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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 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 14 2/16/17 + 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 15 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 19 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 22 2/16/17 + 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) Thursday, February 16, 2017 23 2/16/17 + 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. Thursday, February 16, 2017 24 2/16/17 + 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. Thursday, February 16, 2017 25 2/16/17 + 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 26 2/16/17 + 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 2/16/17 + 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. + 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 Thursday, February 16, 2017 28 2/16/17 + 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 Thursday, February 16, 2017 29 2/16/17 + 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. Thursday, February 16, 2017 30 2/16/17 + 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) © Tyler Argüello, Ph.D. Thursday, February 16, 2017 31 2/16/17 + 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. + 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 Thursday, February 16, 2017 32 2/16/17 + 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 Thursday, February 16, 2017 33 2/16/17 + 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. + 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. Thursday, February 16, 2017 34 2/16/17 + 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. Thursday, February 16, 2017 35 2/16/17 + 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 2/16/17 + 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. Thursday, February 16, 2017 37 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 43 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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 2/16/17 + 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) © Tyler Argüello, Ph.D. Thursday, February 16, 2017 60 2/16/17 + 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 61 2/16/17 + 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 + Somatic Symptom Related Disorders Thursday, February 16, 2017 © Tyler Argüello, Ph.D. 62 2/16/17 + 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 63 2/16/17 + 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 64 2/16/17 + 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. + 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) © Tyler Argüello, Ph.D. Thursday, February 16, 2017 65 2/16/17 + 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 Thursday, February 16, 2017 66 2/16/17 + 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. + 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 67 2/16/17 + 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. + 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 Thursday, February 16, 2017 68 2/16/17 + 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 69 2/16/17 + 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. + 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) © Tyler Argüello, Ph.D. Thursday, February 16, 2017 70 2/16/17 + 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. + 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 Thursday, February 16, 2017 71 2/16/17 + 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 + Disruptive, ImpulseControl, Conduct D/O’s Thursday, February 16, 2017 © Tyler Argüello, Ph.D. 72 2/16/17 + 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. + 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’ Thursday, February 16, 2017 73 2/16/17 + • 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. + 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 74 2/16/17 + Neurocognitive Disorders Thursday, February 16, 2017 + © 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 75 2/16/17 + 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 76 2/16/17 + 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. Thursday, February 16, 2017 77 2/16/17 + 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 78 2/16/17 + 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. Thursday, February 16, 2017 79 2/16/17 + 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. Thursday, February 16, 2017 80 2/16/17 + 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. Thursday, February 16, 2017 81 2/16/17 + 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 © Tyler Argüello, Ph.D. Thursday, February 16, 2017 82 2/16/17 + 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 © Tyler Argüello, Ph.D. 83 2/16/17 + 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. Thursday, February 16, 2017 84 2/16/17 + © 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 Thursday, February 16, 2017 85 2/16/17 + 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. Thursday, February 16, 2017 86 2/16/17 + 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. Thursday, February 16, 2017 87 2/16/17 + 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. Thursday, February 16, 2017 88 2/16/17 + 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. Thursday, February 16, 2017 89 2/16/17 + 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. Thursday, February 16, 2017 90 2/16/17 + 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. Thursday, February 16, 2017 91 2/16/17 + 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 Thursday, February 16, 2017 92 2/16/17 + 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. Thursday, February 16, 2017 93 2/16/17 + 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 © Tyler Argüello, Ph.D. 94 2/16/17 + 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 Thursday, February 16, 2017 95 2/16/17 + 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. Thursday, February 16, 2017 96 2/16/17 + 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. Thursday, February 16, 2017 97