being a good diagnostician: changes in diagnosis
DESCRIPTION
Being a Good Diagnostician: Changes in Diagnosis. Rhoda Olkin, Ph.D. Distinguished Professor California School of Professional Psychology – SF [email protected]. DZ. 7 Facts. DSM 5 (not V) to allow for numbering of revisions (5.1, 5.2, etc ). - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/1.jpg)
Being a Good Diagnostician: Changes in Diagnosis
DZ
1
Rhoda Olkin, Ph.D.Distinguished Professor
California School of Professional Psychology – [email protected]
![Page 2: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/2.jpg)
7 Facts1) DSM 5 (not V) to allow for numbering of
revisions (5.1, 5.2, etc).2) Was targeted for 2009, then 2011, now
May 22, 2013. 3) Am Psychiatric Assoc mtg in SF.4) 2-year grace period for implementation.5) Complete interface with ICD-11; codes in
parentheses.6) NIMH7) Cost: $139 – $199
DZ
2
![Page 3: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/3.jpg)
Pet Peeves?
DZ
3
![Page 4: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/4.jpg)
History
• Each DSM has tried to resolve problems in previous versions.
• Problems in DSM-IV-TR–Not very user friendly.–9 categories for diagnostic uncertainty. –NOS predominated.– Insufficient on culture.– Index not as good.
DZ
4
![Page 5: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/5.jpg)
Guiding Principles for Changes to DSM
Research evidence should support any addition or substantive modification.
Continuity with the current manual should be maintained when possible.
No restraints should limit the degree of change between DSM-5 and past editions. (Contradiction)
Routine clinical practices must be able to implement any changes.
5
![Page 6: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/6.jpg)
6 Types of Changes1) Structural changes.2) Shifting criteria.3) New diagnoses.4) Reclassification of diagnoses. 5) Deleted diagnoses. 6) Code #s
6
![Page 7: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/7.jpg)
Sections• Section 1: Intro to updates, how to use.
• Section II: The diagnoses (22 chapters)
• Section III: Conditions requiring further research; cultural formulations; glossary.
RO
7
![Page 8: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/8.jpg)
Overall Structural Changes What is the order of chapters (chronology?
Relatedness?). No axes info goes elsewhere. Ego syntonic / dystonic (insight) specifiers:–Good or Fair (dystonic)–Poor insight (ambivalent)–Absent insight (syntonic)
RO
8
![Page 9: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/9.jpg)
Overall Structural Changes p. 2
• Some require direct knowledge over 12 mos. • Severity indicators (replaces Axis V: GAF). • Severity level is “over time & circumstances.”• Some diagnoses go up to severity level 2, some
to 3. Rating scales. 0 = None (>70 GAF)1 = Mild (>70 GAF)2 = Severe3 = Very severe (<31 GAF)
RO
9
![Page 10: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/10.jpg)
Changes• Axis III: Part of diagnosis on Axis I.• Axis IV: Make notation of psychosocial and
contextual factors. • What happened to The Big 4 from DSM IV?– (GMC, substance use, malingering or factitious,
normal)?
RO
10
![Page 11: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/11.jpg)
The Big 4
• GMC: –Not in index. –But evident throughout.–Often option of X Disorder Due to Another
Medical Condition (e.g., Depressive Disorder Due to MS).–Sometimes not (e.g., Bipolar Dis Due to
A.M.C.)RO
11
![Page 12: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/12.jpg)
The Big 4
• Malingering Factitious Disorder – In Somatic Symptom & Related Disorders chapter.– Factitious Disorder Imposed on Self– Factitious Disorder Imposed on Another (was “by
proxy).– Single vs Recurrent Episodes– “Surreptitious actions to misrepresent, simulate, or
cause signs or symptoms of illness or injury in absence of obvious external rewards.” (p. 325)
– May co-occur with medical condition (e.g., manipulating blood sugar in person with diabetes).
