normal mood swings; vs/and/or BPD / Cluster B
n
Schizo Spectrum & Other Psychotic D/O
n
n
Schizoaffective Disorder - Resembles Bipolar I w psychotic fxs BUT psychotic sxs occur in
absence of mood sxs
Schizophrenia or Delusional Disorder - Psychotic symptoms dominate and occur without
prominent mood sxs
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
39
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+
Bipolar II Disorder R/O
(More Depression)
n
n
Mood
n
Major Depressive Disorder- No h/o hypomania
n
Bipolar I D/O - at least one clear cut manic episode
n
Cyclothymic D/O - Mood swings cause clinically significant distress &
no history of major depressive episode
n
Bipolar D/O due to another medical condition – Parkinson’s,
Huntington’s, tumors, MS, head trauma, infection, cancer, Rx’s, vit. def.
n
Substance–Induced Bipolar D/O – Hypomania secondary antidep Rx
Personality
n
Normal Mood Swings – No clinically significant distress
n
Personality D/O – BPD, Cluster B
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
+
BREAK
Thursday,
February 16,
2017
© Tyler Argüello, Ph.D.
40
2/16/17
+
Anxieties
Anxiety Disorders
Obsessive-Compulsive & Related Disorders
Trauma- & Stressor-Related Disorders
Thursday, February
16, 2017
+
© Tyler Argüello, Ph.D.
Anxiety Disorders
DSM-IV-TR to DSM-5
DSM 5
Anxiety Disorders
DSM IV TR
Anxiety Disorders
DSM 5
Obsessive Compulsive and
Related Disorder
DSM 5
Trauma and Stress Related
Disorders
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
41
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+
Anxiety
Disorders
Thursday,
February 16,
2017
+
© Tyler Argüello, Ph.D.
Anxiety Disorders
From the DSM IV TR to the DSM 5
DSM IV TR
n
n
n
n
n
n
n
n
n
Panic Disorder
n w/o Agoraphobia
n with Agoraphobia
Agoraphobia w/o a history of PD
Specific Phobia
Social Phobia
Generalized Anxiety D/O
AD due Medical Condition
Substance Induced AD
Obsessive Compulsive Disorder
Post Traumatic and Acute Stress
Disorder
© Tyler Argüello, Ph.D.
DSM 5
n
Separation Anxiety Disorder
n
Selective Mutism
n
n
Specific Phobia
Social Anxiety Disorder
n
Panic Disorder
n
Panic Attack (Specifier)
n
Agoraphobia
n
Generalized Anxiety Disorder
n
AD due to another Medical
Condition
n
Substance Induced AD
No change;
supposed to
be “GAWD”
Thursday, February 16, 2017
42
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+
Panic Attack
DSM IV
n
Variety of different types of
panic attacks
n
Situationally bound/cued
n
Situationally predisposed
n
Unexpected/cued
DSM 5
n
Not a disorder to code
n
Unexpected
n No obvious cue or trigger
n
Expected
n Obvious cue or trigger
n
Serves as a marker and
prognostic factor for severity of
a diagnosis, course and
comorbidity across disorders
n
n
Related to a higher rate of suicide
ideation and suicide attempts
Can be listed as a specifier for
many diagnoses
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Agoraphobia, Specific Phobia,
& Social Anxiety
DSM IV
DSM 5
n
Requires that the client over 18
years of age realize anxiety is
excessive or unreasonable
n
6 month duration for
individuals under 18 years old
n
n
Within children:
n Anxiety may be expressed
by crying, tantrums,
freezing, or shrinking from
social situations with
unfamiliar people
n
© Tyler Argüello, Ph.D.
n
n
More consistency across phobias
n All emphasize fear, anxiety,
avoidance
n No longer use the age criteria
n Types of phobias now specifiers
No insight requirement, rather replaced
with phrasing around clinician’s
judgment
n Anxiety must be out of proportion to
actual danger or threat
n Consider culture
6 months duration now applied to all
ages to curb over diagnosis of transient
fears
Within children:
n Anxiety may be expressed by
crying, tantrums, freezing, clinging,
shrinking, or failing to speak in
social situations with unfamiliar
people
Thursday, February 16, 2017
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+
Panic Disorder and Agoraphobia
DSM IV
n
n
Panic Disorder
n
with Agoraphobia
n
without Agoraphobia
Agoraphobia w/o h/o panic
disorder
DSM 5
n
2 separate disorders now
n Panic Disorder
n Agoraphobia
n Co-occurrence now coded
as two diagnoses
n
Agoraphobia
n Need to endorse fears of 2+
agoraphobic situations
n Clinician judgments of fears
being out of proportion
n Duration of 6+ months
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Separation Anxiety Disorder
DSM IV
n
n
Within disorders usually first
dx’d in infancy, childhood or
adolescence
DSM 5
n
Within Anxiety Disorders
n
Wording encompasses
separation disorder in
adulthood
n
No age onset requirement
Onset before 18yo
n
n
© Tyler Argüello, Ph.D.
no longer must be before
18yo
Duration of 6+ months for
adults
Thursday, February 16, 2017
44
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+
ObsessiveCompulsive
& Related
Disorders
Thursday,
February 16,
2017
+
© Tyler Argüello, Ph.D.
Obsessive Compulsive & Related D/Os
Commonality:
Obsessive preoccupations and repetitive bx’s
n
Obsessive Compulsive Disorder (OCD)
n
Body Dysmorphic Disorder
n
Hoarding Disorder (new)
n
Trichotillomania (hair pulling disorder)
n
Excoriation Disorder (skin picking) (new)
n
Substance/Medication Induced OC and related Disorder
n
OC & Related Disorder due to Another Medical Condition
n
Other Specified OC and Related Disorder
n
Unspecified OC and Related Disorder
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
45
2/16/17
+
Notable Changes in OCD Chapter
IV-TR into the DSM-5
n
Definitional
n
n
n
“Urge” replaces “impulse”
“Unwanted” replaces “inappropriate”
“In most individuals cause marked anxiety or distress”
n
New tic-related specifier: Current or past h/o tic d/o
n
Cx’s no longer must recognize their OCD obsessions or compulsions
are excessive or unreasonable
n
Delusional variants only within OCD (BDD); not w psychosis section
n
OCD’s “poor insight” specifier has been expanded to include a broader
range of insight options, including delusional OCD beliefs
n
Insight specifier added to OCD, BDD, hoarding
n Good or fair; Poor; Absent/Delusional
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Differential Dx’ing
Anxiety & OCD Related Disorders
n
Substance induced disorders or etiology
n
n
n
Meth, cocaine, etc.
Prescribed
Specify drug with ICD-10 code
n
R/O or specify cultural explanation or concepts
n
Medical conditions
n
n
Heart attack, GI problems
PTSD, MDD, psychotic disorders
n
Other disorder w anxiety sxs or panic attacks
n
Eating disorders
n
Conduct, impulse-control, disruptive
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
46
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+
OCD & Hoarding
n
Anxieties, Compulsions
n GAD – worries are more re real-life concerns; OCD don’t have to be, can include content
that is odd, irrational, even magical
n SUD (EtOH) = compulsion? … Is there pleasure?
n
Hoarding
n Focus is on difficulty discarding possessions, distress assoc’d, excessive accumulation
n If obsessions present typical of OCD (harm) which in turn lead to hoarding (objects that
prevent harm), OCD should be dx’d
n Hoarding in OCD more often focused on bizarre items (trash, feces, nails)
n Severe hoarding concurrent w other typical OCD sxs – but independent from sxs – both
hoarding and OCD can be dx’d.
n Prevalence (estimates) = 1.4 to 5% (whereas OCD is ~1.2%)
n 75% comorbid depression or anxiety d/o; 20% comorbid OCD
n Men have more aggressive, sexual/religious compulsions w checking, and then comorbid
with GAD, tics
n Women more comorbid BDD, skin picking
n
OCD
n Men have earlier onset, more impairing prognosis
n Typically, men have more religious/sexual and aggressive sxs; women more
contamination/cleaning
n Comorbidities: 76% anxiety d/o; 63% mood; 30% OCPD
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
+ Trauma- & Stressor-Related
Disorders
Thursday, February
16, 2017
© Tyler Argüello, Ph.D.
