Download Mood and Anxiety Disorders

Advancing Social Work Practice with
Clients: Understanding the DSM 5
Social Work and the DSM-5:
Mood and Anxiety Disorders
Robin Gearing, PhD
December 6, 2013
Overview
Mood and Anxiety Disorders:
1. What has changed?
2. What has stayed the same?
3. What is the significance of this revision to clinical social
work practice?
DSM
• Strength of the DSM is to provide a common language for
describing psychopathology
• More of a dictionary that creates a set of labels and defines
each, than a “Bible” for the field
(Insel, 2013)
Social Work:
Be Informed, (then) Be Critical
Clinical and practicing social workers:
– Should familiarize themselves with the DSM-5 and
related controversies
Then
– Be able to apply critical thinking to the question of their
client’s diagnoses and treatment relevant to their context
(Littrell & Lacasse, 2012)
DSM-5 and Culture
• The cultural formulation interview guide will help clinicians
to assess cultural factors influencing patients’ perspectives of
their symptoms and treatment options
– Includes questions about patients’ background in terms
of their culture, race, ethnicity, religion or geographical
origin (APA, 2013)
• Practice application of criteria across individual demographic
characteristics (e.g., cultures, race, sex, age)?
Mood Disorders
• Depression (melancholia) was recognized as a medical illness
by Hippocrates (460-377 BC)
• Depression can be considered across a spectrum, with
symptoms and severity assessed on a continuum
– Unitary Theory of Depression (Akiskal & McKinney, 1973)
– Severe, moderate, and mild depressions may not be points
on a single spectrum
• Depression can be a symptom or a disorder
• Mood is disproportionate to external stressors
Depressive Disorders
Depressive Disorders
What has changed- What has stayed the same?
Overview:
1. Moderate revisions between the DSM-IV and DSM-5
2. Mood disorders (DSM-IV) now two sequential, but separate
chapters:
A) Depressive Disorders; B) Bipolar and Related Disorder
3. Two new depressive disorders added
1.
2.
Disruptive Mood Dysregulation Disorder
Premenstrual Dysphoric Disorder
4. Same core criterion symptoms applied to a MDD diagnosis
5. Bereavement exclusion for a MDE has been removed
Depressive Disorders
What has changed- What has stayed the same?
Change:
Major Depressive Disorder (MDD)
• Changes to the criteria that define depression
• No longer required to exclude bereavement
– Pro: Depressive symptoms whether caused by grief or
other life stressors are similar
– Con: may not differentiate between normal and
pathological
– Persistent complex bereavement disorder added to
the appendix
Depressive Disorders
What has changed- What has stayed the same?
Change:
Persistent Depressive Disorder (Dsythymia)
• Name changed:
– From Dsythymia
– To Persistent Depressive Disorder
– Criteria are the same
(APA, 2013)
New Depressive Disorder
Premenstrual Dysphoric Disorder (PMDD):
• 7 criterion areas: onset and duration within
menstrual cycle, mood and physical symptoms,
clinical distress, exclusion of other conditions,
minimum number of occurrences
Disruptive Mood Dysregulation Disorder (DMDD):
• 11 criterion area: presentation during episodes,
mood between episodes, number of settings
present, frequency, duration, age of onset, age at
time of diagnosis, consideration of developmental
(APA, 2013)
Depressive Disorders
Implications of Changes?
Overview of Implications:
1. Bereavement exclusion:
– Difficulty distinguishing normal from pathological
depression
2. Having a cognitive construct, hopeless, in
depression:
– As a feeling criteria to define one’s depressed
mood most of the day, nearly every day
3. Premenstrual Dysphoric Disorder
– Potential stigmatization of women
Depressive Disorders
Implications of Changes?
4. Disruptive Mood Dysregulation Disorder
– Address concerns of potential
overdiagnosis/overtreatment of bipolar Dx in
children
– One condition or perhaps a modifier? Explosive
outbursts can occur with other conditions (e.g.,
ADHD, ODD, mania, depression, autism, anxiety,
schizophrenia)
Bipolar and
Related Disorders
Bipolar and Related Disorders:
What has changed- What has stayed the same?
Overview:
1. Bipolar and Related Disorders is a separate
chapter
2. Minimal Bipolar changes between DSM-IV and
DSM-5
3. Criterion A for manic/hypomanic episodes
 Now includes a focus on changes in activity and
energy, as well as mood
 More narrowly defined: Present most of the day,
Bipolar and Related Disorders:
What has changed- What has stayed the same?
Overall these are essentially the same
Bipolar I Disorder
Bipolar II Disorder
Hypomanic Episode
Except there is a change to the criteria that define
Manic Episode and Hypomanic Episode
• Criterion changes to mood presentation, length of the episode, and distinct
from typical behavior
• New specifiers: with anxious distress, with mixed features
• New diagnostic codes for a single episode and recurrent episodes of differing
severity levels and other specifiers
Bipolar and Related Disorders
What has changed- What has stayed the same?
Overall Cyclothymic Disorder is essentially the same
Except there is a new specifier: with anxious distress
(APA, 2013)
Bipolar Disorders:
Implications of Changes?
Overview of Implications:
1. Clearer/tighter boundaries with the following
additions:
 Criterion A: persistently increased mood AND
activity or energy
 Criterion A: Present most of the day, nearly every
day (1 week/4 days)
 Criterion A: Hypomania- lasting at least 4
consecutive days
 Criterion B: Represents a noticeable change from
usual behavior
Anxiety Disorders
Anxiety Disorders:
What has changed- What has stayed the same?
Overview:
1. 5 disorders were reassigned: 3 removed & 2 added
Removed:

