Session 26 A NP Conference Handout - Session 5

7/29/2019 Session 26 A NP Conference Handout - Session 5

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The DSM-5

J. Lynsey Psimas, PhD

Big Changes Ahead

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Agenda

The origins of mental health classification systems

History of the DSM

Big changes in the DSM-5

Changes in Specific Diagnoses

Impact on IDEA and Special Education

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History of the DSM

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HIPPOCRATESBefore the DSM:Classification in the Ancient World

Hippocrates (460-377 B.C.)

First to place psychiatric conditions within the domain of medicine. He identified 6 conditions:

1. Phrenitis

2. Mania

3. Scythian disease

4. Epilepsy

5. Hysteria

6. Melancholia

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Before the DSM

* Sources: First et al., 2004; Gaines, 1992; Malik & Beutler, 2002

1840 (US Census)

Initial attempts at formal psychiatric classification

Idiocy and Insanity vs. Normals

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DSM-I

Concern that lack of a uniform classification system wouldinhibit science by preventing accurate comparisons amongpatient groups

(Statistics of the American Medico-Psychological Association)

1952 - First edition of the Diagnostic & Statistical Manual ofMental Disorders(DSM-I) was published

7 Beginning Revisions: DSM-II

1968DSM-II

The first of ficial changes were made to DSM

Based in Psychoanalytic Theory (Freud)

Objective: To conform to the system used in the ICD

Number of diagnoses: From 106 to 182

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International Classification of Diseases (ICD)

F0: Organic, including symptomatic, mental disorders

F1: Mental and behavioral disorders due to use of psychoactivesubstances

F2: Schizophrenia, schizotypal and delusional disorders

F3: Mood disorders

F4: Neurotic, stress-related and somatoform disorders

F5: Behavioral syndromes associated with physiological disturbancesand physical factors

F6: Disorders of personality and behavior in adult persons

F7: Mental retardation

F8: Disorders of psychological development

F9: Behavioral and emotional disorders with onset usuallyoccurring in childhood and adolescence

F10: a group of "unspecified mental disorders"

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DSM-III

1980DSM-III

Objective: Retain conformity with the newest ICD

Number of diagnoses: 182 to 265 diagnoses

Multi-axial system established

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Multi-axial Classification System

Axis I: Clinical Disorders All mental disorders except Personalit y Disorders and Mental

Retardation

Axis II: Personality Disorders and Mental Retardation

Axis III: General Medical Conditions Must be connected to a Mental Disorder

Axis IV: Psychosocial and Env ironmental Problems Ex. limited social support network

Axis V: Global Assessment of Functioning (GAF) Psychological, social and job-relate d functions are evaluated on a

continuum between mental health and extreme mental disorder

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* Sources: Gaines, 1995; Houts, 2002; Kutchins & Kirk, 1995; Malik & Beutler, 2002; Rentoul, 1995; Widiger, 2004

Revisions: DSM-III-R

1987 - DSM-III-R

Effort includes women, minorities, psychologists &social workers

Number of diagnoses: From 265 to 292 diagnoses

Objective: Renamed & re-organize due to criticalreviews

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DSM-IV1994DSM-IV

Objective: To retain conformity with ICD-10 Number of diagnoses: From 292 to 365 diagnoses

13 DSM-IV-TR

2000DSM-IV-TR

Number of Diagnoses: No new diagnoses added

The 50-page increase from the DSM-IVreflected an effort

to include the growth that occurred in research knowledgeCultural

Ethnic

Age group variations

New lab and physical findings

Currently translated in 22 languages

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Understanding 50 Years of Change

DSM-II: 182 disorders

DSM-IV: 365 disorders

494 pages

134 pages

567 pages

DSM-III: 265 disorders

DSM-III-R: 265 disorders

DSM-IV-TR: 365 disorders

886 pages

943 pages

In 50 years: 800% increase in the number of diagnoses

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The DSM-5

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Timeline of DSM-5 1999-2001

Development of Research Agenda

2002-2007

APA/WHO/NIMH DSM-5/ICD-11 Research Planning conferences 2006

Appointment of DSM-5 Taskforce

2007 Appointment of Workgroups

2007-2011 Literature Review and Data Re-analysis

2010-2011 1st phase Field Trials ended July 2011

2011-2012 2nd phase Field Trials began Fall 2011

July 2012 Final Draft of DSM-5 for APA review

March 2013 Publication Date of DSM-5

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Big Changes in the DSM-5

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NEW: DSM-5 Classification System

Axes I, II, and III: (COMBINED)

All psychiatric and general medical diagnoses

Axis IV:

Current: Psychosocial and environmental problems

Goal: Correlate with ICD codes

Axis V:

Current: Global Assessment of Functioning (GAF)