12
![Page 13: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/13.jpg)
The Big 4
• Substance Abuse: and Suicidality: –Elevated status. –Will always note the correlation. –Some disorders can be: “Substance/Medication-Induced.
13
![Page 14: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/14.jpg)
The Big 4
• Normal:–Less of a concern?• Bereavement (V code).• Disruptive Mood Dysregulation Disorder (new).• ASD (increased stigma?).
– “Saving normal” (Allen Francis, 2013)
14
![Page 15: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/15.jpg)
Overall Structural Changes p. 3• NOS CNEC (conditions not
elsewhere classified):–Only for 6 months. –Only for specific reasons:
1) Diagnosis unclear (e.g., psychotic disorder CNEC)2) Clinician not trained to make the dx.3) Clinician cannot get info (e.g., client uncooperative;
records not available).4) You do not have enough info.5) Clinicians needs or is required to take more time of
direct observation (e.g., 12 months).
RO
15
![Page 16: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/16.jpg)
Implications?• Positives: –More reliability?–Better treatment planning?–Longer therapy authorized?
• More work & time in the diagnostic process.• Demand for outcome studies; clinicians to
validate their treatments (Dept of Corrections)• Responsibilities of diagnostician.– Severity index.– Symptom scales for some disorders.
RO
16
![Page 17: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/17.jpg)
The Chapters
• 22 chapters.• New order (?).• Some split (e.g., anxiety disorders).• Some renamed (e.g., neurodevelopmental
disorders).• Some new (e.g., Trauma- & Stressor-
Related Disorders)RO
17
![Page 18: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/18.jpg)
22 Chapters:1. Neurodevelopmental
Disorders2. Schizophrenia Spectrum &
Other Psychotic Disorders3. Bipolar & Related Disorders4. Depressive Disorders5. Anxiety Disorders6. Obs-Compulsive & Related 7. Trauma- & Stressor-Related 8. Dissociative Disorders9. Somatic Symptom Disorders10.Feeding & Eating Disorders11.Elimination Disorders12.Sleep/Wake Disorders
13. Sexual Dysfunctions14. Gender Dysphoria15. Disruptive, Impulse-Control
& Conduct Disorders16. Substance Related &
Addictive Disorders17. Neurocognitive Disorders18. Personality Disorders19. Paraphilic Disorders20. Other Mental Disorders21. Medication-induced
Movement…Med Effects22. Other Conditions (v codes)
RO
18
![Page 19: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/19.jpg)
Neurodevelopmental • Not just a rename – – Etiology important;–Disorders here are considered genetic/biochemical; –Not responses to environment.
• Eliminated Rett’s Disorder (genetic).• Includes: ADHD, ID, ASD, Communication
Disorders, Global Developmental Delay, Motor (Tic) Disorders, Specific LD.
• May include specifier: “associated with known med/genetic condition or environmental factor.”• NO: Sensory Processing Disorder (SID)
RO
19
p. 31
![Page 20: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/20.jpg)
MR Intellectual Disability (ICD-11: Int Dev Dis.)– PL 111-256, 2010, “ID.”– 3 criteria: Deficits in (a) intellectual functions, (b) adaptive
functioning, (c) onset during develop. period. – Code 319 with severity specifier: Mild (F70), Moderate
(F71), Severe (F72), Profound (F73). (Table for severity)– Severity is based on adaptive functioning, not IQ scores. – Functioning in Conceptual Domain, Social Domain,
Practical Domain.– Usually IQ scores 70 + 5 (Mean = 100; s.d. = 15). – Requires testing with instruments “normed for individual’s
sociocultural background and native language.” (p. 37)
Neurodevelopmental
20
![Page 21: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/21.jpg)
Autism Spectrum Disorder (ASD): (p. 50)
–Now included as ASD: Autism, Aspergers, PDD NOS, Disintegrative Disorder. –2 areas of disturbance:
• Social Communication & Social Interaction;• Restricted repetitive patterns of behavior.
