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11/4/2013 Workshop for Clinicians Psychological Solutions November, 2013 DSM-5 The Bigger Picture 1840 1 11/4/2013 Know this malady coined in 1840s? Clue 1 Clue 2 2 11/4/2013 Final Clue Drapetomania The inexplicable, mad longing of a slave for freedom. DSM in 1952 3 11/4/2013 DSM-5 in 2013 There’s been a lot of progress in mental health through the years …….. but what will be our “drapetomania” in the next century? Isaac Newton said it best almost 250 years ago; 'I can calculate the motions of the heavens, but not the madness of men." Figuring out how the universe works is simple stuff compared to figuring out what causes schizophrenia. Allen Frances, 2013 4 11/4/2013 APA study groups worked on DSM-5 from 1999-2013 Professionals who worked on IV did not work on 5 Expanded international and female representation Limited financial conflict (per year industry compensation to < $10,000) Same transparency/confidentiality requirements as for NIH, Institutes of Medicine, WHO, and scientific journals Published the work in the task groups on the APA website for review DSM5.org Align with ICD-9 and ICD-10 to unify psychological/medical Changed from Roman numerals Online component Cultural issues more clearly delineated Offers Cultural Formulation Interview (CFI) Lifespan Focus Revised Chapter Organization 5 11/4/2013 Diagnoses move away from Yes/No categories to more dimensional/spectrum diagnosis. Examples Learning Disabilities Autism Spectrum Disorder Results in fewer NOS Results in fewer disorders DSM-IV TR: 172 DSM-5: 157 Single Axis rather than 5 axis No more Axis II! ▪ Axis II disorders led to misguided belief that these were largely untreatable (Good, 2012; Krueger & Eaton) So how get holistic picture? More V codes to denote stressors (pg 715) Use subtypes, specifiers, and severity ratings Severity ratings likely more reliable than GAF 6 11/4/2013 Example in handouts (see pg. 52 in DSM-5) Gets at real-life functioning For instance, ADHD now has a severity rating. Severity may vary by context and over time. Will Level 2 be the threshold for services? Disclaimer in DSM-5: The severity specifiers should not be used to determine eligibility for and provision of services; these can only be developed at an individual level and through discussion of personal priorities and targets. Think dimensions. No more 5-axis diagnosis. Severity level and specifiers for more description. 7 11/4/2013 Except for autism, all the DSM-5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSMs teaches us that if anything can be turned into a fad, it will be. Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and ‘behavioral addictions’ will soon be mislabeled as psychiatrically sick and given inappropriate treatment. Taken from Weeks, Howard, 2013. Director Insel’s Blog http://www.nimh.nih.gov/about/director/2013 /transforming-diagnosis.shtml Psychology Today responds http://www.psychologytoday.com/blog/sideeffects/201305/the-nimh-withdraws-supportdsm-5 The ineffable complexity of brain functioning has defeated past DSM hopes and will frustrate even the best NIMH efforts. Progress in understanding mental disorders will necessarily be slow, retail, and painstakingwith no grand slam home runs, just occasional singles, no walks, and lots of strikeouts. No sweeping explanations- no Newtons, or Darwins, or Einsteins. Allen Frances, 2013 8 11/4/2013 9 11/4/2013 APA website on DSM-5 http://www.psychiatry.org/practice/dsm/dsm5 PSI website http://www.psychologicalsolutions.org/ Mike’s DSM-IV diagnosis at Admission Use resources to find information you need to translate into DSM-5 Share resources with those around you— colleagues are a great resource See pg. 59-66 in DSM-5 314.01 ADHD, Combined Type, moderate V61.20 Parent-Child Relational Problem V62.3 Academic or Educational Problems What other areas would you want more information about to consider other possibly relevant diagnoses? Learning disabilities, oppositional behavior, possible substance abuse, mood, anxiety? Also need more information to consider possible V-codes: V61.8 High Expressed Emotion Level Within Family V61.8 Sibling Relational Problem V62.89 Phase of Life Problem 10 11/4/2013 Pervasive Developmental Disorders Autistic Disorder/ HFA Asperger Disorder Rett Disorder Childhood Disintegrative Disorder PDD/NOS 11 11/4/2013 Autism Spectrum Disorder Autistic Disorder (includes HFA) Asperger Disorder PDD/NOS Write down which ASD diagnosis, if any, you think fit for these cases Oxymoron Touch Restaurant Sugar Motta 12 11/4/2013 Autism Spectrum Disorder Autistic Disorder (includes HFA) Asperger Disorder PDD/NOS Experts in the field reliably distinguish if someone has an ASD, but not between them. Interestingly, this does not affect treatment. Autism Spectrum Disorder According to the DSM-5, Sheldon now has “Autism Spectrum Disorder.” There is no more Asperger’s Disorder. Asperger’s Disorder 1964-2013 13 11/4/2013 Social Interaction Restrictive/ Repetitive Social Communication And Interaction Restrictive Repetitive Behaviors Communication 1. 