47
2/16/17
+
Trauma- & Stressor-Related
Disorders (TSRD)
Anxieties
• All 3 categories
• Anxiety
• OCD & Related
• Trauma & Stress Related
Anxiety &
OCD
• Anxiety sxs (anticipation of
future events); worry
• Fear sxs (emotional response);
• Internalizing; fight/flight
• Avoidant
Trauma &
PTSD
• Anhedonia
• Dysphoria
• Externalizing anger, aggression
• Dissociation
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Trauma-and Stressor-Related D/Os
New Category in DSM 5
Code
Disorder
313.89 (F94.1)
Reactive Attachment Disorder
313.89 (F94.2)
Disinhibited Social Engagement Disorder
309.81 (F43.10)
Posttraumatic Stress Disorder
308.3 (F43.0)
Acute Stress Disorder
309.0(F43.21)
309.24(F43.22)
309.28(F43.23)
309.3 (F43.24)
309.4 (F43.25)
309.9 (F43,20)
Adjustment Disorder
with depressed mood
with anxiety
with mixed anxiety and depressed mood
with disturbance of conduct
with mixed disturbance of emotions and conduct
Unspecified
309.89 (F43.8)
Other-Specified Trauma and Stressor Related Disorder
309.9(F43.9)
Unspecified Trauma and Stressor Related Disorder
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
48
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+
RAD &
DSED
Reactive Attachment Disorder (RAD)
Disinhibited Social Engagement Disorder
(DSED)
Thursday,
February 16,
2017
+
© Tyler Argüello, Ph.D.
Transformulating
Reactive Attachment Disorder
DSM-IV-TR
Reactive Attachment Disorder
Inhibited Type
Disinhibited Type
© Tyler Argüello, Ph.D.
DSM-5
Reactive Attachment
Disorder (RAD)
DSM-5
Disinhibited Social
Engagement
Disorder (DSED)
Thursday, February 16, 2017
49
2/16/17
+ Reactive Attachment D/O &
Disinhibited Social Engagement D/O
Common and Differing Elements
n
Both are rare disorders
n
Both are results of social neglect, inadequate care, or other
situations that limit young children’s opportunity to form
selective attachments
n
Both must be developmentally able to form selective
attachments therefore must not be younger than 9 months to be
diagnosed with RAD or DSED
n
Differences
n
n
RAD
n Dampened positive affect
n Internalizing Disorder
n Lack of or incompletely formed attachments to caregiving adults
n Sxs evident before 5yo
DSED
n “Opposite” of RAD
n Can occur in those who do not lack attachments and may even have
established and secure attachments
© Tyler Argüello, Ph.D.
+
Understanding the MH
problems of Children
& Adolescents (2015),
K. Painter & M.
Scannapieco
Thursday, February 16, 2017
RAD & DSED :: Diagnostic Features
RAD
n
Pattern of markedly disturbed & developmentally
inappropriate attachment bx
n
Rarely or minimally turns to attachment figure for
comfort, support, protection & nurturance
n
Absent or grossly underdeveloped attachment
between child & caregiving adult
n
Can form selective attachments but as a RESULT of
limited opportunities during early development
fail to express selective attachments
n
What does this look like?
n
No consistent effort to obtain comfort ,
support, protection and nurturance
n
Do not respond (minimally) to comforting
n
Minimal / absent expression of positive
emotions in routine interactions w caregivers
n
Emotional dysregulation: unexplainable
episodes of negative emotions of sadness,
fear, irritability
© Tyler Argüello, Ph.D.
DSED
n
Pattern of behavior that involves
culturally inappropriate, overly familiar
behavior with relative strangers
n
Violates social boundaries of the
culture
n
Absent reticence in interacting c
unfamiliar adults
n
Overly familiar
n
Diminished checking back c
caregivers
n
Willingness to go off c unfamiliar
adults
Thursday, February 16, 2017
50
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+
RAD & DSED
Differential Dx
n
n
RAD
n
Autism Spectrum Disorder
n
Intellectual Disability (Intellectual Developmental Disorder)
n
Depressive Disorders
DSED
n
Attention Deficit Hyperactivity Disorder
n
Not just impulsivity; focus on disinhibition
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
+
Acute Stress D/O
& PTSD
© Tyler Argüello, Ph.D.
Thursday,
February 16,
2017
51
2/16/17
+
Acute Stress Disorder and PTSD:
Criterion A
DSM-IV-TR
n
Trauma event
n
n
DSM-5
n
Trauma event
n More explicit in regard to
HOW it is experienced:
n Directly
n Witnessed
n Experienced Indirectly
n Learning of event
n Repeated, extreme
exposure
n Does not include
exposure via media
unless at work
n
Eliminate
n A2 Criterion: Subjective
Reaction
Experienced, witnessed or
confronted with event
involving actual or
threatened death, serious
injury, or threat to physical
integrity of self or others
A2 (subjective reaction)
n
Individual’s response
involves intense fear,
helplessness or horror
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
+ PTSD Tidbits
n
Almost 90% of population experiences trauma (Morrison, 2014; Corcoran & Walsh, 2014)
n
n
Risk Factors
n
n
n
n
n
n
n
n
n
But, estimated lifetime prevalence ~8 - 10% (U.S.)
n Not everyone goes through a dangerous event
n More common dx for women; possibly runs in families
n Less dx, tx c communities of Color; estimated higher prevalence
n Standardized measures less sensitive to culture (especially non-US context)
n More common in veterans (combat exposed), sexual violence, terrorism
H/o mental illness, especially Borderline (Cluster B) traits
Past h/o childhood trauma
Living through dangerous events and traumas
Getting hurt
Seeing people hurt or killed
Feeling horror, helplessness, or extreme fear
Having little or no social support after the event
Dealing with extra stress p event, eg, loss of a loved one, pain, injury, or lose job, home
Resilience Factors
n
n
n
(Prior h/o) Effective coping strategies in face of pain, fear, death, other trauma
Social supports
Being able to incorporate experience into rest of life
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
52
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+
Acute Stress Disorder
“Early form” of PTSD (??)
n
Criterion
n
A – Exposure to trauma (direct, witnessed, learned, repeated)
n
B – 9+ sxs from any of 5 categories
n
n
Intrusion, Negative Mood, Dissociative, Avoidance, Arousal
n
C – Duration 3 days and up to 1 month
n
D – Causes distress or impairment
n
Not due to drugs or medical condition
Can be diagnosed in children
n
Use noted developmentally sensitive criteria
n
Diagnostic thresholds lowered for children and adolescents
n
Separate criteria for children 6 years and younger
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Posttraumatic Stress Disorder
PTSD
DSM-IV-TR
n
3 major symptom clusters
DSM-5
n
4 major symptom clusters
n
Re-experiencing/Intrusion
n
Intrusion
n
Avoidance/numbing
n
Avoidance
n
Arousal and Reactivity
n
Persistent negative
alterations in cognitions &
mood
n
Arousal & Reactivity
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
53
2/16/17
+
PTSD Criterion
A. Traumatic Event
• Direct, Witnessed, Learned, Repeated
B. Intrusion – 1+ sx
• Recurrent, invol, intrusive memories, dreams, dissociation, psych/physiological
distress
C. Avoidance – Either/Or
• People, places, things
• Thoughts
≥ 1mo.
D. Negative Alterations – 2+ sxs
• Prob’s w memory; persistent, exaggerated negative beliefs; self-blame
• Negative emotional state; anhedonia; estrangement; inability to have + emotions
E. Arousal – 2+ sxs
• Irritability, anger, aggression, self-destructive bx’s
• Hypervigilance, exaggerated startle, prob’s w concentration, sleep disturbance
© Tyler Argüello, Ph.D.
+
PTSD
Subtypes – Note: Not mutually exclusive
n
Specify if With
Delayed
Expression (full
criterion at 6+
mo.)
Children 6yrs and Younger
n
n
n
Thursday, February 16, 2017
Using adult criterion: 1+ from B; 1 from C or D; 2 from E
n Sxs must last ≥ 1 month
May experience persistent distressing memories of event, keep re-enacting event in
play, recurrent nightmares of event, dissociation of event, avoidance of any reminders of
the event, exhibit hyper-vigilance, angry/aggressive bx,& show problems with
concentration
With Prominent Dissociative Sxs
n
n
n
n
Depersonalization: Persistent or recurrent experiences of feeling detached from, as
if one were an outside observer of one’s mental processes or body
n Often described as feeling an experience is happening to someone else, like
watching a film rather than being directly involved.
Derealization: Persistent or recurrent experiences of unreality of surroundings
n Often described as feeling that what is happening is not real or being in a dream
Sxs very difficult to describe; most cxs use metaphors and “as if” language to
describe: “It’s as if I’m outside my body”
Does not involve positive sxs of psychosis; also, not amnestic; affect range normal,
maybe some blunting
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
54
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+
PTSD and ASD
Differential Dx
n
Adjustment Disorders
n
Panic Disorder
n
Dissociative Disorders
n
PTSD for ASD
n
Vice versa
n
OCD
n
Psychotic Disorders
n
Traumatic Brain Injury
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
+
Adjustment,
Other, and the
Rest
Thursday,
February 16,
2017
© Tyler Argüello, Ph.D.
