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Co-Occurring Disorders: Diagnostic
Considerations
Dr. Phil O’Dwyer
Brookfield Clinics
Oakland University
March 12, 2014
CEAD
MILE
FAILTE
“Primum Non Nocere”
Hippocrates
Clinical vs. Legal Considerations
• Clinical
• Mental Disorder
• Mental Disease
• Mental Disability
• Legal
• Individual Responsibility
• Competency
• 1 in every 100 Americans live in jail (2.3
million)
- N.Y. Times, Feb 29 ’08
• 50% of inmates are drug dependent and
less than 20% of them get treatment – NIDA
• An estimated 15-20% of inmates have a
mental illness
– Walsh, 2004
• “The state of Michigan spends more
money on its prisons than on its
universities”
- CNN 1/23/2009
PREVALENCE OF MENTAL DISORDERS IN THE
GENERAL POPULATION (AMA)
Male
• Alcohol & Drug Dependencies
• Anxiety Disorders
• Dysthymia & Other Mood Disorders
• Antisocial Personality Disorders
Female
• Anxiety Disorders
• Major Depressive & Other Mood Disorders
• Alcohol & Drug Dependencies
• Obsessive-Compulsive Disorders
Making a Diagnosis
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Avoid the rush to certainty
It’s a process not an event
It’s an art as well as a science
It’s a “search for the locus of pain”
DSM IV TR
What is in DSM?
• It contains criteria, descriptions, symptoms
and other criteria for diagnosing mental
disorders.
• Its purpose is to ensure that a diagnosis is
both accurate and reliable.
• It offers no recommendation on the
preferred course of treatment
History of DSM
• 1952 – DSM I – 106 disorders
• 1968 – DSM II – 182 disorders
• 1980 – DSM III – 265 disorders
• 1987 – DSM III-R Revised – 292
disorders
• 1994 – DSM IV – 297 disorders
• 2000 – DSM IV-TR – 365 disorders
• May, 2013 – DSM 5
The History
History of DSM
• Psychological
– DSM I & II
– Why? Cause?
▪
Descriptive
▪
▪
DSM III & IV & V
Signs, symptoms,
what is happening
• Etiology
– The etiology of a disorder is what causes it. Many
disorders have multiple etiologies, which can be
different in each client even though they have the
same disorder
Limitations
• DSM IV is a categorical system
• Categorical diagnoses have only 2 values
– Positive – Pt has the dx
– Negative – Pt does not
• Categorical systems have construct
validity problems because they don’t/can’t
capture the clinical complexity of a
patient’s experience
Limitations
There are real world challenges with categorical
systems
• Categorical systems do not always fit with the
range of symptoms of a specific client
– Client with schizophrenia can have several other
symptoms not included in the criteria set
• Depression, anxiety, insomnia, suicidal ideation,
– There was no way to directly assess the level or
severity of these other symptoms (dimensions)
– So, Dimensional Assessments were added in DSM 5
Why is it Being Revised?
• To reflect new information in neurobiology,
genetics, and behavioral sciences
• To reflect clearer understanding of how
the brain works
• To guide clinicians in making more
accurate and consistent diagnoses
• To help researchers study how disorders
relate to each other
The 3 Sections of DSM 5
• Section 1
– Introduction on use
• Section 2
– The 20 Chapters of categorical Disorders
• Section 3
– Conditions that require further research
– Assessment Instruments
The 20 Chapters
• Neurodevelopmental Disorders
• Schizophrenia Spectrum and other
Psychotic Disorders
• Bipolar and Related disorders
• Depressive Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related
Disorders
The 20 Chapters
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Trauma and Stressor Related Disorders
Dissociative Disorders
Somatic Symptom Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
The 20 Chapters
• Disruptive, Impulse Control and Conduct
Disorders
• Substance Use and Addictive Disorders
• Neurocognitive Disorders
• Personality Disorders
• Paraphillic Disorders
• Other Disorders
Chapter Sequence
• DSM 5 Chapters are broad categories
• Each category describes related disorders
in developmental lifespan sequence
– Childhood, Adolescence, Adulthood and later
life
• The rationale is to advance the
understanding of the relationship between
diagnoses
Overarching Perspective
• Most of DSM 5 will be familiar
• Important organizational and criteria set
differences exist
• Comorbidity within and across diagnoses
addressed
• Criteria sets parallel the ICD 11
(proposed)
Overarching Perspective
• Most of DSM 5 will be familiar
• Important organizational and criteria set
differences exist
• Comorbidity within and across diagnoses
addressed
• Criteria sets parallel the ICD 11
(proposed)
Purpose of Diagnosis
• Facilitate treatment
• Uniform clinical language
• Features of a diagnosis
– Must show some impairment of function.