2. The Autism Spectrum Disorder diagnosis is the only diagnosis. As in picture, there are now 2 main categories instead of 3. Social Communication and Interaction Restrictive Repetitive Behaviors 3. 4. 5. 6. Some criteria can be by history, rather than current presentation. Each category receives it’s own “severity rating.” New “specifiers” provide more robust, holistic, interconnected information. ADHD is diagnosed along with an ASD. from a total of 8 criteria to 3 Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (not exhaustive): Deficits in social-emotional reciprocity. Deficits in nonverbal communicative behaviors used for social interaction. 3. Deficits in developing, maintaining, and understanding relationships. 1. 2. 14 11/4/2013 1. Deficits in social-emotional reciprocity Failure to initiate or respond to social interactions Failure of normal backand-forth conversations 2. Deficits in nonverbal communicative behaviors used for social interaction Total lack of facial expressions And nonverbal communication Poorly integrated verbal and nonverbal communication 3. Deficits in developing maintaining and understanding relationships Absence of interest In peers Difficulty adjusting behavior to suit various social contexts 15 11/4/2013 Of behavior, interests or activities, as manifest by at least 2 of the following, currently or by history Stereotyped or repetitive motor movements (lined up toys when young/stereotyped phrases “cool”) Insistence on sameness (rigid thinking patterns) Perseverative interests/preoccupation with unusual objects Sensory issues . Axis I: 299.80 Asperger’s Disorder 294.9 Cognitive Disorder, NOS (includes V61.20 Parent-Child Relational Problem Axis II: V71.09 No Diagnosis. Axis III: In utero cocaine/alcohol exposure noted. Axis IV: Problems with primary support group; social environment; placement in a structured therapeutic environment Axis V: 38 broad deficits from in utero exposure to alcohol and cocaine in areas such as impulsivity, mental inflexibility, and dysregulation) 299.00 Autism Spectrum Disorder Requiring support for deficits in social communication/interaction Requiring support for restricted, repetitive behaviors. Without accompanying intellectual impairment. Without accompanying language impairment. Fluent speech with adequate receptive language and mild deficits in expressive language. associated with 315.8 Neurodevelopmental disorder associated with prenatal alcohol and cocaine exposure in utero, includes broad deficits in areas such as impulsivity, mental inflexibility, and dysregulation. V61.20 Parent-Child Relational Problem V62.4 Social Exclusion or Rejection *best estimate-specifiers/format likely to evolve over time. 16 11/4/2013 Persistent difficulties in social use of verbal and nonverbal communication. All below: Deficits in using communication for social purposes (i.e. sharing information) Impairment in adapting communication style to the context (classroom vs. recess) Difficulties following rules for conversation and storytelling, including nonverbals Difficulties with nonliteral language Not in the DSM-5 Lots of research on ASD, not NLD/NVLD No Learning Disorder, NOS diagnosis Options (best guess based on what info we have so far) Carefully consider Autism Spectrum Disorder and SPCD Describe NVLD in summary but not formally diagnose Diagnose LD and/or ADHD if warranted and note “Associated with Nonverbal Learning Disability” Diagnose Other Specified Neurodevelopmental Disorder “Associated with Nonverbal Learning Disability” 17 11/4/2013 Academics IQ IQ Discrepancy Model: An old-fashioned approach Writing Spelling Grammar/ punctuation Organization Academic PROCESSES Mathematics Number Sense Accuracy/fluency Math Reasoning Reading Word Reading Fluency Comprehension Severity Level Case Study-Lexi Remember to use resources 18 11/4/2013 Autism Spectrum Disorder 299.00 Social communication: Requiring support Restricted, repetitive behaviors: Requiring support Without accompanying intellectual impairment Without accompanying language impairment Associated with ADHD/Primarily inattentive presentation 314.00, moderate Note: V62.4 Social Exclusion or Rejection and V62.3 Academic or educational problem would have applied when Lexi was admitted at the