55
2/16/17
+
Adjustment Disorders
n
In DSM-IV-TR
n
n
Tended to be a catch-all for those who expressed clinically significant
distress and didn’t meet criteria for more discrete disorders
In DSM-5
n
n
n
Criterion remains unchanged
n Stressor; distressing sxs develop within 3 mo
Elimination of bereavement exclusion
Specifiers
n with depressed mood
n with anxiety
n with mixed anxiety and depressed mood
n with disturbance of conduct
n with mixed disturbance of emotions and conduct
n Unspecified
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Other Specified Trauma- and StressorRelated D/O’s
Do not meet full criterion
Think: Maladaptive response
n
Adjustment-like disorders with delayed onset of symptoms
that occur more than 3 months after the stressor
n
Adjustment-like disorders with prolonged duration of more
than 6 months without prolonged duration of stressor
n
Ataque de nervios
n
Other cultural syndromes
n
Persistent complex bereavement disorder
n
Severe and persistent grief and mourning reactions
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
56
2/16/17
+
BREAK
Thursday,
February 16,
2017
© Tyler Argüello, Ph.D.
+
Feeding, Eating, Somatic
Thursday, February
16, 2017
© Tyler Argüello, Ph.D.
57
2/16/17
+
Feeding &
Eating
Disorders
Thursday,
February 16,
2017
+
© Tyler Argüello, Ph.D.
Feeding & Eating Disorders
New Category in DSM-5
Code
Diagnosis
307.52
Pica – Children
Pica – Adults
307.53
Rumination D/O
307.59
Avoidant / Restrictive Food Intake D/O
307.1
Anorexia Nervosa
-Restrictive Type
-Binge-Eating / Purging Type
307.51
Bulimia Nervosa
307.51
Binge-Eating D/O
307.59
Other Specified
307.50
Unspecified
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
58
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+
Feeding & Eating Disorders
Pica, Rumination, A/RFID
n
Pica
n
n
Rumination
n
n
> 1 month of eating non-nutritive substances; can occur at any age; dx
can be given in combination with other eating d/o’s; does not include
use of diet products
> 1 month of regurgitating food, rechewing, reswallowing, and/or
spitting out; exclusive of anorexia, bulimia, or other GI problems; can
occur at any age;
n Typically: 1/3 don’t care; 1/3 have adverse experience; 1/3 have
sensory issues
Avoidant / Restrictive Food Intake Disorder
n
Includes those who do not eat enough, limit diet due to senses, and
those who refuse due to aversive experiences – as characterized by
weight loss, nutritional deficiencies, dependence on enteral feeding or
supplements, or fx’al impairment
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Anorexia Nervosa
“Refusal” is gone;
intention no longer a
factor.
Clarifying and reducing EDNOS
DSM-IV-TR
DSM-5
A.
Refusal to maintain body weight at or
above a minimally normal weight for
age and height (e.g., 85% of that
expected).
A.
Restriction of energy intake
relative to requirements leading to a
significantly low body weight in the
context of age, sex developmental
trajectory, and physical health.
B.
Intense fear of gaining weight or
becoming fat, even though
underweight.
B.
Intense fear of gaining weight or
becoming fat, or persistent behavior
to avoid weight gain, even though at
a significantly low weight.
C.
Disturbance in the way in which one's
body weight or shape is experienced,
undue influence of body shape or
weight on self-evaluation, or denial of
the seriousness of current low body
weight.
C.
Disturbance in the way in which one's
body weight or shape is experienced,
undue influence of body shape or
weight on self- evaluation, or
persistent lack of recognition of the
seriousness of current low body
weight.
D.
In postmenarchal females,
amenorrhea
Current subtype (> 3 mo duration):
n
Restricting (diet, fast, excessive
exercise)
n
Binge/Purge (vomit, laxatives,
diuretics, enemas)
Subtype: Restricting vs. Binge/Purge
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
59
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+
Bulimia Nervosa
Maintains
body weight
DSM-IV-TR
A.
Recurrent episodes of binge eating.
B.
Recurrent inappropriate
compensatory behavior to prevent
weight gain, such as self-induced
vomiting; misuse of laxatives,
diuretics, or other medications,
fasting; or excessive exercise.
C.
Criterion C:
n
The binge eating and inappropriate
behavior both occur, on average, at
least twice a week for three months.
D.
Self evaluation is unduly influenced
by body shape and weight.
E.
The disturbance does not occur
exclusively during episodes of
Anorexia Nervosa.
Subtype: Purging vs Non-Purging
© Tyler Argüello, Ph.D.
+
DSM-5
n
n
At least once a week for
three months
n
Mild = 1-3 x’s/wk
n
Moderate = 4-7
n
Severe = 8-13
n
Extreme = 14+
Eliminate subtypes
Do not
fear
getting
fat.
Thursday, February 16, 2017
Binge Eating Disorder
Codified in DSM-5
A.
B.
Recurrent episodes of binge eating.
The binge-eating episodes are associated with three (or more) of the following:
n
n
n
n
n
C.
D.
E.
eating much more rapidly than normal
eating until feeling uncomfortably full
eating large amounts of food when not feeling physically hungry
eating alone because of being embarrassed by how much one is eating
feeling disgusted with oneself, depressed, or very guilty after overeating
Marked distress regarding BE is present.
BE occurs, on average, at least once a week for 3 months.
BE is not associated with the recurrent use of inappropriate compensatory
behavior and does not occur exclusively during the course of bulimia nervosa or
anorexia nervosa
Tidbits
n Those with BED have higher rates of anxiety & depression, and do not respond well to
overweight/obesity treatments
n Prevalence = ~2% (2x’s more common in women as men; also in those w Diabetes II)
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Comparing 3 main d/o’s
AN
BN
Binge
Eat in binges
No
Yes
Yes
Self
Perception
Abnormal
(perceives self
as fat)
Influenced by
body weight,
shape
Not
remarkable
Compensates
c exercise,
purging
Yes
Yes
No
Body weight
is low
Yes
No
No
Feels lack of
control
No
Yes
Yes
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Other Specified F&ED
Most common = Atypical AN
n
Atypical Anorexia Nervosa
n
n
Subthreshold Bulimia Nervosa (Low Freq. or Limited Duration)
n
n
BED criteria met but occurs less than once a week and/or fewer than 3 months
Purging D/O
n
n
Meet all BN criteria but bx occur less than once a week and/or fewer than 3
months
Subthreshold BED (low freq or ltd duration)
n
n
All of the criteria for Anorexia Nervosa are met, except that, despite significant
weight loss, the individual’s weight is within or above the normal range.
Recurrent purging (eg, vomiting, laxatives, diuretics, Rx’s) to influence weight in
absence of bingeing
Night Eating Syndrome
n
Consume large amount of food p evening meal or p awakening; awareness &
recall; not due to substance ab/use
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F&ED
Differential Dx
n
AN – BN – BE
n
ASD – while there is rigidity in eating, does not result in
impairment (eg, weight loss)
n
MDD – food restriction and weight change limited to mood
episode
n
Substance Use – may have up/down weight, tho typically w/o
fear of weight gain or other self-persecution
n
OCD – anxiety and repetitive bx’s need to go beyond food,
eating, weight
n
BDD – distortions go beyond weight or size (being fat)
n
Personality D/O’s – (more to come)
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
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Somatic
Symptom
Related
Disorders
Thursday,
February 16,
2017
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Somatic Sx & Related D/O’s
From IV-TR to 5
DSM-IV-TR
n
n
n
n
n
n
In DSM-IV-TR, referred to as
“Somatoform D/Os”
Overlapping disorders
n Somatoform
n Psych factors affecting medical
n Factitious
Criteria are too sensitive and too
specific
Pejorative – labels suffering as
inauthentic
Reinforces mind-body dualism
Over-emphasis on medically
unexplained symptoms (poor
reliability)
n Disorders can occur with or
without medical diagnoses
n Confusing to primary care doctors
n Physicians don’t use
© Tyler Argüello, Ph.D.
+
DSM-5
n
n
n
n
n
New combined chapter
n Characterized by thoughts,
feelings, bx’s related to
somatic sx’s
Removal of unexplained sxs as a
key dx fx of somatic sx d/o
Conversion D/O renamed
Pain d/o is now a specifier of
Somatic Sx D/O
Hypochondriasis broken out
into
n Somatic Sx D/O (for the
majority)
n Illness Anxiety D/O (for the
rest, w/o somatic sx’s)
Thursday, February 16, 2017
DSM-IV-TR
Somatoform & the Like Dispersed thru-out the Text
n
n
Somatoform Disorders
n
Somatization Disorder
n
Undifferentiated Somatoform Disorder
n
Conversion Disorder
n
Pain Disorder (2 variants)
n
Hypochondriasis
n
Body Dysmorphic Disorder
Other conditions that may be a focus of clinical attention
n
Psychological factors affecting medical conditions
n
n
n
6 subtypes: mental disorder, psych. symptoms, personality traits/coping style, stress-related
physiological response, maladaptive health behaviors, other
Factitious Disorders
n
With predominantly psychological signs & symptoms
n
With predom. physical signs & symptoms
n
With combined psych & physical symptoms
n
Factitious Dis. NOS
Appendix B Criteria sets and axes for further study
n
Factitious D/O by proxy
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Somatic Sx & Related D/O
New Category in DSM-5
Code
Diagnosis
300.82
Somatic Sx D/O
300.7
Illness Anxiety D/O
300.11
Conversion D/O (Functional Neurological Sx D/O)
316
Psychological Factors Affecting Other Medical Conditions
300.19
Factitious D/O
300.89
Other Specified
300.82
Unspecified
© Tyler Argüello, Ph.D.