–Diagnostic criteria are “illustrative, not exhaustive.”–Table for severity level, requiring: 1-support; 2-
substantial support; 3-very substantial support. –M:F = 4:1
RO
Neurodevelopmental
21
![Page 22: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/22.jpg)
NeurodevelopmentalCommunication Disorders:•Social Communication Disorder (new):•Language Disorders•Speech Disorders•Unspecified Communication Disorder•All of the following DSM IV disorders are subsumed under above: Language Emergence; Specific Language Impairment; Social Communication Disorder; Voice Disorder; Speech-Sound Disorder; Motor Speech Disorder; Child Onset Fluency Disorder.
RO
22
![Page 23: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/23.jpg)
Social Communication Disorder:•Must have all of A.•A. Persistent difficulties in social use of verbal and nonverbal communication:– Social purposes: (greeting, sharing info).– Changing communication to match listener or context.– Difficulties following rules for conversation or
storytelling (taking turns).– Difficulties understanding what is not explicitly stated,
and nonliteral or ambiguous meanings (idioms, humor, metaphors).
Neurodevelopmental
23
![Page 24: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/24.jpg)
DSM-IV-TRAutism
AspergersOverlap
DSM 5
Autism Spectrum Disorder
Social Communication Disorder
RO
24
![Page 25: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/25.jpg)
ADHD (p. 59)
• Inattention (>6/9) and/or hyperactivity-impulsivity (>6/9) that interferes with functioning or development.
• Prior to age 12 (instead of 7).• 2 or more settings. • Specify: Combined (314.01), Predominantly
inattentive presentation (314.00), Predominantly hyper/impulsive presentation (314.01). (Typo?)
• Specify: Mild, moderate, Severe. • Prevalence: About 5% of children, 2.5% of adults.• M:F 2:1R
O
Neurodevelopmental
25
![Page 26: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/26.jpg)
Specific Learning Disorder: (p. 66)
–Difficulties despite “provision of interventions” in:–A. 6 areas (no specified # to be met).–Specify and code: Reading; Written expression;
Mathematics. –Specify: Mild, Moderate, Severe.
Neurodevelopmental
26
![Page 27: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/27.jpg)
Motor Disorders (p. 74)
–Developmental Coordination Disorder.–Stereotypic Movement Disorder.–Tic Disorders (specify: Tourette’s; Persistent
Motor or Vocal Tic disorder; Provisional Tic Disorder.)
Other childhood disorders:–See other chapters.
Neurodevelopmental
27
![Page 28: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/28.jpg)
Anxiety Disorders
Split into 3 chapters:–Anxiety Disorders:• Fight or flight system (Amygdala).
–Trauma- & Stressor-Related Disorders.• Greater focus on affective response to external stressors.
–OCD & Related Disorders. • Based on imaging and genetic studies, and treatment
response. • Basal ganglia – movement circuit – focus on urge and
behavior, less on anxiety. DZ
28
![Page 29: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/29.jpg)
• Fear (fight or flight) + Anxiety (hyper-vigilance) + Behavior (avoidance).
• Separation Anxiety.• Selective Mutism. • Specific Phobias (more specifiers). • Social Anxiety Dis. (in chldrn, not just w adults). • Panic Disorder (4/12 symptoms + worry + behav.).• Agoraphobia. • GAD (3/6 sxs for adults, 1/6 for children). • Substance/medication induced; Anxiety due to AMC• Also Panic Attack Specifier (p. 214)
Anxiety Disorders
29p. 189
![Page 30: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/30.jpg)
Obsessive-Compulsive & Related Disorders
OCD. Hoarding Disorder. Excoriation (Skin Picking Disorder). Hair Pulling Disorder. Substance/Medication Induced. Due to Another Medical Condition.
DZ
30p. 235
![Page 31: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/31.jpg)
Obsessions vs Compulsions
Obsessions: Recurrent & persistent thoughts, urges, or images that are experiences as intrusive and unwanted.
Compulsions: Repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be rigidly applied.