program but no longer seems warranted. What other possible diagnoses would you want more information about? Learning disabilities. Possibly, anxiety. Missed a lot of school before, possibly from anxiety. Is this resolved? Had symptoms of mood problems at admission. Have these resolved? Other issues you thought of? Tracine Smoot, Ph.D. Psychological Solutions www.psychologicalsolutions.org Email: [email protected] Cell: 801-824-0825 Office: 435-425-2234 19 Mike (17) From the DSM-IV to DSM-5 Mike is a 17 year old male who is seeking admission in a therapeutic boarding school following about 8 weeks in a wilderness program. Prior to being admitted to the wilderness program, he was acting out in school, staying out after his parent’s curfew, sneaking out of the house at night, and arguing with his mother and father. He has always had lots of friends but lately had been hanging out with a more negative group; his parents are very concerned about the impact of these negative peers. His mother described him as “always on the go” when he was younger but more recently she has noticed that he is easily bored and often restless. He “stirs things up” with his siblings, resulting in family conflict. He also tends to act without thinking, often getting into trouble and then feeling badly about it afterwards. He has difficulty with personal space, has difficulty waiting for his turn when playing games, and interrupts while others are talking. Even though he is a bright young man, he has always had difficulty following multi-step directions and following-through with things. He frequently loses his possessions and loses track of his homework assignments; either not completing them or forgetting to turn them in once they were completed. Particularly in school, he has difficulty paying attention, is easily distracted, and is fidgety. He tends to “check out” when he is not interested but is eager to participate when he is interested, often blurting out his answers in class discussions. His grades have never been stellar and on his last report card, he had 3 failing grades. Mike recently had a psychological evaluation in his community and was provided with the following DSM-IV TR diagnosis: DSM-IV Axis I: Axis II: Axis III: Axis IV: Axis V: 314.01 ADHD Combined Type V61.20 Parent-Child Relational Problem V62.3 Academic Problems V71.09 No Diagnosis Deferred to physician Problems with primary support group, difficulty in school, current placement. Current GAF: 51 DSM-5 What other areas would you want more information about to consider other possibly relevant diagnoses? Psychological Solutions Mastering the Nuts and Bolts of the DSM-5 11/2013 Lexi (16) From the DSM-IV to DSM-5 Lexi is a 16-year old female currently in a residential treatment center, where she has been for nine months. She has made excellent progress, is preparing to graduate, and will soon be returning to her home. Her parents and treatment team have planned carefully for this transition and have an array of services in her community in place for her return. Assume that you are Lexi’s therapist in this program and you need to have DSM-5 diagnoses for her discharge summary. Lexi entered the program after experiencing significant bullying and social rejection. She had also been having serious academic problems. Moreover, she had been missing a great deal of school. It did not help that she often stayed up very late playing video games and was tired in the morning. Her parents had significant difficulty managing her behavior at home. She resisted following rules and when she didn’t get her way, Lexi had angry outbursts that were more intense than the situation seemed to call for. In school, Lexi’s grades had dropped dramatically in the year before entering the program. She had always had difficulty in school and had previously been in special education with an “Other Health Impaired” classification due to having severe ADHD, Inattentive Type. Lexi has made very good progress in residential treatment. She formed a strong therapeutic alliance with her therapist, in spite of a slow start. She has learned to better regulate her emotions and behavior. She is also better able to understand the impact of her behavior on others and her ability to adapt her behavior to the context has improved, even though she continues to have mild social problems in the milieu (such as with conversational give-and-take). Even though she still tends to be a rigid thinker and has difficulty switching between activities, she has learned to accept other’s feedback, follow the rules, and has gotten better at being able to “go with the flow.” She has also learned how having Asperger’s Disorder impacts