Download Durand and Barlow Chapter 4: Anxiety Disorders

The future of the DSM
• Next revision of the DSM will likely see
major changes like we have never seen
before.
– Focus of NIMH research in the future
will be on underlying
genetic/neurobiological causes that
are common among psychological
disorders. This is known as the
Research Domain Criteria (RDoC)
project.
The future of the DSM
• “In brief, the RDoC is to define basic
dimensions of functioning (such as fear
circuitry or working memory) to be studied
across multiple units of analysis, from genes
to neural circuits to behaviors, cutting across
disorders as traditionally defined. The intent
is to translate rapid progress in basic
neurobiological and behavioral research to an
improved integrative understanding of
psychopathology and the development of
new and/or optimally matched treatments for
mental disorders.” source: NIMH website
DSM-5 – Important Section
• There is a section in
DSM-5 titled:
–Highlights of Changes
from DSM-IV to DSM5 (p. 809)
DSM-5 – Multiaxial System
is Gone
• AXIS I, II, and III – gone.
–DSM-5 recognizes that
separating things out in terms
of AXIS I, II, and III really
served no purpose because of
the overlap of I, II, and III.
Separating out could actually
be misleading.
DSM-5 – Multiaxial System
is Gone
• AXIS IV is gone. Instead of writing
out social problems, environmental
problems, etc., the list of V codes
(p. 715) has been expanded
significantly to cover anything that
would have gone under AXIS IV
–Very important to have a solid
working knowledge of V codes
DSM-5 – Multiaxial System
is Gone
• AXIS V – gone.
– For many of the disorders in DSM-5
severity rating specifiers have been added
– These specifiers are much better in helping
to explain the severity of specific disorders,
rather than trying to explain overall
functioning via the AXIS V, GAF, which
was not reliable across clinicians
A very brief case study
• Leroy is 40-years-old. He just lost his
job, which has caused a financial strain.
He is experiencing marital distress.
Leroy has been depressed off and on
for 10 years. He is considering suicide,
and has attempted suicide in the past.
He worries constantly, and he cannot
concentrate. He drinks a 6 pack every
night.
DSM-5 Diagnosis – Case Study - The
Way It Should Be Done
• 296.33 Major Depressive Disorder,
Recurrent, Severe
• 303.90 Alcohol Use Disorder, Severe
• 300.02 Generalized Anxiety Disorder
• V61.10 Relationship Distress With
Spouse or Intimate Partner
• V60.2 Low Income
• V15.59 Personal History of Self-Harm
DSM-5 Diagnosis
• The primary diagnosis
(listed first) will be the
most acute condition that
requires the most
intensive professional
services.
DSM-5 ICD-9 Codes
• Note: The ICD-9 codes in the DSM-5
will be used until October 1, 2014. After
this time, the ICD-10 codes will be used.
– The ICD-10 codes are in gray and in
parenthesis after each ICD-9 code.
– For example:
• 301.22 (F21) Schizotypal
Personality Disorder
DSM-5 – no more NOS
categories
• With DSM-5, the NOS categories are no
more.
• DSM-5 includes for each group of related
disorders “Other Specified” and “Unspecified”
categories
• Other Specified category – the clinician can
specify why the person does not meet the full
diagnostic criteria for a disorder
• Unspecified category – the clinician does not
specify why the full diagnostic criteria is not
met for a disorder
DSM-5 – Other Specified and
Unspecified Category Examples
• 300.3 Other Specified Obsessive-Compulsive
and Related Disorder, Body-focused
repetitive behavior disorder (nail and lip
biting)
– Will likely use Other Specified category
most often
• 300.3 Unspecified Obsessive-Compulsive
and Related Disorder
– Will likely use Unspecified category less
often; when the category is used, it is often
in emergency settings, when there is not
enough time for full assessment
Neurodevelopmental
Disorders
• Intellectual Disability
–no longer called Mental
Retardation
–Severity no longer
determined by IQ, but
rather adaptive functioning
Neurodevelopmental
Disorders
• Communication Disorders
– Language Disorder – combines what was
called Expressive and Mixed ReceptiveExpressive Language Disorders
– Speech Sound Disorder – fka Phonological
Disorder
– Childhood-onset Fluency Disorder – fka
Stuttering
– Social (pragmatic) Communication
Disorder – a new disorder; difficulties in
social uses of verbal/nonverbal
communication
Neurodevelopmental
Disorders
• Autism Spectrum Disorder
– A new DSM-5 diagnosis
– Encompasses several DSM-IV diagnoses:
•
•
•
•
•
Autism
Asperger’s