31
![Page 32: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/32.jpg)
Trauma- & Stressor-RelatedExposure to traumatic or stressful event. New grouping of disorders from various places in DSM Adjustment Disorder.Acute Stress Disorder. PTSD.– 4 clusters of symptoms: Intrusion, Avoidance, Negative
mood/cognitions, Arousal & reactivity. – Children: expanded definition; section for < 6 yo.– Specifiers: (a) dissociative sxs (depersonalizationor derealization); (b) delayed expression.
Attachment disorders (next slide).
DZ
32
p. 265
![Page 33: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/33.jpg)
Attachment related disorders: Common etiology: Absence of adequate caregiving
during childhood. Reactive Attachment Disorder: Internalizing disorder: depression, withdrawal. New criteria (4/5 sxs; onset between 9 mos. & 5
yrs.) Disinhibited Social Engagement: (NEW). Externalizing disorder: disinhibition, externalizing
behavior. 2/4 sxs; onset > 9 mos.
Trauma- & Stressor-Related
33
![Page 34: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/34.jpg)
5 Pathogenic Realms
Some disorders are considered to arise from one or more of five pathogenic realms. This distinguishes them from disorders that are thought to be biochemical (e.g., bipolar disorder).
1. Persistent disregard of child’s emotional needs; &/or2. Persistent disregard of child’s physical needs; &/or3. Repeated changes in primary caregivers; &/or4. Raised in settings with limited opportunities for
stable attachments; &/or5. Persistent harsh punishment or other types of grossly
inept parenting. RO
34
![Page 35: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/35.jpg)
Bipolar Disorders
• 1974: Increased focus on distinguishing BP from schizophrenia.
• Mid-1980s: Broadening the “BP spectrum”–Avoid antidepressant-induced mania–Treat the spectrum properly
• Mid-1990s: Pediatric BD–Catch it early, avoid kindling
DZ
35p. 123
![Page 36: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/36.jpg)
• Late 1990s: Increased use of 2nd generation antipsychotics for BD.• Now: Narrowing the gate on Pediatric
BD.
Bipolar Disorders
36
![Page 37: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/37.jpg)
• Bipolar I: no change (> 1 episode mania). (NB: suicide risk 15 x’s greater)
• Bipolar II: no change (hypomania & MDD) (Lethality of suicide methods greater than Bipolar I)
• Cyclothymia: (hypomanic episodes below criteria for hypomania + depression below threshold for MD); (minimum of 2 years for adults, 1 year in children/adolescents).
DZ
37
Bipolar Disorders
![Page 38: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/38.jpg)
38
Bipolar Disorders
Specifiers:oAnxious distress (mild, moderate, moderate-severe, severe).oMixed features.oRapid cycling (4 mood episodes in 12/ months. oWith melancholic features.oWith atypical features.
![Page 39: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/39.jpg)
What about Pediatric Bipolar?• Increasing diagnosis, over-diagnosis, wrong medication
interventions, inaccurate prediction, heterogenous disorder. • There may be two types of currently diagnosed PBD:
– a narrow definition that looks like adult BD > still BD.– a different form that includes explosive emotional outbursts that don’t
look like mania (no grandiosity, delusions) and are not so cyclical. • Looks a little like ADHD, but there may be more aggression.
Looks like disruptive behavior disorder, but more emotional lability.
• Believed that they will not grow up with BD and should perhaps be treated with antidepressants and/or Ritalin.
