Download Neurodevelopmental disorders

Update on DSM-5
MICHAEL J. LABELLARTE, SR., M.D.
Annapolis, Millersville, Towson, and Columbia, MD
[email protected]
cell:443-956-2463
www.cpeclinic.com
Tip of the Hat
• Michael First, M.D.
• Master the Changes in the DSM-5
(TM)
The Universe
School
Home
Everywhere Else
Outline
• Preface
• Highlights
• Neurodevelopmental disorders
• Other disorders of interest
• Symptom/Disorder overlap
Whodunit?
• Field Trials: large academic and small clinal
centers
• Work Groups
• DSM-5 Task Forces
• Review committees
• APA Board of Trustees
DSM-5 Tidbits
• Not obligatory to use DSM in U.S.
• ICD-CM (“clinical modification”) is obligatory
(HIPPA!)
• Implementation of ICD-9 and ICD-10 (lands
10-1-14)
• Incorporated into boards 2017
• “Online enhancements”: www.psych.org/dsm5
AXIS I-V Replaced
• Non-axial documentation
• Important psychosocial /contextual factors (V
and Z codes)
• Disability (may be replaced with the
“WHODAS”)
• GAF is eliminated
WHODAS
• WHO Disability Assessment Schedule
• “For further study”
• Based on International Classification of
Functioning, Disability, and Health (ICF)
• A “useful” STD “measure of disability”
• Designed for medical; presumptively “for
mental disorders”
• Child version not included
Elements of a Dx
• Dx criteria
• Dx subtypes and specifiers
• Severity qualifiers are gone
• Principal Dx
• Provisional Dx - “strong presumption full
criteria will be met”
DSM-5 Components
• Section I
• Section II
• Section III
• Appendices
Section I: Basics
• Introduction
• Use of the manual
• Cautionary statement about forensics
Section II: Dx Criteria
• Dx groupings of mental disorders
• Medication-induced movement
disorders/other adverse effects
• Other conditions that may be a focus of
clinical attention
Section II: Other ...
• V codes and Z codes
• Relational problems
• “child affected by parental relationship
distress”
• Abuse and neglect
• Etc.
Section III: Emerging
• Assessment measures (e.g. WHODAS)
• Cultural formulation
• Alternative model for personality disorders
• Conditions for further study
Appendices
• Highlights of changes DSM-IV to DSM-5
• Glossary of technical terms
• Glossary of cultural concepts of distress
• Alphabetical and numerical listings of
disorders
Mental Disorders:
Metastructure I
• Neurodevelopmental disorders:
“intellectual disability”, global
developmental delay, “ASD”, LDs,
communication disorders (ex; social
(pragmatic) communication disorder,
ADHD, “motor disorders”
• Schizophrenia spectrum and psychotic
disorders: the usual, plus catatonia is
expanded upon
Metastructure II
• Bipolar and related disorders: includes
“substance induced bipolar”
• Depressive disorders: the usual plus DMDD
(disruptive mood dysregulation disorder)
and PMDD (premenstrual dysphoric
disorder)
• Bereavement exclusion eliminated from
MDD
Metastructure III
• Anxiety disorders: the usual
• OCD and related disorders: bodydysmorphic disorder (BDD), hoarding,
excoriation disorder, etc.