+
Other causes of somatic complaints:
•
Actual physical illness
•
Mood d/o
•
SUD
•
Adjustment d/o
•
Malingering
Thursday, February 16, 2017
SSRD
Somatic Sx and Illness Anxiety D/O’s
(formerly Somatoform and Hypochondriasis)
n
Somatic Sx D/O
n
n
Somatic sxs that are distressing and result in significant
disruption of daily life. Includes only one of the following:
excessive thoughts, feelings (anxiety), behaviors (time,
energy) related to the somatic symptoms or associated
health concerns. Lasts ~ 6+ months.
n Specify pain, persistence (6+ months), severity
n This d/o includes 75% of those who were previously dx’d
w hypochondriasis
•
•
•
•
•
•
Onset early 20’s
Can last years
Often overlooked
1% women
7-8% in MH pop
50%+ anx/mood
Illness Anxiety D/O
n
Mild to no somatic sxs; preoccupation of having or acquiring
serious illness; excessive health-related bx’s or exhibit
maladaptive avoidance; lasting 6+ months
n Specify if care-seeking or care-avoidant
n The other 25% of previous hypochondriasis dx’s
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SSRD
FNSD, FD, PFAMC
n
Conversion D/O (Functional Neurological Sx D/O)
n
n
n
n
n
Factitious D/O
n
n
n
n
Falsifying illness about self or imposing on another – in the absence of obvious external rewards (not malingering)
n
Focus is not on intent (ie, undelrying motive) – rather they falsification of signs and sxs
n
Involves deception, abuse, possible criminal bx
Once had its own category, is now grouped in SSRD
Often seen in medical settings (~1%)
Psychological Factors Affecting Medical Condition
n
n
Major change from DSM-IV-TR is the name itself
Most clients w FNSD are seen by neurologists
n
Typical complaints include weakness, paralysis, tremors, altered speech / hearing / vision
n
Note these in specifiers
Sxs must be incompatible w medical exams, or exams are internally inconsistent
Can’t prove feigning or factitious-ness
n
Note sxs over place and space
Minor wording changes; codified in DSM-5 SSRD category
Other Specified SSRD
n
Pseudocyesis (false pregnancy) moved into here
© Tyler Argüello, Ph.D.
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Thursday, February 16, 2017
SSRD
Differential Dx
n
SSD – IAD – Conversion
n
GAD – worry re: multiple events, situations, activities
n
Panic – somatic in context of panic attacks
n
OCD – More intrusive concerns/worry; repetitive bxs
n
MDD – somatic complaints limited to depressive episode
n
Psychotic D/O – somatic sx delusional
n
BDD – concerns limited to one’s appearance
n
Adjustment D/O – concern/worry is time-limited
n
Personality D/O’s – (more to come)
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Neurodevelopmental
Thursday, February
16, 2017
+
© Tyler Argüello, Ph.D.
From IV-TR to DSM-5
DSM-IV-TR : D/Os 1st Dx’d in
Infancy, Childhood, Adolescents
n
n
n
n
n
n
n
n
n
n
Mental Retardation
Learning Disorders
Motor Skills Disorders
Communication Disorders
Pervasive Developmental Disorders
Attention Deficit and Disruptive
Behavior Disorders
Feeding & Eating Dis. Of Infancy and
Early Childhood
Tic Disorders
Elimination Disorders
Other Disorders
n Separation Anxiety Disorders
n Selective Mutism
n Reactive Attachment Disorder
n Stereotypic Movement Disorder
n NOS
© Tyler Argüello, Ph.D.
DSM-5 : Neurodevelopmental
Disorders
n
Intellectual Disability
n
Communication Disorder
n
Autism Spectrum Disorder
n
Attention Deficit/Hyperactivity
Disorder
n
Specific Learning Disorder
n
Motor Disorders
n Tic Disorders-Tourette’s Disorder
n
Other Neurodevelopmental Disorders
n
n
n
n
Elimination D/Os Category
Anxiety
Trauma
Feeding
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DSM-IV-TR to DSM-5
n
n
n
n
DSM-IV-TR
Mental Retardation
Expressive and Mixed ReceptiveExpressive Language
Phenological Disorder
Stuttering
DSM-5
n
Intellectual Disability
n
Communication Disorders
n
n
n
Autistic Disorder, Aspberger’s,
Childhood Disintegrative, Pervasive
Developmental Disorder
n
ADHD
n
Autism Spectrum Disorder
n
Reading, Mathematics, Written
Expression and Learning Disorder
NOS
n
ADHD
n
Developmental Coordination,
Stereotypic Movement, Tourette’s,
Persistent motor or vocal tic,
Provisional Tic, Other Tic Specified,
Unspecified Tic
n
Specific Learning Disorder
n
Motor Disorders
n
© Tyler Argüello, Ph.D.
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New!!
Speech Sound Disorder
Childhood Onset Fluency
Disorder
Social Communication Disorder
Thursday, February 16, 2017
Differential Dx’ing
Determining if a Child has a Particular Disorder
n
n
Critical to consider developmental stages of the child
n
Differentiate between what is “normal” childhood development
n
And what might be a specific clinical diagnoses
Some potential indicator / warning signs
n
Withdrawal or Social Struggles
n
Attention or Thought Problems
n
Anxiety or Depression
n
Delinquency or Aggression
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Signs / Sxs of Potential Child D/O
Withdrawn or
Social Problems
• Prefers to be alone
• Isolated
• Secretive
• Sulks a lot
• Lack of Energy
• Unhappy
• Overly dependent
on others
• Prefers to Play with
Younger children
Attention or
Thought
Problems
• Unable to
concentrate
• Cannot sit still
• Acts without
thinking
• Performs poorly in
School
• Obsessive or
ruminating
thoughts
Anxiety or
Depression
Delinquency or
Aggression
• Lonely
• Numerous fears
and worries
• Needs to be
perfect
• Feels unloved,
nervous, sad and
depressed
• Conduct problems
• Academic
problems (eg,
tardy, conduct,
socializing)
• Hitting, hurting,
harming
© Tyler Argüello, Ph.D.
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Thursday, February 16, 2017
Autism Spectrum D/O
IV-TR to 5
n
Reduction in number of ASDs
n
DSM-IV (Pervasive Dev. D/O’s)
n
Autistic Disorder
n
Asperger Disorder
n
n
“Milder” form of ASD w/o language
impairment
n
Pervasive Devo. Disorder NOS
n
Childhood Disintegrative Disorder
n
Rett Disorder
DSM-5 (Autism Spectrum Disorder)
n
ASD = Comm + Socialization + Motor Bx
Specifiers doing heavy lifting
© Tyler Argüello, Ph.D.
Use SPECIFIERS to indicate STRENGTHS,
WEAKNESSES & CO-OCCURRING
CONDITIONS!!!
• Age of first concern and type of onset
• With/without accompanying intellectual
impairment
• With/without accompanying structural
language impairment
• Associated w known medical or genetic
condition or environmental factor
• Associated w another neurodevelopmental,
mental, or bx disorder (incl catatonia)
• Severity of sxs
– Social communication
– Restricted interests and repetitive bxs
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Autism Spectrum D/O (ASD)
DSM-5
A. Persistent deficits in social communication and social interaction across multiple contexts, as
manifested by the following, currently or by history:
•1. Deficits in social-emotional reciprocity
•2. Deficits in nonverbal communicative behaviors used for social interaction
•3. Deficits in developing, maintaining, and understanding relationships
B. Restricted, repetitive patterns of bx, interests, or activities, as manifested by 2+ of the following,
currently or by hx:
•1. Stereotyped or repetitive motor movements, use of objects, or speech
•2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior
•3. Highly restricted, fixated interests that are abnormal in intensity or focus
•4. Hyper-or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment.
C. Sxs must be present in early developmental period (but may not become fully manifest until social
demands exceed limited capacities, or may be masked by learned strategies later in life).
D. Sxs cause clinically significant impairment in social, occupational, or other important areas of current
functioning.
E. These disturbances are not better explained by intellectual disability or global developmental delay.
Intellectual disability and ASD frequently co-occur; to make comorbid dx’s of ASD and intellectual
disability,
social
communication should be below that expected for general developmental
level. 16, 2017
© Tyler Argüello,
Ph.D.