• Many will now be diagnosed with Disruptive Mood Dysregulation Disorder (under Depression). D
Z39
![Page 40: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/40.jpg)
Depressive DisordersDisruptive Mood Dysregulation Disorder:– New disorder.– Older than 5 yrs;– Persistent irritability;– Frequent episodes of behavior outbursts > 3 a
week for more than 1 year; – Intended to address concerns about potential over-
dx & over-trmnt of bipolar disorder in children; – First diagnosis between ages 6-18;onset <10.– Cannot coexist with ODD or bipolar disorder.– Children with this dx typically develop unipolardepression or anxiety, not bipolar disorder.R
O40
p. 155
![Page 41: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/41.jpg)
Depression DisordersMajor Depressive Episode – –Need 5/9 symptoms.– In children/adol mood may be irritable.– Table of codes for severity and single vs recurrent
Dysthymia Persistent Depressive Disorder– Still 2 years (adults); 1 yr children/adol– Five specifiers. (p. 169)
o Nixed Mixed Anxiety Depression Section 3.RO
![Page 42: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/42.jpg)
Premenstrual Dysphoric Disorder•5 sxs in week before menses.•Improvement few days after onset of menses. •A: 1/4 mood symptoms + B: 1/7 behavior symptoms = combined to equal 5 sxs.
42
Depression Disorders
![Page 43: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/43.jpg)
Bereavement“Responses to a significant loss (e.g., bereavement…) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in the Criterion A [for MDE], which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a MDE in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and cultural norms for the expression of distress in the context of loss.” (p. 125-126) {V Code}•See footnote p. 126; same footnote p. 161 43
![Page 44: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/44.jpg)
Schizophrenia & Other Psychotic Disorders
• Schizophrenia:– Eliminated subtypes (paranoid, hebephrenic,
disorganized, residual, catatonic).– 2/5 sxs (a. delusions, b. hallucinations, c.
disorganized speech, d. disorganized or catatonic behavior, e. negative symptoms); 1 sx must be a, b, or c; 1 month.
–What are negative sxs? “diminished emotional expression or avolition”).
– Functional impairment. –Disturbance persist for > 6 months.
RO
44
p. 87
![Page 45: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/45.jpg)
Schizophrenia & Other Psychotic Disorders
Delusional Disorders: Few changes. •Subtypes: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified. •Specifier: w. bizarre content (implausible, not within ordinary experience).Brief Psychotic Disorder: – 1 day to 1 month.– Specifiers: w./w-o stressors; postpartum; with
catatonia, severity (0-4 for each symptom). RO
45
![Page 46: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/46.jpg)
Schizophrenia & Other Psychotic Disorders
• Schizophreniform Disorder.– 1 to 6 months.– Specifiers: good/w-o good prognostic features, with
catatonia, each sxs severity 0-4 • Schizoaffective Disorder: • Major Mood Episode + Criterion A of
schizophrenia.• >2 weeks of delusions or hallucinations w-o mood.
• Some discussion of Schizotypal PD here. 46
![Page 47: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/47.jpg)
Substance-Related & Addictive Disorders
• No “abuse” or “dependence”; now “use.” • Chapter reorganized by substance.–10 classes of drugs:Alcohol; Caffeine; Cannabis; Hallucinogens;
Inhalants; Opioids; Sedatives, hypnotics & anxiolytics; Stimulants; Tobacco; Other.
• Two groups of disorders: (a) Substance use disorders, (b) Substance-induced disorders.
47p. 481
![Page 48: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/48.jpg)
• Substance use disorder: continued use of substance despite significant substance-related problems. 4 sets of criteria:– Impaired control (4 criteria).–Social impairment (3 criteria).–Risky use (2 criteria).–Pharmacological criteria (2 criteria:
tolerance & withdrawal). 48
Substance-Related & Addictive Disorders
![Page 49: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/49.jpg)
• Severity levels:–Mild (2-3 symptoms)–Moderate (4-5 symptoms)–Severe (> 6 symptoms)
• Remission: –Early vs Sustained; –Maintenance therapy–Controlled environment
49
Substance-Related & Addictive Disorders
Example: Moderate Valium use disorder; Mild alcohol use disorder; Secobarbital withdrawal.