• Trauma and stress-related disorders: PTSD,
Acute SD, reactive attachment, disinhibited
social engagement disorder, adjustment
disorders
Metastructure IV
• Dissociative disorders
• Somatic symptom disorders
• Feeding and eating disorders: AN, bulemia,
binge eating disorder,
avoidant/restrictive food intake, pica,
rumination disorder
• Elimination disorders
Metastructure V
• Sleep/wake disorders: several new
disorders ICSD including REM sleep
behavior, restless leg syndrome
• Sexual dysfunctions
• Gender dysphoria
Metastructure VI
• Disruptive, impulse control, and conduct
disorders: ODD, CD, antisocial PD,
pyromania, kleptomania, IED
• Substance abuse and addictive disorders:
substance use, substance induced,
intoxication, withdrawal, gambling disorder
• “Internet gaming disorder” in further research
section (see appendix)
Metastructure VII
• Neurocognitive disorders: delirium, major
neurocognitive disorder, mild
neurocognitive disorder
• Personality Disorders
• Paraphilias
Neuro-developmental
Disorders
Development
• No clear distinction between child and adult
disorders
• Child specific disorders are relocated to
appropriate sections
• Groupings are etiology/risk/comorbidity, not age
at dx
• Disorders listed along “lifespan” (within
groupings), ex. anxiety
• Developmental modifications appropriate for Dx
• Text includes “Development and Course”
Intellectual Disability
• MR language is out
• Clinical and STD IQ testing needed
• Severity of impairment based on adaptive
scores (not IQ): mild, moderate, severe,
profound
• Severity specifiers: conceptual, social, and
practical domains
Global Developmental Delay
• Akin to MR NOS
• Age < 5 years, severity of ID cannot be
reliably assessed
• Unable to undergo systematic
assessments
Autism Spectrum Disorder
• Dimensional nature
• Subsumes previous 5 types of PDD
• Aspergers not distinct, but milder form of
autism
• False negatives could cause many w PDD
to lose services
• “Individuals with well-established DSM-IV
dx” of PDD “should be given the dx of
ASD”.
Autism Spectrum
Disorder
• Specifiers
• Known med/gen/environ factor/other disorder
• Severity (A, B): support, substantial, very
substantial
• If intelligence, if language, if catatonia
Autism Spectrum Disorder
• A. Persistent deficits in social
communication or social interaction across
multiple contexts, current/by history (3/3)
•
•
•
1. Social-emotional reciprocity
2. Non-verbal communicative behavior used
for social interaction
3. Developing, maintaining, understanding
relationships
Autism Spectrum Disorder
• B. Restricted, repetitive behavior, interests,
activities (2/4)
•
•
•
•
1. Stereotyped or repetitive speech, motor
movements, or use of objects
2. Adherence to routines, ritualized patterns of
verbal or non-verbal, or resistance to change
3. Highly restricted, fixated interests
(intense/focus)
4. Hyper/hypo-reactivity to sensory input/aspects
Communication Disorders
• Language disorders: combines expressive
and expressive-receptive language
disorders
• Speech sound disorder (formerly
phonological disorder)
• Childhood-onset fluency disorder (formerly
stuttering)
Social (Pragmatic)
Communication Disorder
• Persistent difficulty with verbal and non-verbal
communication for social purposes (not better
explained by ASD)
• Previously PDD NOS
ADHD
• Age of onset before age 12
• Age > 17: 5/9 symptoms diagnose
• New (and better) text
• Can officially be co-morbid with ASD
ADHD
• Specifiers
• In partial remission
• Severity: mild, moderate, severe
ADHD Hallmarks
• Inattention & Hyperactivity/Impulsivity
• (Diagnostic criteria)
• Frustration and negative emotionality
• (DSM V Text)
ADHD DSM-5:
Associated Features...Dx
• “Tests of attention, executive function, or
memory...are not sufficiently sensitive or
specific to serve as diagnostic indices.”
• “No biological marker is diagnostic for ADHD.”
Specific Learning Disorder
• A single broader LD (subsumes the three Rs)
• “Synthesis of history, school reports, and psychoed. testing.”
• Impairment specifiers: reading, written
expression, math
• Ex.-word reading accuracy, grammar and
punctuation accuracy, memorization of arithmetic
facts (not just designate dyslexia or dyscalculia)
• Severity specifier: mild, moderate, severe
• A. Difficulties learning and using academic
skills
(1/6, 6 mo)
despite... provision
of
Specific
Learning
Disorder
interventions... target those difficulties.