Thursday, February
Comparison of DSM IV and DSM 5 Criteria
+ DSM IV
DSM 5 Proposed
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Autism Spectrum Disorder
Differential Dx and Rule Out Conditions
n
n
Neurological illnesses with onset in infancy or early childhood
Intellectual Disability Disorder
n
n
n
Social awkwardness but not other social, speech, bx idiosyncracies
Schizophrenia
Schizotypal Personality Disorder
n
n
May have strange rituals – but OCD typically has later onset, normal
attachment, and intact language
Social Anxiety Disorder (Social Phobia)
n
n
Specific academic deficits w/o characteristic autistic bxs
Obsessive Compulsive Disorder
n
n
Low IQ w/o characteristic social disconnectedness and ritualistic bxs
Learning Disorder
n
n
Later onset, but considerable overlap
Psychotic D/O’s in
children EXTREMELY rare
before 10yo
Normal Eccentricity
© Tyler Argüello, Ph.D.
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1% gen. pop.; 20fold inc.; boys 2-4
x’s more likely;
high comorbidity
w other SPMIs
Thursday, February 16, 2017
Attention–Deficit/Hyperactivity D/O
DSM IV-TR to DSM 5
n
n
n
n
n
n
Differential Dx
Placed in the Neurodevo D/Os to reflect brain development correlates
• Normal immaturity
n Onset 7 to 12
• Individual Difference
• ODD
Examples added to criterion items
• Conduct
n New criterion descriptions for adults
• Intellectual Disability
n Sx criterion reduction to 5, at age of onset 17yo
• Other Mental Disorder
• Malingering
n Difficulty focusing during lectures, conversations, or lengthy reading
n Often forgetful in daily activities (e.g., doing chores, running errands; for older
adolescents and adults, returning calls, paying bills, keeping appointments)
n Often interrupts (e.g., butt into conversations, games, activities; uses other people’s
things w/o asking; intrude into / take over what others are doing)
Subtypes replaced c presentation specifiers
n e.g., with inattention, with impulsivity
Cross-situational strengthened to several sxs in each
Comorbid dx c ASD is allowed
Problems??
n Onset changed from “sxs” that caused impairment present before 7 to several
inattentive or hyperactive-impulsive present prior to 12
n Sx threshold made for adults reduced to 5 (6 required for younger persons)
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Intellectual Disability Disorder
Differential Diagnosis: Rule Out Conditions
§
External Factors
§
§
§
IQ Testing
§
Several Levels: Conceptual, Social & Practical Domains
§
Misleading IQ scores below 70
§
Other reasons for low scores (e.g., bias, measurement, ext
factors)
Age of Onset before 18yo
§
§
§
After 18, classified as a major neurocognitive disorder
ADHD, Autism
§
Differentials
§
Can co-occur
Learning Disorder: can also be dx’d if disproportionate to IQ
© Tyler Argüello, Ph.D.
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Essentially:
1. Fundamental deficit in thinking
2. Impairment to adaption to
demands of normal life
e.g., lack of access, poor instruction, ESL
Thursday, February 16, 2017
Communication & Specific Learning
Differential Dx’s
Communication D/O
n
Normal variations in language
n
Hearing or sensory impairment
n
Intellectual Disability
n
Neurological Disorders-ex epilepsy
n
Language regression-seizures
n
Dysarthria-motor disorder such as
Cerebral Palsy
n
Selective Mutism, anxiety disorder
n
Medication side effects
n
Normal speech dysfluencies
n
Tourette’s disorder
n
ADHD
n
Social Anxiety
© Tyler Argüello, Ph.D.
Specific Learning D/O
n
Intellectual Disability Disorder
n Prob no greater than expected from
persona’s overall IQ
n
Autism Spectrum Disorder
n This is the cause of poor fx, but both
dx’s can be given together if specific
academic area is disproportionately
impaired
n
Sensory Deficit
n This accounts for learning prob
n
ADHD
n Causes poor test taking, but both
dx’s can be given together when
appropriate
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Motor Tics & Tic D/O
Differentials
Motor Tics
n
Motor impairments due to
another medical condition
n
Tic D/O
n
Intellectual Disabilities
Disorder
Medical conditions
accompanied by abnormal
movements
n
Substance induced
n
ADHD
n
n
Autism Spectrum
Myoclonus-sudden
unidirectional movements
most often nonrhythmic
n
Joint Hypermobility
n
OCD
n
Tic Disorders
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
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Disruptive,
ImpulseControl,
Conduct D/O’s
Thursday,
February 16,
2017
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Disruptive, Impulse-Control,
& Conduct Disorders
From IV-TR to the 5
n
n
n
Dx’s
New chapter in DSM 5,
combining
n Some from D/Os 1st Dx’d in
Infancy, Childhood or
Adolescence
n Conduct, Oppositional
Defiance D/Os
n Impulse Control NOS
n
313.81 (F91.3) Oppositional Defiant
Disorder
n
312.32 (F63.81) Intermittent Explosive
Disorder
n
312.82 (F91.2) Conduct Disorder
n
301.7 (F60.2) Antisocial PD
Brings together D/O’s
characterized by problems in
emotional and bx self-control
n
312.33 (F63.1) Pyromania
n
312.32 (F63.3) Kleptomania
ADHD is frequently comorbid
with disorders in this chapter
n
312.89 (F91.8) Other Specified
Disruptive, Impulse-Control, and
Conduct Disorder
n
312.9 (F91.9) Unspecified Disruptive,
Impulse-Control, and Conduct Disorder
© Tyler Argüello, Ph.D.
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Thursday, February 16, 2017
Oppositional Defiant Disorder
DSM-IV-TR into DSM-5
n
Symptoms are grouped into 3 types
n Angry/ Irritable Mood
n Argumentative/Defiant Behavior
n Vindictiveness
n
Exclusion removed for Conduct Disorder
n One could now have both ODD and CD
n
Guidance on frequency of sxs to prevent
common developmental expressions of
oppositional or defiant behaviors from
being used in error
n
e.g., Pain to parent; angry, argumentative,
quick to say “NO!” to everything; unwilling
to obey rules, follow instructions; easily
annoyed, and seeming delight in being
annoying; every limit tested; everything
everyone else’s fault; feel forever
misunderstood and put upon
© Tyler Argüello, Ph.D.
“Do you have a
lot of power
struggles w
your child?”
Specifiers
n
Severity
n Not uncommon to show sxs only at
home or with family
n PERVASIVENESS is key
n Mild
n Sxs confined to one setting
n Moderate
n Some sxs present in 2+ settings
n Severe
n Some sxs present in 3+ settings
ODD + Conduct =
Continuum of ‘bad bx’
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• Balance contribution from child
&/w/vs (impossible) enviro.
• When in doubt: Adjustment D/O
• Substance?
• Earlier bad bx, greater
aggressiveness and severity -- &
persistence into adulthood
Conduct Disorder
“Does your
child get
into a lot of
trouble?”
From the DSM IV to DSM 5
n
In DSM 5, descriptive fx specifier
added to capture expressions of limited
pro-social emotions when individual
meets full criteria for conduct d/o
n
Applies to those who evidence a
callous & unemotional interpersonal
style across multiple settings and
relationships
n Research evidences that those who
meet this specifier tend to have a
more severe form of CD and
different tx response
n e.g., phy / verbal aggression, theft /
destruction of property, deception /
cheating / manipulation, violation of
rules / laws; disrupts family, gets into
trouble at school, maybe periodic
run-in’s w juvenile justice
n Problems always “someone else’s
fault”
© Tyler Argüello, Ph.D.
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Specifiers
n
n
n
Onset specifier
n 312.81 (F91.1) Childhood Onset type
n 1+ sx prior to 10
n 312.82 (F91.2) Adolescent Onset
type
n No sxs prior to 10
n 312.89 (F91.9) Unspecified Onset
type
n Criteria met but insufficient info
re age of first symptom
Limited prosocial emotions
n Lack of remorse or guilt
n Callous-lack of empathy
n Unconcerned about performance
n Shallow or deficient affect
Severity
n Mild, Moderate, Severe
Thursday, February 16, 2017
Intermittent Explosive Disorder
From the DSM IV to DSM 5
n
Minimum age of 6 years or developmental equivalency is now required
n
In the DSM 5 expanded types of aggressive outbursts
n
n
n
DSM IV:
n
Physical Aggression only
DMS 5:
n Physical Aggression
n Verbal Aggression
n Destructive/Noninjurious Physical Aggression
n Outbursts must be impulsive and/or anger based AND
n MUST cause marked distress, impairment in occupational or interpersonal
functioning OR associated with negative financial or legal consequences
DSM 5 provides more specific criteria for defining frequency
n
Occur 2 x weekly, on average for ate least 3 months & within a 12 month period
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Neurocognitive Disorders
Thursday, February
16, 2017
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© Tyler Argüello, Ph.D.