Childhood Disintegrative Disorder
Rett’s Disorder
Pervasive Developmental Disorder NOS
– Deficits in two core domains:
• 1. social communication and social interaction
• 2. restrictive, repetitive patterns of behavior,
interests, and activities
Neurodevelopmental
Disorders
• ADHD
– Under DSM-5 must see symptoms prior to
age 12 (used to be age 7 under DSM-IV)
– For adults (17 and older), only have to
meet 5 symptoms of inattention and/or
hyperactivity/impulsivity
• For children, threshold is higher, must meet 6
criteria
Neurodevelopmental
Disorders
• Specific Learning Disorder
– Used to be separate learning disorders
(Reading, Disorder of Written Expression,
etc.) under DSM-IV
– Under DSM-5, the diagnosis is Specific
Learning Disorder, and then there are
specifiers for each type
• Example: 315.00 Specific Learning Disorder,
with impairment in reading (reading rate)
Schizophrenia Spectrum and Other
Psychotic Disorders
• In DSM-5, the subtypes of
Schizophrenia have been eliminated
(e.g., Schizophrenia, Paranoid Type)
– They were eliminated because of low
reliability and poor validity
– The subtypes have been replaced with the
Clinician-Rated Dimensions of Psychosis
Symptom Severity (p. 743) to help gauge
the degree of types and severity of
symptoms – see handout
Schizophrenia Spectrum and
Other Psychotic Disorders
• Catatonia - rather than being a subtype
of Schizophrenia as seen under DSMIV, Catanonia is now its own diagnosis.
• Example:
– 295.70 Schizoaffective Disorder,
Depressive Type
– 293.89 Catatonia Associated with
Schizoaffective Disorder
Depressive Disorders
• There was significant concern that
Bipolar D/O was being over diagnosed
in children
• For this reason, a new diagnosis,
Disruptive Mood Dysregulation Disorder
was created.
– cannot diagnose over age 18
– Persistent irritability
– Frequent episodes of extreme lack of
behavioral control
Depressive Disorders
• Premenstrual Dysphoric D/O is new to
DSM-5
– Persistent problems with mood around the
time of menses
Depressive Disorders
• No longer a diagnosis of Dysthymia, the
diagnosis is now called: Persistent
Depressive Disorder (Dysthymia)
– The disorder encompasses what was
called Dysthymia under DSM-IV
– Disorder also includes Chronic Major
Depressive Disorder, never a break in
depressive symptoms of at least two
months
• Note: If a break in depressive symptoms for at
least 2 months, then diagnose MDD, Recurrent
Depressive Disorders
• On p. 161 of DSM-5, there is a lengthy
footnote describing how to distinguish
characteristics of Bereavement and
MDD
• If Bereavement, then there are a couple
of diagnostic possibilities:
– 309.89 Other Specified Trauma- and
Stressor-Related Disorder, Persistent
Complex Bereavement Disorder
or
– V62.82 Uncomplicated Bereavement
Anxiety Disorders
• Anxiety Disorders under DSM-5 no
longer includes the following:
– OCD – has been moved to ObsessiveCompulsive and Related Disorders
– PTSD and Acute Stress Disorder – have
been moved to Trauma and StressorRelated Disorders
Anxiety Disorders
• Now included under Anxiety Disorders
in DSM-5:
– Separation Anxiety Disorder
• Wording has been modified to better fit when
SAD occurs in adulthood
• Wording removed that you must be under 18
– Selective Mutism
Anxiety Disorders
• Panic Attacks
– Panic attacks can now be listed as a
potential specifier for all psychological
disorders
• Example: PTSD with Panic Attacks
Anxiety Disorders
• Under DSM-5, no longer the following
diagnoses:
– Panic Disorder with Agoraphobia
– Panic Disorder without Agoraphobia
– Agoraphobia without a history of Panic
Disorder
• Under DSM-5, the diagnoses are now:
– 300.01 Panic Disorder
– 300.22 Agoraphobia
• Note: you could have one diagnosis without the
other
Obsessive-Compulsive and
Related Disorders
• This new section in DSM-5 includes the following
newly created disorders:
– Hoarding Disorder
– Excoriation (skin-picking) Disorder
– Substance/Medication-induced ObsessiveCompulsive and Related Disorder
– Obsessive-Compulsive and Related Disorder due
to Another Medical Condition
– Trichotillomania (hair-pulling disorder) – moved
from Impulse Control Disorders in DSM-IV; the
term in parentheses has been added in DSM-5
Trauma and Stessor-Related
Disorders
• PTSD – diagnostic thresholds have
been lowered for children
– Separate criteria in the DSM-5 have been
added for children age 6 and under
• These criteria are better descriptions of how
PTSD presents in childhood (e.g., reliving
events during play)
Trauma and Stessor-Related
Disorders
• Under DSM-IV, there were two
subtypes of Reactive Attachment
Disorder.