• 1. Inaccurate/slow/effortful word reading
• 2. Difficulty understanding meaning of what is
read
• 3. Difficulties with spelling
• 4. Difficulties with written expression
• 5. Difficulties mastering number sense,
number facts, or calculation
• 6. Difficulties with mathematical reasoning
Motor Disorders
• Developmental coordination disorder
• Stereotypic movement disorder
• Tic disorders
OTHER
• Other specified neurodevelopmental disorder,
e.g. FAE
• Other unspecified neurodevelopmental disorder
Schizophrenia
Spectrum
• Schizotypal (personality) disorder
• Delusional disorder
• Brief psychotic disorder
• Schizophreniform disorder
• Schizophrenia
• Schizoaffective disorder
Schizophrenia
Spectrum
• Schizophrenia: “bizarre”/Schneiderian AH do
not stand alone
• Schizophrenia subtypes are eliminated!
• Delusional disorder: no longer just “nonbizarre”
• Catatonia can be diagnosed with a specifier
• 0-4 Severity ratings for psychosis (not
included in desk ref)
Bipolar and Related
• Bipolar I
• Bipolar II
• Cyclothymia
Bipolar Disorder
• BPAD criteria same in children/adults
• A. 1. mood disturbance (e.g elevated,
expansive, irritable) and 2. increase in activity
or energy
• “Mixed episode” eliminated in BPAD I, but can
be specified as “mixed features”
• Duration: 4 days hypomania, 7 days mania;
every day
• Treatment-induced mania is “true mania”
Bipolar Disorder
• B. 3/7 or 4/7 (if irritable mood)
• 1. Inflated self-esteem grandiosity
• 2. Decrease need for sleep
• 3. More talkative/pressured speech
• 4. Flights of ideas/racing thoughts
• 5. Distractibility
• 6. Goal directed activity/psychomotor agitation
• 7. Increase... activities/painful consequences
Bipolar Disorder
and Depressive Disorders
• Specify:
With anxious distress (2/5; m,m,m/s,
s)
• 1. Feeling keyed up/tense
• 2. Feeling unusually restless
• 3. Difficulty concentrating because of worry
• 4. Fear that something awful may happen
• 5. Feeling that the individual might lose control
BPAD vs. ADHD
(Miller, Chiang, Ketter 2013)
• Feature
•
•
•
•
•
•
•
•
•
BPAD
ADHD
Age
adoles./adult <12 yo
Gender
M=F
M>F
Course
episodic
persistent
Suicidal
common
rare
Psychotic
“
“
Euphoria
“
“
Less need sleep
“
“
Grandiose
“
“
Hypersexuality
“
“
47
25
Depressive Disorders
• DMDD
• Major depressive disorder (MDD)
• Persistent depressive disorder
(Dysthymia)
• Premenstrual dysphoric disorder
(PMDD)
Disruptive Mood
Dysregulation Disorder
(DMDD)
• Controversial
• Grouped with depressive disorders, not
bipolar disorders
• “Cannot coexist” with ODD, IED, or
BPAD
DMDD
• A.
Severe recurrent temper outbursts
manifested verbally (e.g. verbal rages) and/or
behaviorally (e.g. physical aggression toward
people or property) ... grossly out of proportion
in intensity or duration to situation/provocation
• B. Inconsistent with developmental level.
• C. Frequency: tantrums on average >3 /week.
DMDD
• D. Mood between temper outbursts is
persistently irritable/angry
• 1.
• 2.
Nearly every day, most of the day
The irritable/angry mood is
observable by others
•
•
•
•
•
•
•
DMDD
E. Duration: >12 months (< 3 consecutive months
w/o)