![Page 50: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/50.jpg)
• New language:“All drugs that are taken in excess have in common direct activation of the brain reward system…. Individuals with lower levels of self-control, which may reflect impairments of brain inhibitory mechanisms, may be particularly predisposed to develop substance use disorders, suggesting that the roots of substance use disorders for some persons can be seen in behaviors long before the onset of actual substance use itself.” (p. 481)
50
Substance-Related & Addictive Disorders
![Page 51: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/51.jpg)
• “This chapter also includes gambling disorder, reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse, and produce some behavioral symptoms that appear comparable to those produced by the substance use disorders.” (p. 481)
51
Substance-Related & Addictive Disorders
![Page 52: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/52.jpg)
• Controversy about other behavioral “addictions” to be included here/elsewhere.–Gambling is here.
–Other behavioral patterns are not: Internet gaming, shopping, sex, exercise addiction.
52
Substance-Related & Addictive Disorders
![Page 53: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/53.jpg)
Disruptive, Impulse Control, & Conduct Disorders
• Some childhood disorders went here.• These disorders share symptom of problems of
self-control of emotions and behaviors.• Unique in that they violate the rights of others
or brings person into conflict with authority. • Typical onset is in childhood or adolescence.
53p. 461
![Page 54: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/54.jpg)
Disruptive, Impulse Control, & Conduct Disorders
• Oppositional defiant disorder.• Intermittent explosive disorder.• Conduct disorder.• Antisocial PD (see PD chapter)• Pyromania.• Kleptomania.• Other.
RO
54
![Page 55: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/55.jpg)
Disruptive, Impulse Control, & Conduct Disorders
Conceptualizing the relationship across ODD, CD, & Antisocial PD:
55
ODD
CD APD
ANXIETY
DEPRESSION
![Page 56: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/56.jpg)
Oppositional Defiant Disorder: o4/7 symptoms• Angry/Irritable Mood (3) • Argumentative/Defiant Behavior (4)
oPlus has been spiteful or vindictive > x2 in past 6 months.
o6 months; not just with sibling.oMild (1 setting); Moderate (2 settings); Severe (>3
settings)
RO
56
Disruptive, Impulse Control, & Conduct Disorders
![Page 57: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/57.jpg)
Intermittent Explosive Disorder–Either verbal aggression 2/week for 3 mos., or
behavioral outbursts resulting in damage of property or assault on animals or person, 3 xs in 12 mos. –Minimum age of 6. (For ages 6-18 is not part
of Adjustment Disorder.)
RO
57
Disruptive, Impulse Control, & Conduct Disorders
![Page 58: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/58.jpg)
Conduct Disorder (minor wording changes)o 3/15 criteria in 12 mos, from any category:•Aggression to people and animals (7)•Destruction of property (2)•Deceitfulness or theft (3)•Serious violation of rules (3)o Subtypes: Age of onset (<10, >10, unspecified)o Specifier: With limited prosocial emotions (use
multiple sources of information). (see p. 470)
RO
58
Disruptive, Impulse Control, & Conduct Disorders
![Page 59: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/59.jpg)
Disruptive, Impulse Control, & Conduct Disorders
• Pyromania and Kleptomania remained. • All disorders in this chapter:
Are correlated with substance abuse. Prognosis guarded.
• Not included: Nonsuicidal self-injury (see proposed criteria in Section 3).
RO
59
![Page 60: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/60.jpg)
Gender Dysphoria• Different criteria for children, & adoles. & adults. • 6/8 symptoms over 6 mos (must include strong desire
to be other gender)• Language: – Sex = biology; Gender = social role/identity; – Transgender = identify with other gender; – Transexual = seeks/has undergone social transition to other
gender.– Gender dysphoria = distress that may accompany the
incongruience between assigned and expressed gender. – Thus dysphoria, not identity, is key to this diagnosis.
• Specifier: With disorder of sex development (for children & adults); post-transition (adolescents & adults).
60
p. 451
![Page 61: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/61.jpg)
Gender Dysphoria• Less pathologizing term than Disorder.• Balancing Needs:–Not a Mental Disorder per se.–How to get insurance coverage?
• Imperfect compromise.• Other dysphorias?• Keeping pathology in gender identity?• No “Discrimination Disorder” A new V
code?