– Must be a clear deviation from usual roles, i.e.
most people do not have it.
– Must cause distress to the person with it.
• All 3 items must be clinically significant.
Diagnostic Criteria Sets
• Signs are an objective finding observed
by the therapist.
• Symptoms Are subjective experiences
described by the client
• Syndromes A group of signs and
symptoms that occur together and
present the picture of a recognizable
condition.
The Severity Index Across Time
and Circumstance (Type I)
GAF Comparison
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0 – No Impairment
1 – Mild Impairment
2 – Moderate Impairment
3 – Severe Impairment
50
• 4 – Very Severe Impairment
30
GAF 100 - 71
GAF 61 - 70
GAF 51 - 60
GAF 31 GAF
1-
The Severity Index Across Time
and Circumstance (Type II)
• Mild Impairment
- Meets 2 criteria
• Moderate
- Meets 4 criteria
• Severe
- Meets 6 criteria
The Severity Index Across Time
and Circumstance (Type III)
• Mild Impairment
- BMI > 17
• Moderate
- BMI 15
• Severe
- BMI < 15
Major Changes
• DSM 5 is not a final document. “5” and
not “V” for that reason
• DSM 5 will not increase the number of
mental disorders although several will
change and only few substantially
• The Multiaxial system has been dropped
in favor of the list of 20 chapters
Most Innovative Change
• Dimensional Assessments
– Disorder Specific:
• re-experiencing of the trauma in PTSD
– Cross-cutting:
• features that may appear in conjunction with many
disorders; suicidal risk, anxiety, depressed mood
etc.
Dimensional Assessments
• A Dimensional scale has 3 or more ordered
values. ie: no symptoms, some symptoms,
severe symptoms in Likert fashion
• DSM 5 does not replace the Categorical
diagnosis but adds a dimensional option
• Among the people who have a given dx there is
often a wide variation in pre-morbid
physiological, psychological, behavioral and
neurological characteristics present
• Substantial Research validates the use of
Dimensional Assessments
Crosscutting Dimensional
Instruments
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PROMIS
ASSIST
PHQ-9
PHQ-8
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GAD-7
PHQ-15
WHO-DAS
The Altman Scale for
Bipolar
Other Changes in DSM 5
• Abuse/Dependence gone
• Replaced by:
– Alcohol Use Disorders
– Cocaine Use Disorders
– Etc…
• Criteria set are similar but expanded to 11.
Must have at least 2 in 12 month period
Substance Use and Addictive
Disorders
• Dependence/abuse distinction replaced by
continuum of impairment approach
• Craving added as a symptom
• Physical Tolerance and Withdrawal
dropped
– deemed ”not necessary to the dx”
• Gambling Disorder is the only “Behavioral”
addiction listed
• The word “addiction” not used
Substance Use Dis. vs.
Substance Induced Dis.
• SID:
– Intoxication
– Withdrawal
– Other substance/med. induced mental
disorders
DSM5: Opioid-Related Dis.
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Opioid use dis.
Opioid intoxication
Opioid withdrawal
Other opioid-induced dis.
Unspecified opioid-related dis.
Opioid Use Disorder
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Diagnostic Criteria:
1. Opioids taken in larger amounts than intended
2. Unsuccessful efforts to control use
3. Time spent acquiring/recovering from opioids
4. Craving to use
5. Recurrent use despite adverse effect on work/home
6. Use despite recurrent interpersonal problems
7. Important social/occupational/recreational activities
given up
8. Use where physically hazardous
Opioid Use Disorder (cont.)
