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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 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? Deviations from statistical norm? Deviations from social norm? Maladaptive behavior? Personal Distress? What is abnormal? 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? Grouping of symptoms? Illness in and of itself? Psychological construct versus physical existence. Misuse of diagnoses (K and K p93) These problems persist (94 and 95) History of DSM DSM I (1952) 132 pages Disorders as “reactions” Disorders were nonspecific Definitions were nonspecific Descriptions were paragraphs of prototypical cases Psychodynamic in orientation History of DSM DSM II (1968) 134 pages Reaction terminology dropped Multiple diagnoses encouraged Coincided with ICD 8 Psychodynamic in orientation A revolution? From DSM II to III something changed Who was pushing the change? What was changing? “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 DSM III 494 pages Multi-axial classification system introduced Neutral, atheoretical, and descriptive in terms of etiology More specific criteria The problem of Reliability Reliability versus validity DSM III-Reliability-Validity Reliability Validity Interplay between the two Research versus clinical practice SCID (Structured Clinical Interview) DIS (Diagnostic Interview Schedule) History of DSM DSM IV (1994) 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 DSM 5 (2013) 947 pages Dimensional or severity scales adopted Cultural and gender issues considered more Multi-axial system dropped Diagnoses and associated illness listed together in order of importance DSM 5 Changes Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence replaced by: Neurodevelopmental Disorders Neurodevelopmental Disorders Intellectual Disorder (DSM pps 34-41) Used to be mental retardation More emphasis placed on adaptive functioning IQ still used but balanced against functioning High quality descriptions. Neurodevelopmental Disorders Communication Disorders (used to be’s) Language Disorder (mixed expressivereceptive language disorders) Speech Sound Disorder (phonological disorder) Childhood Onset Fluency Disorder (stuttering) Social Communication Disorder (new) Neurodevelopmental Disorders Autism Spectrum Disorder 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 Core Domains: Deficits in social communication and social interaction. Restricted repetitive behaviors, interests, and activities BOTH DOMAINS ARE REQUIRED FOR A DIAGNOSIS Autism Spectrum Disorder 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 Criteria very similar 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 Reading Disorder, Math Disorder, and Disorder of Written Expression all combined Different learning disorders will be differentiated with specifiers Motor Disorders 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 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 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 Criteria largely unchanged from DSM-IV Specifier added to distinguish callous and cold interpersonal style. Intermittent-Explosive Disorder 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 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! 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 Excoriation (skin picking) Disorder Substance or medication induced OCD OCD related to a medical condition Disruptive Mood Dysregulation Disorder Added in response to over-diagnosis of Bipolar Disorder in children (DSM5 pp156) What I am happy about… 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… Dropping 5 Axis diagnosis Dropping Global Assessment of Functioning No clear diagnostic category for children who have endured chronic long term trauma.