PTSD & Acute Stress Disorder (Trauma and Stressor-related disorders)

Obsessive-Compulsive Disorder (Obsessive-compulsive and related disorders)
Added:

Separation Anxiety Disorder & Selective Mutism were re-classified from DSM-IV the chapter
(deleted): Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
2. Criteria changes (Agoraphobia, Specific phobia, Social
anxiety disorder):



Deleted: recognizing anxiety as excessive or unreasonable
New: recognizing anxiety must be out of proportion to the actual danger or threat
Also, 6-month duration (previously limited to under 18yrs) now extended to all ages
3. Diagnoses changes


Panic Disorder and Agoraphobia: now two separate disorders (no longer linked)
New name: Social Anxiety Disorder (replacing Social Phobia)
Anxiety Disorders:
What has changed- What has stayed the same?
Change:
Separation Anxiety Disorder:
• New to Anxiety disorders, reassigned from the,
now deleted, DSM-IV section “Disorders Usually
First Diagnosed in Infancy, Childhood, or
Adolescence.”
• Criterion: no longer specifies that age at onset
must be before 18 years
• Duration criterion for adults: lasting for 6 months
or more
Anxiety Disorders:
What has changed- What has stayed the same?
Change:
Specific Phobia:
• No longer a requirement that individuals (over
18 yrs) must recognize that their fear and
anxiety are excessive or unreasonable
• Duration requirement: lasting for 6 months or
more now applies to all ages
Change:
Social Anxiety Disorder (Social Phobia):
Anxiety Disorders:
What has changed- What has stayed the same?
Change:
Panic Disorder :
• No longer linked to Agoraphobia
Change:
Agoraphobia:
• No longer linked to Panic Disorder
• Criterion A: Requires fear or anxiety about two or
more situations (not 1)
• No longer a requirement that individuals (over
Anxiety Disorders:
What has changed- What has stayed the same?
Change:
Generalized Anxiety Disorder (GAD):
• Minor wording changes
Anxiety Disorders:
Implications of Changes?
Overview of Implications:
1. Anxiety disorders as a section has become more
focused
– 5 disorders were reassigned:
•
3 moved out (PTSD, ASD, OCD); 2 disorders included
(Separation, Mutism)
2. Individuals with Agoraphobia, Specific phobia, and
Social anxiety disorder are no longer required to
recognize their “anxiety as excessive or
unreasonable” (APA, 2000)
– Rather (DSM-5) their anxiety “must be out of
proportion to the actual danger or threat” (APA, 2013)
Reliability - Validity
• The strength of each of the editions of DSM has
been “reliability”
– – each edition has ensured that clinicians use the
same terms in the same ways
• The weakness is its lack of validity
– Unlike our definitions of ischemic heart disease,
lymphoma, or AIDS, the DSM diagnoses are based on
a consensus about clusters of clinical symptoms, not
any objective laboratory measure
NIMH Research Domain Criteria
(RDoC)
• Diagnosis in mental disorders is based on
clinical observation and patients’
phenomenological symptom reports
• The current diagnostic system is not informed
by recent breakthroughs in genetics; and
molecular, cellular and systems neuroscience
NIMH Research Domain Criteria
(RDoC)
• RDoC is intended as a framework to guide
classification of patients for research studies,
not as an immediately useful clinical tool
• The initial steps must be to build a sufficient
research foundation that can eventually inform
the best approaches for clinical diagnosis and
treatment
• It is hoped that by creating a framework that
interfaces directly with genomics, neuroscience,
and behavioral science, progress in explicating
Mission Creep
One of the most serious problems for the DSM-5
is that it extends the concept of mental disorder.
It can be used to diagnose those who only have
subclinical symptoms or problems
(Paris, 2013, p. 40)
False-Positives
Concerns with the potential for false-positives
Be Informed, (then) Be Critical
• Practicing social workers should familiarize
themselves with the many controversies
related to DSM-5
• Apply critical thinking to the question of
diagnoses relevant to their practice context
(Littrell & Lacasse, 2012)
DSM-5 Won’t Solve the Overdiagnosis Problem— but
Clinicians Can
(Phelps, 2013)