RO
61
![Page 62: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/62.jpg)
Other Disorders: V codes!
Relational problems (7) [uncomplicated bereavement] Abuse & Neglect (approximately 48) Educational Problems (1) Occupational Problems (2) Housing & Economic Problems (9) Other problems related to social environment (6) [discrimination] Problems related to crime or interaction w legal system (5) Other health srvc encounters for counseling & medical advice (2) Problems related to other psychosocial, personal, &
environmental circumstances (7) Other circumstances of personal history (7) Problems related to access to medical & other health care (2) Nonadherence to medical treatment (5) [malingering]
RO
62
p. 715
![Page 63: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/63.jpg)
Re Suicidal Behaviors• Kapusta, N. (2012). Non-suicidal self-
injury and suicide risk assessment, quo vadis DSM-V? Suicidology Online, 3, 1-3.
63
![Page 64: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/64.jpg)
Diagnosing Personality Disorders
What is a “personality” and how can it be “disordered”?
RO
64
![Page 65: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/65.jpg)
Where Are We?Where were we?
Where did we go wrong? Where should we go?
RO
65
![Page 66: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/66.jpg)
Personality TraitsPreviously:
Gordon Allport: 4,000 personality traitsUnmanageable.
Raymond Cattell: 16 personality factorsStill too complex.
Hans Eysenck: 3-factor theoryToo simplistic.
Then: D. W. Fiske (1949); Norman (1967); Smith (1967); Goldberg (1981); and McCrae & Costa (1987): THE BIG FIVE –Studied in over 50 cultures; remarkably consistent.
RO
66
![Page 67: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/67.jpg)
The Big Five(OCEAN)
Openness: This trait features characteristics such as imagination and insight, and those high in this trait also tend to have a broad range of interests.
Conscientiousness: Common features of this dimension include high levels of thoughtfulness, with good impulse control and goal-directed behaviors. Those high in conscientiousness tend to be organized and mindful of details.
Extraversion: This trait includes characteristics such as excitability, sociability, talkativeness, assertiveness and high amounts of emotional expressiveness.
Agreeableness: This personality dimension includes attributes such as trust, altruism, kindness, affection, & other pro-social behaviors.
Neuroticism: Individuals high in this trait tend to experience emotional instability, anxiety, moodiness, irritability, and sadness.
•RO
67
![Page 68: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/68.jpg)
Dimensional Scale Based on Big Five
RO
68
![Page 69: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/69.jpg)
Big 5 vs DSM-IVThe five personality dimensions were not
the building blocks for the personality disorders in DSM-IV.
Instead, 10 PD were put into three clusters.
The characterization of the clusters did not coincide with the Big 5.
RO
69
![Page 70: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/70.jpg)
DSM-IV-TR Clusters• Cluster A : Odd or eccentric
– Schizoid, Paranoid, Schizotypal
• Cluster B : Dramatic, emotional or erratic
–Antisocial, Borderline, Narcissistic, Histrionic
• Cluster C : Anxious, fearful–Avoidant, Dependent, Obsessive-Compulsive
RO
70
![Page 71: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/71.jpg)
The Categorical System
71
![Page 72: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/72.jpg)
Personality DisordersStudy on clients diagnosed with PD who were in treatment, conducted by DSM TF, 1999-2007:–Rediagnosed using RDC on 5,000 clients 75%
false positives. – Those with “BPD” 85% false positives.–After 1 yr most no longer meet criteria.
Therefore, workgroup considered:– Eliminating some PD.– Elevating criteria for PD.–Making process of dx more daunting.
RO
72
![Page 73: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/73.jpg)
From DSM-IV to DSM 5• Erase all PD?
• Recluster?
• Redefine?
DZ
73
![Page 74: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/74.jpg)
Could Redefine “Personality”• DSM-IV: A pervasive pattern of thinking/
behaving/emotionality.• Perhaps? A personality disorder reflects
"adaptive failure" involving: – "Impaired sense of self-identity" or – "Failure to develop effective interpersonal
functioning."