F. At least two settings (severe in at least one)
G. Dx Age 6 - 18
H. Onset before age 10.
I. Mania caveat (>1 day)
J. Not during MDD... not other mental dx
K. Not attributable to substances or other medical
condition
Anxiety Disorders
• Separation anxiety disorder
• Selective mutism
• Specific phobia
• Social anxiety disorder
• Panic disorder; Panic attack specifier
• Agoraphobia
• Generalized anxiety disorder
OC and Related
Disorders
• OCD
• Body dysmorphic disorder
• Hoarding Disorder
• Trichotillomania
• Excoriation (skin-picking) disorder
Trauma and
Stressor-Related
Disorders
• Reactive attachment disorder
• Disinhibited social engagement disorder
• PTSD
• ASD
• Adjustment disorders
Dissociative
Disorders
• Dissociative identity disorder (DID)
• Dissociative amnesia
• Depersonalization/derealization
disorder
Somatic Symptoms
and Related
• Somatic symptom disorder
• Illness anxiety disorder
• Conversion (Functional neurological symptom
disorder)
• Psychological factors affecting medical condition
• Factitious disorder
Feeding and Eating
Disorders
• Pica
• Rumination disorder
• Avoidant/restrictive food intake disorder
• Anorexia nervosa
• Bulimia nervosa
• Binge eating disorder
Elimination Disorders
• Enuresis
• Encopresis
Sleep-Wake
Disorders
• Insomnia disorder
• Hypersomnolence disorder
• Narcolepsy
• Breathing-related sleep disorder
• Circadian rhythm sleep wake disorder
• Parasomnias
• Restless leg syndrome
Sexual Dysfunctions
• Delayed ejaculation
• Erectile disorder
• Female orgasmic disorder
• Female sexual interest/arousal disorder
• Genito-pelvic pain/penetration disorder
• Male hypoactive sexual desire disorder
• Premature (early) ejaculation disorder
Gender Dysphoria
• Gender Dysphoria
• Other
• Unspecified
Disruptive, Impulse
Control, and Conduct
Disorders
“Problems With Emotional and
Behavioral Self Control”
• Oppositional defiant disorder (ODD)
• Intermittent Explosive Disorder (IED)
• Conduct disorder (CD)
• Antisocial personality disorder (ASPD)
• Pyromania
• Kleptomania
ODD
• “A pattern angry/irritable mood,
argumentative/defiant behavior, or
vindictiveness
• ... >6 mo... >4 symptoms... interaction
with one individual not a sibling.”
ODD
• Angry/irritable mood:
• Often loses temper
• Is often touchy or easily annoyed
• Is often angry and resentful
ODD
• Argumentative/defiant behavior:
• Often argues with authority figures (C and A:
adults)
• Often actively defies/refuses to comply w
requests/rules
• Often deliberately annoys others
• Often blames others for his/her
mistakes/behavior
ODD
• Vindictiveness:
• Has been spiteful or vindictive >2 within
past 6 months
• ODD Specifiers: mild, moderate, severe
More Changes
• IED: verbal aggression and
nondestructive/non-injurious physical
aggression are criteria
IED
• A: Recurrent behavioral outbursts representing
a failure to control aggressive impulses... either:
• 1. Verbal aggression
• 2. 3... outbursts...damage or destruction...
and/or physical assault/injury...animals/other...
12 months
• B. Out of proportion
• C. Not premeditated.
• E. Age > 6 years
Not to achieve... objective
Conduct Disorder
• Repetitive and persistent pattern... basic rights
or major... societal norms or rules are violated; >
3/15 (12 mo) and > 1/15 (6 months)
• Aggression to people or animals
• Destruction of Property
• Deceitfulness or theft
• Serious violation of rules
•
•
•
•
•
•
•
Aggression:
People/Animals
1. Often bullies, threatens, or intimidates
2. Often initiates physical fights
3. Has used a weapon... serious physical harm
4. Has been physically cruel to people
5.
“
animals
6. Has stolen while confronting a victim
7. Has forced someone into sexual activity
Destruction of Property
• 8. Deliberately engaged in fire setting/cause
damage
• 9. Has deliberately destroyed others property
Deceitfulness or
Theft
• 10. Broken into someone’s house, building, car
• 11. Often lies to obtain goods... obligations
(“cons”)
• 12. Stolen nontrivial items without confrontation
Serious Violation of
Rules
• 13. Often stays out at night despite parental
(<13 y)
• 14. Run away overnight >2, or 1 “lengthy
period”
• 15. Often truant from school (<13 y)
CD Specifiers
• Child onset (10 y) or adolescent onset
• Severity: mild, moderate, severe
• “With limited prosocial emotions”
With Limited Prosocial
Emotions (2/4, 12 m)
• Lack of remorse or guilt
• Callous-lack of empathy
• Unconcerned about performance
• Shallow or deficient affect
Substance Related
and Addictive
• __-relatedDisorders
disorder
• Use disorder
• Induced disorder
• Intoxication
• Withdrawal (cannabis!)