Neurocognitive Disorders
3 Classes of Disorders
n Delirium
Cx either:
1. Gets better
2. Suffers permanent brain damage
3. Dies
n Characterized
by temporary but prominent
disturbances in alertness, confusion and
disorientation
n NCD
(“Dementia”)
n Progressive, degenerative
conditions in which a
broad range of cognitive abilities slowly
deteriorate
n Mild
Unique among DSM disorders
n Major
because underlying pathology
and sometimes the etiology can
be determined
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Neurocognitive Disorders
From the DSM IV TR to the DSM 5
DSM IV-TR
n
Delirium
n
Dementia
n
Amnestic and Other Cognitive
Disorders
DSM 5
n
Neurocognitive Disorders
(NCD)
n
Delirium
n
Major or Mild NCD
n
Dementia still retained in DSM-5 for continuity, and
MDs and pxs both accustomed to term. Still
appropriate for old age-related conditions; newer
categorization of NCD now used for younger pxs
(e.g., from HIV or TBI). Also NCD is broader term
and can be used for conditions that are due to
another medical condition.
Now recognizes less
severe level with mild
NCD to enable provision
of earlier tx and slower
progression
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Neurocogntive Disorders (NCD)
DSM-5
n
Deficit in cognitive functioning that is ACQUIRED rather than
developmental in primary clinical manifestation
n
n
Not present at birth & represent a decline from previous levels of functioning
Significant decline in 1+ cognitive domains
n
n
n
n
n
Executive Functioning
Learning and Memory
Complex Attention
Language
Perceptual and Motor Skills
While cognitive defects
noticeable in many d/o’s
(e.g., Schizophrenia or
Bipolar), NCD dx used
only when cognition is
the main factor in dx
n
ONLY disorders whose MAIN features are cognitive are considered here
n
View Mild and Major NCD as occurring on a spectrum of cognitive and
functional impairment
n
n
Dementia now referred to as Neurocognitive Disorder
Mild NCD new disorder
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From the DSM IV TR to the DSM 5
DSM IV-TR
n
n
n
n
n
Delirium
Dementia of Alzheimer’s Type
Vascular Dementia
Amnestic
Dementia due to another
Medical Condition
n HIV
n Head Trauma
n Parkinson’s
n Huntington’s
n Pick’s
n Creutzfeldt-Jacob
n Other medical condition
n
n
DSM 5
Delirium
Major or Mild NCD
n Alzheimers
n Frontotemporal lobar
degeneration (Pick’s)
n Lewy Body Disease
n Vascular Disease
n Traumatic Brain Injury
n Substance/medication use
n HIV
n Prion (Creutzfeldt-Jacob)
n Parkinson’s
n Huntington’s
n Another medical condition
n Multiple etiologies
n Unspecified
© Tyler Argüello, Ph.D.
+
Delirium
Essential features
Thursday, February 16, 2017
“Consciousness” was too nebulous
to describe sxs of delirium.
“Awareness” a better term.
Visuospatial & executive fx
impairment key sxs.
Criterion A: : Disturbance in attention or awareness
• Trouble shifting or focusing attention, easily distracted
• Accompanied by change in baseline cognitive functioning
• Not better explained by pre-existing NCD
Criterion B: Onset is typically sudden and duration can be short
• Can develop over a few hours or a few days
• Fluctuates and can worsen in the evening (Sundowning)
Criterion C: Additional disturbance in cognition
• Memory deficit, disorientation, language, visuospatial, perception
Criterion D: Not better explained by pre-existing, established or evolving NCD; or not
occurring within reduced level of arousal –coma
Criterion E: Evidence that it is direct physiological consequence
© Tyler Argüello, Ph.D.
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Delirium
Specifiers
n
Specify if:
n
n
n
n
n
n
n
n
Hyperactive: Psychomotor activity, labile mood, agitation, refusal to cooperate
Hypoactive: Decreased psychomotor activity, sluggishness, lethargy,
approaching stupor
Mixed level of Activity: Normal level of psychomotor activity despite disturbed
attention and awareness; rapid fluctuation between hyper and hypo
Specify if: (see pages 596-598)
n
n
Acute: Lasting a few hours
Persistent: Lasting weeks or months
Specify if:
n
n
Substance-Induced delirium dx should be made
instead of Substance Intoxication or Substance
Withdrawal only when the sxs fulfill full criteria for
a DSM-5 delirium and when the sxs are sufficiently
severe to warrant clinical attention
Substance intoxication delirium
Substance withdrawal delirium
Medication induced delirium
780.09 (R41.0) Other Specified Delirium
780.09 (R41.0) Unspecified Delirium
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Delirium: Dx Tips
n
Delirium is a medical emergency
n
Consult – don’t act alone
n
High index of suspicion – mental and medical
n
Rx overdosing
n
Delirium vs primary psychotic, bipolar, depressive D/O’s – VH , think delirium, and
act fast; these are less common in psy. / bip. / dep.; delirium also MUCH later onset
n
Delirium vs. Acute Stress D/O – mislabel terror/confusion / agitation/startle as PTSD
sx, and VH as flashbacks
n
Sundowning
n
Stress, enviro changes, minor illness pain, over-Rx – can trigger delirium in cxs w
dementia
n
Structuring enviro – Familiar objects, people help orient; night lights too
n
EEG findings – generalized slowing EEG can help confirm
n
Quiet cx – Squeaky wheel isn’t only one who needs attention
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NCD
Used to be called
“Dementia”
Different than delirium bc:
- Time course is slow
- Impaired focus / attn not prominent
- Cause usually CNS
- Not typical to recover
Core Concepts
n
Antegrade Memory Loss
n
n
n
n
n
n
n
Disturbance in language that differs depending on area of brain that is damaged
Broca’s Apasia (Expressive): loss of ability to produce spoken , and often written, language
without impairment in comprehension
Wernicke’s Aphasia (Receptive): loss of ability to comprehend language and inability to
produce coherent language
Apraxia
n
n
n
Inability to recognize objects despite intact sensory function; can’t interpret
e.g., can see an object, but can’t name it only w sight
Aphasia
n
n
Difficulty with past memory recall from present point in life
Agnosia
n
n
Can’t make new memories from present point in life
Retrograde Memory Loss
Inability to carry out motor activities and occurs in presence of intact motor function
e.g., forget how to button shirt
Executive Functioning
n
Higher cognitive functioning such as planning, organizing, abstracting, inductive reasoning
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Neurocognitive Domains
DSM-5, p. 593
Cognitive Domain
Examples of Sxs
Examples of Assessments
Complex Attention
Distractability w competing
events (talking, TV, phone)
Divided attention
Executive Functioning
Planning ADLs
Arranging objects by color
then size
Learning & Memory
Difficulty w recall
Recall characters from a
story
Language
Word-finding difficulty
Naming, fluency
Perceptual-Motor
Driving car
Assembly using hand-eye
coordination
Social Cognition
Making decision w/o regard
for safety
Consider others’ points of
views / feelings / actions
© Tyler Argüello, Ph.D.
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Major NCD
Criterion A: Evidence of Significant Cognitive Decline in 1+
cognitive domains (typically two; see domains on previous
page) based on:
•Concern of individual, informant, clinical
•Substantial impairment on documented testing
Criterion B: Cognitive Deficits interfere with independence in
everyday activities requiring assistance with complex
instrumental activities of daily living (paying bills, managing
meds)
Criterion C: Cognitive deficits do not exclusively occur in
context of delirium
Criterion D: Cognitive deficits not better explained by another
mental disorder such as major depressive disorder,
schizophrenia
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Dementia: Differential Dx
n
Age-related cog decline – Sxs are gradual, age-appropriate, do not cause
loss of independence or clinically significant distress
n
Delirium – cog deficits are acute, and clouding consciousness prominent
n
Dementia w superimposed delirium – Two frequently occur together
n
Intellectual Devo. D/O – onset of cog deficits is before age 18
n
Substance intoxication, withdrawal – either may make person seem much
more cognitively disabled than he really is
n
Primary Depressive or Bipolar D/O – cog deficits are restricted Maj. Dep.
Episode
n
Schizophrenia – cog deficits, but with early onset and different pattern
n
Malingering
© Tyler Argüello, Ph.D.
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Major NCD
Subtypes and Specifiers
n Subtypes
n
n
n
n
n
n
n
n
n
n
n
n
n
(“due to”)
Alzheimers
Frontotemporal lobar
degeneration (Pick’s)
Lewy Body Disease
Vascular Disease
Traumatic Brain Injury
Substance/medication use
HIV
Prion(Creutzfeldt-Jacob)
Parkinson’s
Huntington’s
Another medical condition
Multiple etiologies
Unspecified
n
Specify
n
n
Without Behavioral
disturbance
With Behavioral disturbance
n
n
Eg: psychotic syndrome, mood
disturbance, agitation, apathy,
or other behavioral symptoms
Specify
n
n
n
Mild: difficulties with
instrumental activities of daily
living (housekeeping,
managing money
Moderate: Difficulties with
basic activities of daily living
(feeding, dressing)
Severe: Fully dependent
© Tyler Argüello, Ph.D.