RO
74
![Page 75: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/75.jpg)
Personality Disorders – The way it almost was
• Personality types defined by personality domains and facets:–Negative affect (facets: lability,anxiety/
insecurity, hostility)–Detachment (facets: withdrawal/depression,
suspicion)–Antagonism (facets: difficult to get along with:
manipulative, deceitful, hostile)–Disinhibition (facets: impulsive/irresponsible)– Psychoticism (facets: unusual/bizarre
experiences, eccentric)RO
75
![Page 76: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/76.jpg)
Personality Disorders – The way it almost was
More emphasis on process of PD diagnosis:1.Does person have a personality problem (self, interpersonal)2.Determine if it matches 1 of the 6 personality types (former PD’s)3.If it does, describe using domains and their facets4.If it doesn’t PD-trait specified (PDTS) category: you can describe people even if they don’t have a trait diagnosis.5.Would require knowing more about a client, increase involvement of psychotherapist in diagnosis, reduce use of PD diagnosis. 6.Sequestered to Section 3 as of December 2012
76
![Page 77: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/77.jpg)
Personality DisordersSuggested process of diagnosis:1.Documented observations over 12 months of impairments in core functioning (self, interpersonal, empathy, intimacy).2.Personally observed pathological traits over 12 months.3.Recognized overall severity level of 3 over 12 months.
RO
77
![Page 78: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/78.jpg)
Personality Disorders Pathological traits seen in 5 realms, as seen in relationship with therapist over 12 months:1.Negative affectivity:
Lability, anxiety, separation insecurity, hostility, perseveration, submissiveness, suspiciousness, dysphoric attitudes, emotional dysregulation.
2.Detachment: Emotional constriction, anhedonia, withdrawal, intimacy avoidance.
RO
78
![Page 79: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/79.jpg)
Personality Disorders
3. Antagonism:Manipulative, deceitful, attention seeking, grandiose, callous.
4. Disinhibition or compulsivity:Perfectionism, controlling, impulsive, risk taking, distancing, emotionally inaccessible.
5. Psychoticism:Unusual beliefs, eccentric, cognitive dysregulation.
RO
79
![Page 80: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/80.jpg)
Personality Disorders• Considered eliminating:–Schizotypal (to be moved to Schiz.)–Schizoid (to be moved to Schiz.)–Histrionic PD–Dependent PD
RO
80
![Page 81: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/81.jpg)
Personality Disorders
RO
All 10 PDs
The cluster system
What did they change? Removed lower age limit (except
Antisocial PD).
See also Section 3
Instead, retained:
81
![Page 82: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/82.jpg)
CultureDSM-IV: Culture bound syndromes.APA Multicultural Guidelines: How
social, cultural, political, and historical contexts manifest in clinical presentations.
DSM 5: More in text; Cultural formulation chapter (p. 749-759) w CF Interview (16 Qs).
RO
82
![Page 83: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/83.jpg)
Good Article re Culture:Dadlani, Overtree, & Perry-Jenkins (2012). Culture at the center: A reformulation of diagnostic assessment. Professional Psychology: Research & Practice, 43(3), 175-182.
83
![Page 84: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/84.jpg)
Good Books re Diagnosis Beach, Wamboldt, Kaslow, Heyman, First, Underwood,
& Reiss (Eds.) (2006). Relational processes and DSM-V: Neuroscience, assessment, prevention, and treatment. Arlington, VA: American Psychiatric Association.
Garcia, B., & Petrovich, A. (2011). Strengthening the DSM: Incorporating resilience and cultural competence. NY: Springer Publishing Co.
Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM 5, big pharma, & the medicalization of ordinary life. NY: William Morrow.
84
![Page 85: Being a Good Diagnostician: Changes in Diagnosis](https://reader036.vdocuments.net/reader036/viewer/2022062315/56815ccd550346895dcadc54/html5/thumbnails/85.jpg)
Questions?
Answers?
Thank you!85