• Other
• Unspecified
Neurocognitive
• Delirium Disorders
•
•
•
•
•
•
•
•
Major and minor neurocognitive disorders
Due to Alzheimers
Frontotemporal
With Lewy bodies
Vascular disorder
Traumatic brain injury
HIV, Prion disease
Parkinsons, Huntingtons
DSM-5 Personality
Disorders
• Cluster A: Paranoid, Schizoid, Schizotypal
• Cluster B: Antisocial, Borderline, Histrionic,
Narcissistic
• Cluster C: Avoidant, Dependent, Obsessive
Compulsive
• Other specified PD and unspecified PD
General Personality
Disorder
• A. An enduring pattern of inner experience and
behavior that deviates markedly from
expectations... culture (2/4):
• Cognition
• Affectivity
• Interpersonal functioning
• Impulse control
General PD (cont.)
• B. Inflexible and pervasive..
• C. Significant distress and impairment
• D. Stable and long duration, at least adol./early
adult
• E. Not better explained
• F. Not attributable to SA or GMC
Pediatric Application
• ASP cannot be diagnosed <18 yo
• PD otherwise can be diagnosed <18 yo (> 1 y
duration)
• “... particular maladaptive personality traits
appear pervasive, persistent, and unlikely to be
limited to a particular developmental stage or
mental disorder”.
DSM-5 Alternative Model
(PD)
• Level of personality functioning
• Pathological personality traits
• Pervasiveness and stability
• Alternative explanations for personality
pathology (differential diagnosis)
1. Level of Personality
Functioning
• Elements of personality functioning
• Self: identity, self-direction
• Interpersonal: empathy, intimacy
2. Pathological Personality
Traits
• Domains (with 25 corresponding trait facets)
• Negative affectivity (v. emotional stability)
• Detachment (vs. extraversion)
• Antagonism (vs. agreeableness)
• Disinhibition (vs. conscientousness)
• Psychoticism (vs. lucidity)
Negative Affectivity
• Emotional lability
• Anxiousness
• Separation insecurity
• Submissiveness
• Hostility
• Perseveration
Detachment
• Withdrawn
• Intimacy avoidance
• Anhedonia
• Depressivity
• Restricted affectivity
• Suspiciousness
Antagonism
• Manipulativeness
• Deceitfulness
• Grandiosity
• Attention seeking
• Callousness
Disinhibition
• Irresponsibility
• Impulsivity
• Distractibility
• Risk taking
• Rigid perfectionism (lack of)
Psychoticism
• Unusual beliefs and experiences
• Eccentricity
• Cognitive and perceptual dysregulation
3. Pervasiveness and
Stability
• Relative impairments in function/trait
(disposition)
• “All but the most extreme” have some
adaptability
• Traits more stable than symptoms
• Impairment more stable than symptoms
Explanations for
Personality Pathology
(differential diagnosis)
• PD diagnosis “not made” if manifestations
“clearly are an expression of the other mental
disorder”
• PD “can be accurately diagnosed in the
presence of another mental disorder”
DSM-5 Alternative
“Specific”
A. Schizotypal
B. Antisocial
Borderline
Narcissistic
C. Obsessive Compulsive personality (OCP)
Avoidant
*Personality Disorder-Trait Specified (PDTS)
Paraphilic Disorders
• Voyeuristic
• Exhibitionistic
• Frotteuristic
• Sexual masochism
• Sexual sadism
• Pedophilic
• Fetishistic
• Transvestic
Last But Not Least...
• Other mental disorders
• Medication-induced movement disorders and
other adverse effects
• Other conditions that may be focus of clinical
attention
Other/Clinical
• Relational problems
Attention
• Abuse and neglect
• Education and occupational problems
• Housing and economic problems
• ... related to social environment
• ...crime/interaction with legal system
• ...counseling or medical advice
• ... other psychosocial, personal,
environmental
DSM-5 Conclusions
• Ready or not...
• Much more informative text section
• Few surprises (which is surprising)
• More strict criteria can lead to under-diagnosis
• ASD and DMDD are noteworthy
conceptualizations