• Under DSM-V, these subtypes are now
considered separate disorders:
– Reactive Attachment Disorder
– Disinhibited Social Engagement Disorder
Dissociative Disorders
• Under DSM-IV, Dissociate Fugue was a
separate diagnose, but under DSM-5, it
is considered a specifier of the disorder,
Dissociative Amnesia
Somatic Symptom and
Related Disorders
• In DSM-5, there is no longer the
following diagnoses:
– Somatization disorder
– Hypochondriasis
– Pain Disorder
– Undifferentiated Somatoform Disorder
• New to DSM-5:
– Somatic Symptom Disorder – most with
Somatization D/O will now fall here
– Illness Anxiety Disorder – most with
Hypochondriasis will now fall here
Feeding and Eating
Disorders
• Disorders that fell under Feeding and
Eating Disorders of Infancy and Early
Childhood, now fall under this category
in DSM-5 – for example, Pica and
Rumination Disorder
• New disorder: Avoidant/Restrictive Food
Intake Disorder – used to be called
Feeding Disorder of Infancy or Early
Childhood
Feeding and Eating
Disorders
• Anorexia Nervosa
– Criteria for amenorrhea, 3 missed
menstrual cycles has been removed
• Bulimia Nervosa
– Criteria for bingeing and compensatory
behavior has been reduced from 2 x’s to 1
x weekly
• Binge-eating Disorder – a new disorder
Sleep Wake Disorder
• Two new disorders:
– Rapid Eye Movement Sleep Behavior
Disorder
– Restless Leg Syndrome
Sexual Dysfunctions
• Females
– Sexual Desire Disorder and Sexual
Arousal Disorder in DSM-IV have been
combined in DSM-5:
• Female sexual interest/arousal disorder
– Vagnisimus and Dyspareunia have been
combined in DSM-5:
• Genito-pelvic pain/penetration disorder
Disruptive, Impulse-Control,
and Conduct Disorders
• This is a new category to DSM-5
• The following DSM-IV diagnoses now
fall under this DSM-5 category:
– Oppositional Defiant Disorder
– Conduct Disorder
– Disruptive Behavior Disorder NOS
– Intermittent Explosive Disorder – must be
at least age 6 has been added
– Pyromania
– Kleptomania
Disruptive, Impulse-Control,
and Conduct Disorders
• Conduct Disorder – a specifier has been
added called “Limited Prosocial Norms”;
under this specifier, you can get more
specific:
– Lack of remorse or guilt
– Callous – lack of empathy
– Unconcerned about performance
– Shallow or deficient affect
These specifiers make it look more like a
mini-version of Antisocial Personality
Disorder
Substance-Related and
Addictive Behaviors
• Gambling Disorder – new to this
category
• Cannabis Withdrawal – new disorder
• Caffeine Withdrawal – new disorder
• Polysubstance Dependence – deleted
from DSM-5; now diagnose each
substance disorder separately
Substance-Related and
Addictive Behaviors
• No longer separate diagnoses for
Substance Abuse and Substance
Dependence.
– Everything is now considered a Substance
Use Disorder
– Substance Use Disorder criteria/specifiers
include the following:
• Intoxication
• Withdrawal
• Substance-Induced Disorders
Neurocognitive Disorders
• Major Neurocognitive Disorder – new
disorder
– Previous DSM-IV diagnoses of Dementia
and Amnestic Disorder now fall under this
diagnosis
• Mild Neurocognitive Disorder – new
disorder for less disabling syndromes
Personality Disorders
• No changes in criteria for Personality
Disorders from DSM-IV to DSM-5
Personality Disorders
• DSM-5 presents an alternative approach to
diagnosing Personality Disorders for further study
– Due to the approaches thoroughness, I would
STRONGLY encourage you to look at this section
of DSM-5 (p. 761) prior to diagnosing any client
with a personality disorder
– The assessment measures the following:
• Level of personality functioning
• Pathological personality traits
• Pervasiveness and stability of traits
• Possible alternative explanations for personality
pathology
New Useful Tools in DSM-5
• FREE assessment measures for
psychological disorders that can be
found online (www.psychiatry.org/dsm5)
– See p. 733 in DSM-5 for more information
• Forms to be used when trying to assess
the cultural variables in relation to
psychological disorders
– See p. 749 in DSM-5