Download Navigating the Kraepelinian Vortex2

6th Annual Summit
Supporting Children &
Youth Who Struggle
January 24, 2014
Navigating the Kraepelinian Vortex:
Changes in the Diagnoses for Children
from DSM-IV to DSM-V
James A. Burns PhD
Sources
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American Psychiatric Association
DSM IV and IV-TR
DSM 5
The Selling of DSM, The Rhetoric of
Science in Psychiatry
Various other websites and publications
What is Abnormal?
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Deviations from statistical norm?
Deviations from social norm?
Maladaptive behavior?
Personal Distress?
What is abnormal?
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May be statistically uncommon and
socially deviant but these are not
necessary characteristics.
DSM and psychopathologists seems to
weigh more heavily on maladaption and
personal distress.
Example:
What then is a disorder?
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Grouping of symptoms?
Illness in and of itself?
Psychological construct versus physical
existence.
Misuse of diagnoses (K and K p93)
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These problems persist (94 and 95)
History of DSM
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DSM I (1952)
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132 pages
Disorders as “reactions”
Disorders were nonspecific
Definitions were nonspecific
Descriptions were paragraphs of
prototypical cases
Psychodynamic in orientation
History of DSM
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DSM II (1968)
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134 pages
Reaction terminology dropped
Multiple diagnoses encouraged
Coincided with ICD 8
Psychodynamic in orientation
A revolution?
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From DSM II to III something changed
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Who was pushing the change?
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What was changing?
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“scientific psychiatry,” payors, public
Movement away from psychoanalysis
Organized psychiatry and the
medicalization of mental health
The “medical model”
Power and Authority
History of DSM
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DSM III
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494 pages
Multi-axial classification system introduced
Neutral, atheoretical, and descriptive in
terms of etiology
More specific criteria
The problem of Reliability
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Reliability versus validity
DSM III-Reliability-Validity
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Reliability
Validity
Interplay between the two
Research versus clinical practice
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SCID (Structured Clinical Interview)
DIS (Diagnostic Interview Schedule)
History of DSM
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DSM IV (1994)
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886 pages
“clinical significance” criterion
New disorders introduced
PTSD, Acute Stress Disorder, Bipolar II,
and Asperger’s
Others deleted (some personality
disorders)
History of DSM
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DSM 5 (2013)
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947 pages
Dimensional or severity scales adopted
Cultural and gender issues considered
more
Multi-axial system dropped
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Diagnoses and associated illness listed together
in order of importance
DSM 5 Changes
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Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence
replaced by:
Neurodevelopmental Disorders
Neurodevelopmental Disorders
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Intellectual Disorder (DSM pps 34-41)
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Used to be mental retardation
More emphasis placed on adaptive
functioning
IQ still used but balanced against
functioning
High quality descriptions.
Neurodevelopmental Disorders
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Communication Disorders (used to be’s)
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Language Disorder (mixed expressivereceptive language disorders)
Speech Sound Disorder (phonological
disorder)
Childhood Onset Fluency Disorder
(stuttering)
Social Communication Disorder (new)
Neurodevelopmental Disorders
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Autism Spectrum Disorder
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Four previous diagnoses were believed to
encompass one illness with differing
severities in TWO core domains.
Autism, Asperger’s, Childhood
Disintegrative Disorder, and PDD NOS
Autism Spectrum Disorder
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Core Domains:
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Deficits in social communication and social
interaction.
Restricted repetitive behaviors, interests,
and activities
BOTH DOMAINS ARE REQUIRED FOR A
DIAGNOSIS
Autism Spectrum Disorder
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Severity and associated features are
indicated through the use of specifiers
Social communication disorder is
diagnosed if no restricted repetitive
behaviors, interests, and activities are
present.
Attention-Deficit/Hyperactivity
Disorder
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Criteria very similar
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Inattention and Hyperactivity/Impulsivity domains
Better examples added in criteria
Cross-situational requirement strengthened
Onset changed to before 12 years old
Subtypes replaced with specifiers
Comorbidity with ASD now allowed
Symptom threshold lowered for adults
Specific Learning Disorder
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Reading Disorder, Math Disorder, and
Disorder of Written Expression all
combined
Different learning disorders will be
differentiated with specifiers
Motor Disorders
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Developmental Coordination Disorder
Stereotypic Movement Disorder
Tourette’s Disorder
Tic disorders (criteria for a “tic” have
been standardized across all disorders)
Disruptive, Impulse-Control,
and Conduct Disorders
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Brings together two chapters of Impulse
Disorders and Disorders Usually First
Diagnosed in Infancy, Childhood, or
Adolescence.
All are disorders involving emotional
and behavioral self-control.
Oppositional Defiant Disorder
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Symptoms grouped into angry/irritable
mood, argumentative/defiant behavior,
and vindictiveness.
More guidance on frequency of
behavior to justify diagnosis.
Severity rating has been added.
Conduct Disorder
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Criteria largely unchanged from DSM-IV
Specifier added to distinguish callous
and cold interpersonal style.
Intermittent-Explosive
Disorder
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In DSM-IV physical aggression was required
now verbal aggression and non-injurious
lesser physical aggression also meets criteria.
Frequency of outbursts clearly specified.
Negative impairment, functioning, and
consequences added as criteria.
Minimum of 6 years old
Differential diagnoses clarified between this
and other disorders such as ADHD DMDD.
Trauma and Stressor-Related
Disorders
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Reactive Attachment Disorder
Disinhibited Social Engagement
Disorder
PTSD – criteria added for assessing
children under 6 years old (DSM5 pps
272-273)
Acute Stress Disorder
Adjustment Disorders
Diagnoses that have moved!
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Separation anxiety disorder is now an
anxiety disorder.
Selective mutism is now an anxiety
disorder.
Obsessive and Compulsive Disorders
now has a chapter.
New Disorders of interest
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Excoriation (skin picking) Disorder
Substance or medication induced OCD
OCD related to a medical condition
Disruptive Mood Dysregulation Disorder
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Added in response to over-diagnosis of
Bipolar Disorder in children (DSM5 pp156)
What I am happy about…
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Attempts to cut down on overdiagnosing of Bipolar Disorder in
children.
Obsessive and Compulsive Disorders
have their own chapter.
Criteria for PTSD in children under 6
Disruptive Mood Dysregulation Disorder
What I am disappointed by…
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Dropping 5 Axis diagnosis
Dropping Global Assessment of
Functioning
No clear diagnostic category for children
who have endured chronic long term
trauma.