her and how to better advocate for her needs. In school, she still has problems with attention, concentration and organization but has learned to use a planner system and is doing much better at tracking her assignments and getting her work completed. She still struggles in some classes, but with support (especially in organization) earns As, Bs, and some Cs. Her family relationships have always been supportive, and now that her parents understand better how to support Lexi, they each have close and healthy relationships with her. Lexi had a psychological evaluation shortly after she entered the program. Even though Lexi has made good progress, the primary diagnoses still seem to fit and match the diagnoses on her treatment plan so you plan to use these in your discharge summary; however, they need to be updated to the new DSM-5 formulation. Here are highlights from the evaluation, including the IQ scores: WECHSLER INTELLIGENCE SCALES FOR CHILDREN-IV Index/Subtest Verbal Comprehension Similarities Psychological Solutions Mastering the Nuts and Bolts of the DSM-5 11/2013 Scaled Score Standard Score (mean=10, SD=3) (mean=100, SD=15) 108 11 Percentile Rank 70 Vocabulary Comprehension Perceptual Reasoning Block Design Picture Concepts Matrix Reasoning Working Memory Digit Span Letter-Number Sequencing Processing Speed Coding Symbol Search Full Scale IQ Score 12 12 96 39 99 47 85 16 99 47 11 9 8 10 10 7 8 Lexi was noted to have strong verbal comprehension abilities that were consistent with her therapist’s report of having adequate language skills. Lexi’s overall reading scores were on grade level but her math scores and writing scores were below grade level; however, because her scores were not significantly different than her Full Scale IQ score, she was not diagnosed with any learning disabilities. The psychological evaluation noted that Lexi had moderate symptoms of inattention and disorganization but did not diagnose ADHD/Inattentive Type because of a new Asperger’s Disorder diagnosis. Lexi also had specialty social/developmental testing, as well as personality testing. It was noted that Lexi had experienced a great deal of stress related to social problems. DSM-IV 299.80 Asperger’s Disorder V62.3 Academic Problems Axis II: V71.09 No Diagnosis Axis III: Deferred to physician Axis IV: Problems with primary support group, social problems, difficulty in school, current placement. Axis V: Current GAF: 59 Axis I: DSM-5 What other areas would you want more information about to consider other possibly relevant diagnoses/clinical issues? Psychological Solutions Mastering the Nuts and Bolts of the DSM-5 11/2013 11/4/2013 Kevin Fenstermacher, Ph.D. Disorders related to trauma or distress reactions shares many symptoms in common with other Anxiety Disorders including: Hyperarousal, irritably, insomnia, poor concentration, Startle response and avoidance behavior Derealization and depersonalization and, Persistent and intrusive thoughts. Trauma and Stress DSM‐IV Anxiety and Fear‐Based Response 1 11/4/2013 Trauma and Stress Anxiety and Fear‐Based Responses Externalizing Angry and Aggressive Symptoms Dissociative Symptoms Disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion Anhedonic and Dysphoric Symptoms Reactive Attachment Disorder Disinhibited Social Engagement Disorder (NEW) Posttraumatic Stress Disorder Acute Stress Disorder Adjustment Disorders Other Specified Trauma‐and Stressor‐Related Disorder Unspecified Trauma‐and Stressor‐Related Disorder DSM‐IV: Two Types Inhibited Disinhibited DSM‐5: Two Diagnoses Reactive Attachment Disorder Disinhibited Social Engagement Disorder 2 11/4/2013 Although both disorders have a common etiology of “Social Neglect”, they are expressed quite differently Internalizing Symptoms Reactive Attachment Disorder Externalizing Symptoms Disinhibited Social Engagement Disorder Internalizing Symptoms of RAD Consistent pattern of emotionally withdrawn behavior toward adult caregiver(s) Persistent social and emotional disturbance Extremes of Insufficient Caregiving Social Neglect or Deprivation Repeated Changes in primary caregiver Rearing in unusual settings No Autism Spectrum Disorder Evident prior to the age of 5; Developmental age of 9 months Specify if: Persistent (12 months) Specify Severity: Severe (all symptoms at high levels) 3 11/4/2013 Externalizing Symptoms of DSED Reduced/absent reticence in approaching or interacting with unfamiliar adults Overly familiar verbal/physical boundaries Diminished or absent “check‐ins” Willingness to go off with unfamiliar adult Extremes of Insufficient Caregiving Social Neglect or Deprivation Repeated Changes in primary caregiver Rearing in unusual