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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 • • • • 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 • • • • • • • • 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 • • • • 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 • • • • PROMIS ASSIST PHQ-9 PHQ-8 • • • • 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. • • • • • Opioid use dis. Opioid intoxication Opioid withdrawal Other opioid-induced dis. Unspecified opioid-related dis. Opioid Use Disorder • 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 • • • • • • 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 • • • • • • • • • • 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: – – – – – – 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: – – – – – – – 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. E. 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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