9. Using despite awareness of its adverse
physical/psychological consequences
10. Tolerance (either):
a. Need higher dose overtime
b. Markedly diminished effect by same dose
(Tolerance is not met if taking meds under medical
supervision.)
11. Withdrawal manifested by (either):
a. Classic opioid withdrawal symptoms
b. Opioids (or similar) used to avoid withdrawal
(Withdrawal is not met if taking meds under medical
supervision.)
Opioid-Related Dis.
• Level of severity:
Mild (2-3)
305.50
F11.10
Moderate (4-5)
304.00
F11.20
Severe (6+)
304.00
F11.20
Opioid-Related Dis.
Specifiers:
• In early remission
– No criteria met for 3 months but less than 12
• In sustained remission
– No criteria met for 12 months except
“craving”
• On maintenance therapy
– Suboxone, methadone
• In controlled environment
Disruptive, Impulse Control and
Conduct Disorders
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Oppositional Defiant Disorder
Intermittent Explosive Disorder
Conduct Disorder
Antisocial Personality Disorder
Pyromania Disorder
Kleptomania Disorder
Oppositional Defiant Disorder
• A pattern of:
– Angry/Irritable Mood
– Argumentative/Defiant Behavior
– Vindictiveness
• Mild – In one setting
• Moderate – In two settings
• Severe – Three or more settings
Intermittent Explosive Disorder
• Recurrent Behavior Outbursts:
– Verbal Aggression
– Physical Aggression
– Destruction of Property, Assault
• The outburst cause marked distress, impairment in
occupational or interpersonal functioning or
financial or legal consequences
Conduct Disorder
• A repetitive and persistent pattern of:
– Aggression to people and animals
• Fights, weapons, bullies, cruel
– Destruction of property
• Sets fires, deliberately destroys
– Deceitful or theft
• B and E’s, “cons” others, forgery
– Serious violation of rules
• Runs away, truant
Antisocial Personality Disorder
• A pervasive pattern of disregard for and
violation of the rights of others since the
age of 15 (Must be 18 for diagnosis)
– Failure to conform to social norms
– Deceitful
– Impulsive
– Aggressive
– Reckless
– Lack of remorse
Categories of Mood Disorder
• 20.7% of prison inmates exhibit a mood disorder
- Walsh, 2004
• Depressive Disorders
– Major Depressive Disorder, Dythymic Disorder
• Bipolar Disorders
– Bipolar I, Bipolar II, Cyclothymic Disorder, Bipolar
Disorder NOS
• Other Mood Disorders
– Mood Disorder due to medical condition, Substance
abuse induced, Mood Disorder, Mood Disorder NOS
MAJOR DEPRESSIVE EPISODE
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Depressed mood or loss of interest in pleasure
Weight gain/loss
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue
Feeling worthless and guilty nearly everyday
Indecision and inability to concentrate
Recurrent thoughts of death, suicide
Must have five symptoms, including the first
above
For at least two weeks, most of the day, nearly
everyday
Manic Episode
• Abnormally elevated or irritable mood
disturbance lasting at least one week
• During this mood disturbance 3 or 4 of the
following:
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Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative
Racing thoughts (flight of ideas)
Distractibility
Increase in goal directed activity (socially, sexually,
work)
– Excessive involvement in pleasurable activities that
have painful consequences (business, shopping, sex)
Hypomanic Episode
• Elevated or irritable mood lasting four days
• During that period of disturbance 3 or 4 occur:
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Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative
Flight of ideas
Distractibility
Increase in goal directed activity
Excessive involvement in pleasurable activities
• The symptoms are uncharacteristic of the
person when not symptomatic
• The change in mood is noticeable by others
• Not severe enough to cause marked impairment
or need for hospitalization
Recognizing The Bipolar Spectrum
• Bipolar I
• Manic Episode Alone
• Manic Episode and Depressive Episode
• Bipolar II
• Depressive & Hypomanic episodes greater than 4
days
• Bipolar Disorder NOS
• Cyclothymia
– Mild to moderate fluctuating mood
Bipolar Related Disorders
• Criterion A for Manic and Hypomanic
episodes now requires “Change in Energy
and Activity” as well as mood change
• In Bipolar 1 it is no longer necessary to
meet full criteria for both Manic and
Depressive episodes
– a new specifier “with Mixed features” has been
added when the full criteria are only met for
one and not the other
Co-morbid Conditions
• BPD is frequently accompanied by
other disorders
• This fact contributes to misdiagnosis.