settings Developmental age of 9 months Specify if: Persistent, Specify Severity : Severe DSED presents even after signs of neglect are gone DSED can present in children across the attachment spectrum. Significant changes More explicit as to how trauma was experienced ▪ Directly, Witnessed, or Indirectly Removal of subjective emotional reaction to traumatic event (broadening beyond fear‐based and dissociative symptoms) 3 major symptoms clusters become 4 ▪ Avoidance/numbing cluster becomes avoidance and persistent negative emotional states Developmentally sensitive ▪ Thresholds lowered for children and adolescents ▪ Separate criteria added for children age 6 and younger 4 11/4/2013 Avoidance Intrusion Symptoms PTSD Marked alterations in arousal and reactivity Negative alterations in cognitions and mood Specify whether: With Dissociative symptoms 1. Depersonalization 2. Derealization Specify if: With delayed expression Criteria reflect adjustments made to PTSD for clarity as to how trauma was experienced as well as removal of subjective reaction to the traumatic event Five Symptom Categories (9 of 14) Intrusion, negative mood, dissociation, avoidance, and arousal This category was reconceptualized as a heterogeneous array of stress‐response syndromes that occur after exposure to a distressing event. Subtypes are the same (depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of emotions and conduct) 5 11/4/2013 Defined as conditions involving problems with self‐control of emotions and behaviors that impact others ▪ aggression, destruction of property, conflict with society and authority figures, etc. Kleptomania Pyromania Conduct Disorder Oppositional Defiant Disorder Intermittent Explosive Disorder Three groups of symptoms Angry/Irritable Mood Argumentative/Defiant Behavior Vindictiveness Guidance on duration, frequency, and intensity of behavior with regard to age, developmental level, gender, and culture Severity Rating based on number of settings ▪ Mild=1, Moderate=2, Severe=3 or more 6 11/4/2013 Primary Change: Added verbal aggression or physical aggression that is nondestructive/noninjurious in nature Specific criteria defining frequency Aggressive outbursts are impulsive or anger‐ based and not an effort to achieve a tangible objective, cause marked distress to the individual, relationships, or occupational functioning, etc. Minimum age of 6 and (for ages 6‐18) not part of an adjustment disorder Criteria are similar to DSM‐IV Aggression to People/Animals; Destruction of Property; Deceitfulness or Theft, Serious Violation of Rules Specify Whether: Childhood‐onset, Adolescent‐onset; Unspecified onset Specify If: Limited Prosocial Emotion Specify Severity: Mild, Moderate, Severe 7 11/4/2013 Formerly known and loved as Disruptive Behavior Disorder NOS “Other specified disruptive, impulse‐control, and conduct disorder; recurrent behavioral outbursts of insufficient frequency” Changes for the DSM‐5 Dependence and Abuse diagnostic categories have been collapsed (criteria are nearly identical) Substance Use Disorders Substance Induced Disorder ▪ Substance Intoxication and Withdrawal Substance/Medication‐Induced Mental Disorders Unspecified Substance‐Induced Disorders DSM‐IV recurrent legal problems is replaced by craving/urge/strong desire to use a substance. 8 11/4/2013 Polysubstance Dependence is no more Cannabis Withdrawal ,Caffeine Withdrawal, and Tobacco Use Disorder are new to DSM‐5 Gambling Disorder is also new Specify Severity (for substance use disorder) based on number of symptom criteria endorsed : Mild (2‐3) Moderate (4‐5), Severe (6+) ▪ Coding is based on severity Specify : “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.” Alcohol Caffeine * Cannabis Hallucinogens *** Stimulants Tobacco** Other(Unknown) Phencyclidine Other Inhalants*** Opioids Sedatives, Hypnotics or anxiolytics * No Substance Use Disorder ** No Substance Intoxication *** No Substance Withdrawal 9 11/4/2013 No more Axis‐II The Debate: Categorical versus Dimensional An Alternative model was developed for the DSM‐5, considered for inclusion, and then included in Section III for further study. Wanting to destigmatize personality disorders and view them as treatable The criteria for personality disorders has not changed from DSM‐IV Criteria A: Level of Personality Functioning Disturbances in self and interpersonal functioning constitute the core of personality pathology. Self (Identity and Self‐Directions) and Interpersonal (Empathy and Intimacy) Criterion B: Pathological Personality Traits Pathological personality traits are organized into broad domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism Negative Affectivity (vs. Emotional stability) Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/shame, worry, anger) and their behavioral (e.g., self‐harm) and interpersonal (e.g., dependency) manifestations. Detachment (vs. Extraversion) Avoidance of socio‐emotional experiences, including both withdrawal from interpersonal interactions, ranging from casual, daily interactions to friendships to intimate relationships, as well as restricted affective experience and expression, particularly limited hedonic capacity. 