+
Mild NCD
n
Mild!!
Criterion A: Evidence of modest cognitive decline in
1+ cognitive domains (see above) based on:
n
n
n
Thursday, February 16, 2017
Concern of individual, informant, clinical
Substantial impairment documented testing
Criterion B: Cognitive deficits DO NOT interfere
with independence in everyday activities requiring
assistance with complex instrumental activities of daily
living (paying bills, managing meds)
n
Problems:
- New
High falsepositive
- Testing…almost
there
- Needless worry,
stigma
- Ready for
‘prime time’?
BUT Greater effort, strategies, or accommodation may be
needed
n
Criterion C: Cognitive deficits do not exclusively
occur in context of delirium
n
Criterion D: Cognitive deficits not better explained
by another mental disorder such as major depressive
disorder, schizophrenia
© Tyler Argüello, Ph.D.
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Mild NCD
Specifiers
n Specify
n
n
n
n
n
n
n
n
n
n
n
n
n
due to
Alzheimers
Frontotemporal lobar
degeneration (Pick’s)
Lewy Body Disease
Vascular Disease
Traumatic Brain Injury
Substance/medication use
HIV
Prion(Creutzfeldt-Jacob)
Parkinson’s
Huntington’s
Another medical condition
Multiple etiologies
Unspecified
Mild!!
n Specify
n Without
Behavioral
disturbance
n With Behavioral
disturbance
n
Eg: psychotic
syndrome, mood
disturbance,
agitation, apathy, or
other behavioral
symptoms
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
NCD due to Alzheimer’s
n
Criteria met for Minor or Major NCD
n
INSIDEOUS onset and gradual progression of impairment in one or
more cognitive domains
n
n
At least 2 for Major
For MAJOR
n
Probable Alzheimer’s Disease
n Evidence of causative Alzheimer’s genetic mutation from family history or
genetic testing
n All THREE
n Clear evidence of decline in memory & learning and at least 1 other
cognitive domain
n Steadily progressive, gradual decline in cognition without extended
plateaus
n No evidence of mixed etiology
n OTHERWISE diagnose with Possible Alzheimer’s Disease
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Mild NCD due to Alzheimer’s Dx
n
Probable:
n
n
If there is evidence of a causative Alzheimer’s
disease genetic mutation
Possible
n
No evidence of causative Alzheimer’s disease
genetic mutation
n
And ALL THREE of the following are present
n
Clear evidence of decline in memory and
learning
n
Steadily progressive, gradual decline in
cognition, without extended plateaus
n
No evidence of mixed etiology
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
+
Sex & Drugs
Thursday, February
16, 2017
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Gender &
Sex
WARNING: Tread lightly
Thursday,
February 16,
2017
+
© Tyler Argüello, Ph.D.
Let’s talk about sex…
“Sexuality is an inherently difficult arena for psychiatric diagnosis b/c:
1. the field has generated remarkably little research and few researchers;
2. there are no consensus norms in sexual behavior to provide a useful
boundary in deciding what constitutes a sexual mental disorder;
3. individual and cultural biases play a large and difficult to sort out role,
and;
4. decisions regarding the diagnosis of sexual disorders can have profound
and unanticipated forensic and societal implications.”
- Allen Frances, MD, Former Director of NIMH
© Tyler Argüello, Ph.D.
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© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Sexual (Dys)function (?)
Dysfx’s
Often
ignored.
Should also consider
n
Male Hypoactive Sexual Desire: Not much
interest; performance adequate
n
Partner factors
n
Erectile Dysfunction: Insufficient to begin
or complete sex
n
Relationship factors
n
Early Ejaculation: Climax
before/during/just after penetration
n
Delayed Ejaculation: Climax either
delayed or does not occur
n
Female Orgasmic Dysfunction: Climax
delayed or does not occur
n
Female Sexual Interest/Arousal Disorder:
Little or lacking interest in sex
n
Genito-Pelvic Pain/Penetration Disorder:
Pain during intercourse (often insertion)
n
Cultural or religious factors
n
Substance/Medication Induced Sexual
Dysfunction: Problem due to intoxication
or withdrawal
n
n
Other / Unspecified: All else.
Medical factors
n Chronic illness
© Tyler Argüello, Ph.D.
n
n
Poor comm., relation discord,
discrepancies in sex/uality
Individual vulnerability
n
Abuse, poor body image
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Sexual Dysfunction
Key Fxs and Changes
n
Dysfunctions can be lifelong or acquired, or generalized or
situational
n
The sexual disorders have all been changed in terms of length
of time. It is now 6 months duration or longer for all cases. This is
supposed to avoid over-diagnosis of these conditions.
n
In the Introduction, the Masters and Johnson conceptual model
of the sexual response cycle has been abandoned
n
Premature (Early) Ejaculation has introduced a duration
criterion of approximately 60 seconds
n
Both culture and the effects of aging are considered in this
section and there is more sensitivity to religious upbringing as a
factor in sexual difficulties in this newer edition.
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Paraphilias and
Paraphilic Disorders
Context
n
n
n
n
APA still debating whether these are
mental disorders, which cluster around:
n Inanimate objects / non-humans
n Humiliation, suffering
n Non-consenting persons
Almost exclusively men dx’d
Distinction bw normative and nonnormative sexual bx
n Stops at labeling of non-normative
sexual bx as being psychopathological
n This is a huge shift.
n e.g., Transvestism no longer requires
that the patient be either distressed or
impaired by his behaviour—i.e., the
patient is neither harming, or being
harmed by, his behavior.
Also, must take note if cx is in a controlled
environment or that the condition is in
remission.
© Tyler Argüello, Ph.D.
If no victim, is it a d/o?
Paraphillias
n
Exhibitionistic Disorder
n
Fetishistic Disorder
n
Frotteuristic Disorder
n
Pedophilic Disorder
n
Sexual Masochism Disorder
n
Sexual Sadism Disorder
n
Transvestic Disorder
n
Voyeuristic Disorder
n
Unspecified Paraphilic
Disorders
What about a continuum / spectrum of bx?
Distress often lynchpin.
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Gender Dysphoria
May be “Gender
Incongruence” in
future DSMs
Key Changes
n
Name change and definitional reconceptualization
n
For children, Criterion A1 is necessary for the diagnosis
n
For adolescents and adults, introduction of more specific
polythetic criteria
n
The DSM-IV-TR A and B criteria are merged into one criterion set
n
Specifier: with or without a co-occurring Disorder of Sex
Development
© Tyler Argüello, Ph.D.
+
Gender Dysphoria
n
Thursday, February 16, 2017
Many Trans people disagree
with the idea of distress being
part of the diagnosis.
Gender Dysphoria involves a marked incongruence between
one’s experienced/expressed gender and assigned gender,
of at least 6 months duration.
n
Many individuals with Gender Incongruence ceased having
distress once they were on cross-gender hormones or had had
sexual reassignment. Ceasing the treatment would cause the
individual to again experience distress.
n
Overall, there is an increased sensitivity to not stigmatizing
the patient.
n
There are many who feel that this is not a psychiatric
condition at all and that it should not be listed as such.
© Tyler Argüello, Ph.D.
No genetic
component
found in clinical
research.
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Gender Dysphoria in Children
6+ sxs for ≥ 6 months
Cross-gender
playmates
Cross-gender
play
Cross-gender
fantasy
Crossdressing
Rejection of
toys/etc of
given gender
Desire or
other gender
Desire for
other sex
characteristics
Dislike of
anatomy
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Gender Dysphoria in Adol. / Adult
2+ sxs for ≥ 6 months
Incongruence
Desire to
be other
gender
Desire to
be tx’d as
other
gender
Desire to
change
Desire
for other
sex
charac
Conviction
© Tyler Argüello, Ph.D.
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Substances
Thursday,
February 16,
2017
+
© Tyler Argüello, Ph.D.
SUD, SPMI:
Dual Dx or Co-Occuring D/O
n
Chronic, lifelong recovery
n
Absence of sxs does not equal cure
n
Comorbid, confounding, conflating
n
Ubiquitous
n
Sussing out:
n
n
n
n
n
Do episodes of substance use occur after an upsurge of psych sxs?
Do psych sxs tend to occur only after episodes of substance use?
Does substance use continue in the absence of psych sxs?
Do the sxs of mental illness return when psychopharm tx for these sxs is
d/c’d?
Does the cx’s hx suggest the development of a particular psych d/o that
was delayed or obscured by substance use?
© Tyler Argüello, Ph.D.
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Continuum
Abstinence
(no use)
Social / use
(no
problems)
Mis-/ab-use
(with
problems)
© Tyler Argüello, Ph.D.