• Often only the co-morbid condition is
identified:
– Panic Disorder, Alcohol/Drug,
Dependence, Generalized Anxiety
Disorder, ADHD etc.
Diagnosing Schizophrenia
A.
B.
C.
D.
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F.
Two of the following for at least a month
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Disorganized or catatonic behavior
5. Negative symptoms (e.g., flat affect, social withdrawal,
avolition, alogia)
Only one symptom is needed if it is a bizarre delusion or
extreme hallucination (e.g.. hearing voices conversing).
Disturbance causes marked decrease in functioning in either
work, social functioning, or self-care
Six months of symptoms that includes at least a month of
“A” above and the rest may include prodromal or residual
symptoms (i.e., negative symptoms or those in “A” but
attenuated)
Rule-out Schizoaffective and Mood Disorder with Psychosis:
1. No significant mood symptoms during active phase
2. If mood symptoms present during active phase, their
duration is brief relative to active and residual phases
Not due to a medical condition or a substance
Schizophrenia
• Two Changes
– Elimination of the special role of Bizarre
delusions and the Schneiderian first rank
auditory hallucinations (Voices conversing)
• i.e. two symptoms from Criterion A required in DSM
5
– The Subtypes (Paranoid, Disorganized,
Undifferentiated, and Residual) dropped.
• Dimensional Assessment picks up the severity
measure
New Disorder
• “Disruptive Mood Dysregulation Disorder”
– children older than 5 with temper/rage
outbursts
– The working name “Temper Dysregulation
Disorder with Dysphoria” was abandoned
• It is intended to address the over
diagnosis of Bipolar Disorder in children
Personality Disorders
• The planned overhaul of “personality
disorders” does not appear in DSM 5
• The proposed alternative will be published
in Section 3 of DSM 5, diagnoses that
require further study
• So for now nothing changes
– lack of agreement due to a failure of scientific
validators!
– “A horribly wasted opportunity” – Shedler,
University of Colorado Medical School
PROMIS
Patient Reported Outcome Measurement Information
System
• Domains Assessed:
– Pain, fatigue, physical functioning, depression,
anxiety, sleep disturbance, social functioning,
global health, (in the past 7 days)
• Child & Adult versions
ASSIST
The Alcohol, Smoking and Substance Involvement
Screening Test
• Developed by WHO to detect substance
use problems
• Similar instruments include
– MAST, DAST, SASSI-3
PHQ – 9
The Patient Health Questionnaire
• 9 questions with Likert responses
• Used to diagnosis depression level
PHQ-8
The Patient Health Questionnaire
• 8 questions with Likert responses
• Measures depressed mood level
GAD-7
• Generalized Anxiety Disorder
• 7 questions to measure GAD
PHQ-15
• Measures Physical Symptoms
WHO
Disability Assessment Schedule
• A generic assessment of health and disability
• Used across all disorders, including mental, neurological,
and addictive disorders
• Domains assessed:
– Cognitive, mobility, self care, getting along with
others, life activities (work, school, leisure,…) and
participant (social/community involvement)
• 12 questions quick screen
• 36 questions more detailed
Altman Self-Rating Mania Scale
• A 5 question self-reporting diagnostic
scale to assess level of mania and
hypomania symptoms
• Items measured
– Mood, self confidence, sleep, talking and
activity
– Likert scale
SNAP
Swanson Nolan and Pelham
• 90 questions
• Likert scale responses
• Assesses ADD, ADHD, ODD
Questions?
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Participation and
Attendance!
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