10 11/4/2013 Antagonism (vs. Agreeableness) Behaviors that put the individual at odds with other people, including an exaggerated sense of self‐importance and a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both unawareness of others’ needs and feelings, and a readiness to use others in the service of self‐enhancement Disinhibition (vs. Conscientiousness) Orientation toward immediate gratification, leading to impulsive behavior drive by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences. Psychoticism (vs. Lucidity) Exhibiting a wide range of culturally incongruent odd, eccentric, or unusual behaviors and cognitions, including both process (e.g., perception, dissociation) and content (e.g., beliefs) Criterion C and D: Pervasiveness and Stability Impairments in personality function and personality traits are relatively pervasive across a range of personal and social contexts. Criterion E, F, and G: Alternative Explanations for Personality Pathology (Differential Diagnosis) On some occasions, what appears to be a personality disorder maybe better explained by another mental disorder, the effects of substance or medical condition, a normal developmental state, or sociocultural environment. Relational Problems, Abuse, and Neglect 11 11/4/2013 Parent‐Child Relational Problem Sibling Relational Problem Upbringing Away From Parents Child Affected by Parental Relationship Distress Impaired functioning across domains Behavioral: Inadequate parental control, supervision, and involve with child, parental overprotection, excessive parental pressure, arguments that escalate to threats of physical violence, and avoidance without resolution of problems. Cognitive: Negative attributions of other’s intentions, hostility toward or scapegoating other, and unwarranted feelings of estrangement Affective: Feelings of sadness, apathy or anger about the other individual in the relationship 12 11/4/2013 Maltreatment by a family member or nonrelative Suspected versus Confirmed Initial or subsequent therapeutic visit Personal History of Abuse (past history) in childhood Perpetrator or Victim Child Physical Abuse Child Sexual Abuse Child Psychological Abuse Examples include berating, disparaging, or humiliating the child; threatening the child; harming/abandoning (or indicating the alleged offender will harm/abandon) people or things that the child cares about; confining the child (tying to chair, binding, small enclosed area like a closet); egregious scapegoating of the child; coercing the child to inflict pain on himself/herself, and disciplining the child excessively through physical or nonphysical means Educational Problems Problems with academic performance or underachievement (below what is expected given intellectual capacity), discord with teachers, school staff, other students, etc. Phase of Life Problem Problems adjusting to life‐cycle transition (particular developmental phase) Social Exclusion or Rejection Bullying, teasing, intimidation, being targeted for verbal abuse or humiliation, and purposefully excluded Child or Adolescent Antisocial Behavior 13 11/4/2013 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. American Psychiatric Association. DSM‐5. (2012) http://www.psychiatry.org/dsm5 American Psychiatric Association. Task Force Fact Sheet. (2012) http://www.psychiatry.org/dsm5 Duncan, G. (2013). Differential Diagnosis and the DSM‐5. Annual GCAD Summit Presentation Zeanah, C. & Gleason, M. (2010). Reactive Attachment Disorder: A Review for DSM‐V. American Psychiatric Association. 