Dependence
/ addiction
(many
problems)
Thursday, February 16, 2017
Uppers
Downers
• Cocaine, coke
• Amphetamines, meth, Tina
• Bath salts
• ADHD meds (Ritalin)
• Plant-based, Caffeine, nicotine, Go Girl!, 5-Hr Energy, chew, dip
• Release energy; quick metabolism (up/down)
• Opiates/opioids, OxyContin, Tylenol c Codeine, Pain killers, Percocet
• Sedative-hypnotics, Benzo’s, barbituates, quaaludes, valium, klonopin,
ativan
• EtOH
• Antihistamines
• Muscle relaxants
• Depress systems, control pain, reduce anxiety, promote sleep, lower
inhibitions, induce euphoria
All Arounders
Inhalants
• Psychedelics, pot, hash LSD, MDMA, K2
• Alter sensory input, synesthesia, illusions, delusions, hallucinations
• Can cause stimulation, some depression, dissociation
• Organic solvents
• Volatile nitrites
• Nitrous oxide, whippits
• Poppers
• Upper, downer, psychedelic effects
Steroids
PsychRx’s
• Anabolic steroids
• Human growth hormone
• Performance-enhancing drugs
• Increased endurances, muscle size, aggression
• Antideressants
• Antipsychotics
• Anxiolytics
Compulsive Bx’s
• Food, Anorexia, Bulimia, Binge
• Gambling
• Sex
• Internet, gaming
• TV, smartphone, tablets
• Shopping
• Hoarding
© Tyler Argüello, Ph.D.
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Warning Signs
of Commonly Abused Drugs
n
Marijuana
n
n
Depressants (including Xanax, Valium, GHB)
n
n
Watery eyes; impaired vision, memory and thought; secretions from the nose or rashes around the nose and mouth;
headaches and nausea; appearance of intoxication; drowsiness; poor muscle control; changes in appetite; anxiety;
irritability; lots of cans/aerosols in the trash.
Hallucinogens (LSD, PCP)
n
n
Dilated pupils; hyperactivity; euphoria; irritability; anxiety; excessive talking followed by depression or excessive
sleeping at odd times; may go long periods of time without eating or sleeping; weight loss; dry mouth and nose.
Inhalants (glues, aerosols, vapors)
n
n
Contracted pupils; drunk-like; difficulty concentrating; clumsiness; poor judgment; slurred speech; sleepiness.
Stimulants (including amphetamines, cocaine, crystal meth)
n
n
Glassy, red eyes; loud talking, inappropriate laughter followed by sleepiness; loss of interest, motivation; weight gain or
loss.
Dilated pupils; bizarre and irrational behavior including paranoia, aggression, hallucinations; mood swings; detachment
from people; absorption with self or other objects, slurred speech; confusion.
Heroin
n
Contracted pupils; no response of pupils to light; needle marks; sleeping at unusual times; sweating; vomiting; coughing,
sniffling; twitching; loss of appetite.
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
+
© Tyler Argüello, Ph.D.
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From IV-TR to 5
At-a-glance
n
No intermediate state: abuse, dependence
n
n
Only a single dimension / spectrum, with mild, moderate, severe
No “addiction”
n “Dependence” only used for pharmacological dependence which
is not a disorder
n
2 sxs is diagnostic threshold for the combined disorder
n
Delete legal symptom
n
Add craving
n
Group gambling disorder included with SUD
n
Add cannabis withdrawal
© Tyler Argüello, Ph.D.
+
Criticism
§ Miss problematic drinking
§ Inconsistent w ICD-10
Pluses
§ 1 d/o to tx
§ More understandable to pt
§ Severity maps to sxs
Thursday, February 16, 2017
Prior to DSM-5
Evolution of Diagnosing Drug Use
DSM-IV: Substance Abuse
DSM-III, -IV: “Dependence” (Addiction)
n
Tolerance
n
Withdrawal
n
More use than intended
n
Unsuccessful efforts to cut
down
n
Spends excessive time in
acquisition
n
Activities given up because of
use
n
Uses despite negative effects
© Tyler Argüello, Ph.D.
n
Maladaptive use within 12
month period (one or more)
n Failure to fulfill major role
obligations
n Recurrent use in hazardous
situations
n Recurrent substance related
legal problems
n Continued use despite
consistent social or
interpersonal problems
n
Never met dependence
criteria
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Issues that affect treatment:
1. No more abuse and dependence
2. Severity measured by number of sxs:
2- 3 mild, 4-6 moderate, 7-11 severe
3. Agonist maintenance for “moderateto
Substance Use Disorder
DSM-5
DSM-5
n
Use is problematic
n
Pattern exists for use
n
Effects are clinically important
n
Causes distress or impairment
n
Interference in life as
evidenced by 2+ sxs
severe opioid use disorder”
2+ Sxs
n
Tolerance*
n
Withdrawal*
n
More use than intended
n
Craving for the substance
n
Unsuccessful efforts to cut down
n
Spends excessive time in acquisition
n
Activities given up because of use
n
Uses despite negative effects
n
Failure to fulfill major role
obligations
n
Recurrent use in hazardous situations
n
Continued use despite consistent
social or interpersonal problems
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Further study:
§ Neurobiologic D/O assoc’d w
Prenatal EtOH Exposure
§ Caffeine Use D/O
§ Internet Gaming D/O
In the DSM-5…
No Changes
n
Substance-Induced Psychotic
Disorder
n
SI Bipolar Disorder
n
* not counted
if prescribed
by physician
Abuse + Dependence
n
Alcohol-Related D/O
n
Caffeine-Related D/O
n
Cannabis-Related D/O
SI Depressive Disorder
n
Hallucinogen-Related D/O
n
SI Anxiety Disorder
n
Inhalant-Related D/O
n
SI Obsessive-Compulsive or
Related Disorders
n
Opioid-Related D/O
n
Sedative/Hypnotic-Related D/O
n
SI Sleep-Wake Disorder
n
Stimulant-Related D/O
n
SI Sexual Dysfunction
n
Tobacco-Related D/O
n
SI Delirium
n
Unknown Substance D/O
n
SI Neurocognitive Disorder
n
(Non-substance) Gambling D/O
© Tyler Argüello, Ph.D.
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Basic Substance-Related Categories
In other words…
n
Substance Use D/O
n
n
n
A user has taken a substance frequently enough to produce clinically
important distress or impaired fx, and to result in certain bx characteristics
Found w all classes of drugs, except caffeine
Substance-Induced D/O
n
n
Substance Intoxication
n Acute clinical condition results from recent overuse of a substance
n Happens to anyone
n Can happen once
n All drugs have syndrome of intoxication, except nicotine
Substance Withdrawal
n Develops when person who has frequent use of substance discontinues it or
markedly reduces amount used
n All substances included – except PCP, hallucinogens and inhalants
© Tyler Argüello, Ph.D.
Thursday, February 16, 2017
+
Personalities
Thursday, February
16, 2017
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In the DSM-5…
n
Nothing has changed, but…
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Nosological +
Categorical
DSM-5 and Beyond
“Alternative” Dimensional Model
Presence of
pathological
personality
traits
Moderate
impairment in
“Personality
Fx”
© Tyler Argüello, Ph.D.
Relative
stability,
consistency
General
Criteria
for PD
Exclusions for
culture,
substance,
medical
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Alternative Model
Level of Personality Fx Scale
0 – 4 for impairment (p. 775)
Personality Functioning
Self
n
Identity: Experience of oneself
as unique, with clear boundaries
between self and others;
stability of self-esteem and
accuracy of self-appraisal;
capacity for, and ability to
regulate, a range of emotional
experience.
n
Self-direction: Pursuit of coherent
and meaningful short-term and
life goals; utilization of
constructive and prosocial
internal standards of behavior;
ability to self-reflect
productively.
Interpersonal
n
Empathy: Comprehension and
appreciation of others’
experiences and motivations;
tolerance of differing
perspectives; understanding
of effects of own behavior on
others.
n
Intimacy: Depth and duration
of positive connections with
others; desire and capacity for
closeness; mutuality of regard
reflected in interpersonal
behavior.
© Tyler Argüello, Ph.D.
+
Thursday, February 16, 2017
Alternative Model
Personality Trait Domains (25 instead of 37!)
n
Negative Affectivity (vs. Emotional Stability)
n
n
Detachment (vs. Extraversion)
n
n
Trait = Tendency or
“disposition” to feel,
perceive, behave,
think in relatively
consistent ways
across time &
situations in which
trait may manifest
5 trait façets
Disinhibition (vs. Conscientiousness)
n
n
5 trait façets
Antagonism (vs. Agreeableness)
n
n
7 trait façets
Trait ≠ Sxs
5 trait façets
Psychoticism (vs. Lucidity)
n
3 trait façets
© Tyler Argüello, Ph.D.
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Alternative Model
“PD-Trait” for other
DSM-IV-TR PDs and
any other PD
presentations
Personality Disorders :: 6 instead of 10
Antisocial
Schizotypal
Avoidant
Obsessive-Compulsive
Borderline
Narcissistic
© Tyler Argüello, Ph.D.
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