14 11/4/2013 Kevin Fenstermacher, Ph.D. Psychological Solutions www.psychologicalsolutions.org Email: [email protected] Cell: 801‐201‐3139 Office: 435‐425‐2234 15 11/4/2013 Laura Brockbank, Ph.D. Anxiety Disorders DSM‐IV Anxiety Disorders Trauma & Stressor Related Disorders Obsessive‐Compulsive and Related Disorders Separation Disorder Selective Mutism Acute Stress Disorder Obsessive‐Compulsive Disorder Specific Phobia Body Dysmorphia Disorder Posttraumatic Stress Disorder Social Anxiety Disorder (Social Phobia) Trichotillomania (Hair‐Pulling Disorder) Reactive Attachment Disorder Panic Disorder Hoarding Disorder Panic Attack Specific Excoriation (Skin‐Picking) Disorder Disinhibited Social Engagement Disorder Agoraphobia Adjustment Disorders Generalized Anxiety Disorder Other Specified Trauma or Stressor Related Disorder Substance/Medication‐Induced Anxiety Disorder Unspecified Trauma or Stressor Related Disorder Anxiety Disorder Due to Another Medical Condition Separation Anxiety Disorder Generalized Anxiety Disorder Selective Mutism Anxiety Disorders Agoraphobia Specific Phobia Panic Disorder Social Anxiety Disorder Substance/Medication Induced Other Medical Condition Other Specified Unspecified 1 11/4/2013 2 11/4/2013 3 11/4/2013 OCD Body Dysmorphic Disorder Obsessive Compulsive & Related Disorders Hoarding Disorder Trichotillomania (Hair‐Pulling) Excoriation Disorder Substance/Medication‐Induced Other Medical Condition Other Specified Unspecified (Skin‐Picking) 4 11/4/2013 5 11/4/2013 Specify if: With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. Specify if: “With good or fair insight” “With fair insight” “With absent insight or delusional beliefs” 6 11/4/2013 7 11/4/2013 First episode, currently in acute episode First episode, currently in partial remission First episode, currently in full remission Multiple episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous or Unspecified With Catatonia 8 11/4/2013 9 11/4/2013 Full Manic +MDD Now a Specifier nearly every day /1 week “with mixed features” Manic +3/6 MDD Symptoms MDD + 3/7 Manic Symptoms Depressive Disorders Major Depressive Disorder Disruptive Mood Dysregulation Disorder Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder Substance/Medication Induced Other Medical Condition Other Specified Unspecified 10 11/4/2013 11 11/4/2013 12 11/4/2013 ODD Anger‐guided disobedience and noncompliance to authority figures Hostilely defiant behavior and vindictiveness Often loses temper Deliberately annoys others Easily annoyed Argumentative behavior Rare mood symptoms Duration 6 months Can be diagnosed under age 5 One setting Lower severity, chronicity and frequency of temper outbursts Episodic irritability and mood issues Changes in mood Elevated and expansive mood or grandiosity Mania Clear change from typical behavior Low rates of occurrence prior to adolescence steady increase into early adulthood (Mean age onset Bipolar I is 18) Equal gender prevalence DMDD Chronic, persistent irritability without changes in mood Extreme behavior problems with no mania Recurrent temper outbursts More common prior to adolescence Predominately male More likely to develop depression and anxiety disorders later in adulthood Present for 12 or more months w/o 3 months w/o symptoms Age of onset before age 10 (6‐18) Two settings DMDD can not be diagnosed if a child has experienced a full‐duration manic or hypomanic episode (irritability or euphoric), or lasting more than 1 day. Symptom threshold is higher for DMDD If children meet criteria for both ODD and DMDD, only DMDD is given Chronic, persistent irritability Recurrent temper outbursts Irritability without changes in mood Extreme behavior dyscontrol with no mania More common prior to adolescence Predominately male More likely to develop depression and anxiety disorders later in adulthood Present for 12 or more months w/o 3 months w/0 symptoms Age of onset before age 10 (6‐18) DMDD can not be diagnosed if a child has experienced a full‐duration manic or hypomanic episode (irritability or euphoric) or lasting more than 1 day. 13 11/4/2013 Axis I: 296.90 Mood Disorder NOS 305.20 Alcohol Abuse 313.81 Oppositional Defiant Disorder 314.01 Attention Deficit Hyperactivity Disorder – Combined Type 995.5 Neglect of a Child, Victim V61.20 Parent‐Child Relational Problem V62.3 Academic Problems Axis II: None Axis III: Deferred to MD Axis IV: Problems with primary support group, social environment, difficulty in school, history of substance abuse, current placement in residential program. Axis V: Current GAF: 37 14 11/4/2013 Axis I: 296.33 Major Depressive Disorder, recurrent, moderate, without psychotic features 300.00 Anxiety Disorder NOS 305.20 Cannabis Abuse 312.9 Disruptive Behavior Disorder NOS V61.20 Parent‐Child Relational Problem Axis II: Avoidant Personality Traits Axis III: Mild Acne, Headaches, Asthma Axis IV: Problems with primary support group, poor coping skills, difficulty in school, history of substance abuse, multiple hospitalizations, current placement in residential program Axis V: Current GAF: 39 Laura Brockbank, Ph.D. Psychological Solutions, Inc. 7105 Highland Drive #304 Salt Lake City, UT 84121 Phone: 435‐425‐2234 Fax: 435‐425‐3635 Office 801‐483‐3068 [email protected] http://www.psychiatry.org/dsm5 http://www.psychiatry.org/dsm5 . 15