Goal: Follow WHO International Family of

Classifications

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NEW: DSM-5 Organizational Structure Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders

Bipolar and Related Disorders Depressive Disorders

Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Dissociative Disorders

Somatic Symptom Disorders Feeding and Eating Disorders

Elimination Disorders Sleep-Wake Disorders

Sexual Dysfunctions Gender Dysphoria

Disruptive, Impulse Control, and Conduct Disorders Substance Use and Addictive Disorders

Neurocognitive Disorders Personality Disorders

Paraphilic Disorders Other Disorders

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NEW: Not Elsewhere Classified (NEC)

DSM-IV-TR Not Otherwise Specified (NOS)

DSM-5 Eliminated -or- Not Elsewhere Class ified (NEC)

NEC categories Specifiers

Ex: Depressive Disorder NEC 5 specifiers:

1. Recurrent Brief Depression

2. Mixed Sub-syndromal Anxiety and Depression3. Short duration (4-13 day) Depressive Episode4. Sub-threshold Depressive Episode with Insufficient Symptoms

5. Uncertain Depressive Disorder

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New: Diagnostic Considerations.

Caffeine Use Disorder

Internet Use Disorder

Complicated Grief Reaction

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NEW: Eliminate Addictions

Proposed: Eliminate the word Addiction

Instead: Use disorders"

Ex: Opioid use disorder

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Changes in Specific Diagnoses

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Changes to DSM-5 Diagnoses

Depressive Disorders

Major Depressive Disorder

Disruptive Mood Dysregulation Disorder

Disruptive, Impulse Control, and Conduct Disorders

Oppositional Defiant Disorder (ODD)

Neurodevelopmental Disorders

Autism Spectrum Disorders

ADHD

Specific Learning Disorder (SLD)

Intellectual Development Disorder

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Depressive Disorders *Disruptive Mood Dysregulation Disorder

*Major Depressive Disorder, Single EpisodeMajor Depressive Disorder, Recurrent

Dysthymic Disorder

Premenstrual Dysphoric Disorder

Substance-Induced Depressive Disorder

Depressive Disorder Associated with AnotherMedical Condition

Depressive Disorder Not Elsewhere Classified

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Disruptive Mood Dysregulation Disorder

Controversial new designation for children showingpersistent foul temper and bursts of rage

Previously proposed to be TemperDysregulationwith Dysphoria

Differentiation from Bipolar Disorder andOppositional Defiant Disorder (ODD)

DMDD is more severe than ODD and occursacross settings.

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Disruptive Mood Dysregulation Disorder (cont.)

DMDD is in the Depressive Disorders category, not BipolarDisorders

Why?

Provides more stringent criteria and more accurate sub-typing for the diagnosis of Bipolar Disorder (BD) in children

Classic adult BD does present in children and adolescents

Historically, clinicians have considered severe, non-episodicirritability is characteristic of pediatric BD

However, longitudinal studies suggest that many youth withnon-episodic irritability are at increased risk forunipolardepressive and anxiety disorders in adulthood, but not BD.

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Major Depressive Episode Removal of the bereavement exclusion in Major

Depressive Episode.

Considering your total clinical experience with thisparticular population, how mentally ill is the patient atthis time? 0 = Not Assessed

1 = Normal, not at all ill 2 = Borderline mentally ill

3 = M ildly ill

4 = Moderately ill

5 = M arkedly ill 6 = Severely ill

7 = Among the most extremely ill patients

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Disruptive, Impulse Control,and Conduct Disorders *Oppositional Defiant Disorder

Intermittent Explosive Disorder

*Conduct Disorder

*Callous and Unemotional Specifier for ConductDisorder

Dyssocial Personality Disorder (AntisocialPersonality Disorder)

Disruptive Behavior Disorder Not ElsewhereClassified

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Oppositional Defiant Disorder(ODD)Add levels of severity:

0 - Absent

Shows fewer than two symptoms

1 - Subthreshold

Shows at least two but fewer than four symptoms or symptoms donot cause significant impairment in any setting

2Mild

Shows at least four symptoms but symptoms are confined to onlyone setting (e.g., at home, at school, at w ork, with peers)

3Moderate

Shows at least four s ymptoms and some symptoms are present inat least tw o settings

4Severe Shows at least four s ymptoms and some symptoms are present in 3

or more settings

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Conduct Disorder

An additional specifier forCallous andUnemotional Traits in Conduct Disorder has beenproposed

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Neurodevelopmental Disorders

*Intellectual Developmental Disorders

*Autism Spectrum Disorders

*Communication Disorders

*Attention Deficit/Hyperactivity Disorder

*Specific Learning Disorders

Motor Disorders

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NEW: Intellectual Development Disorder

DSM-IV-TR: Mental Retardation

Intelligence Quotient (IQ) score of 70 or below (+/- 5 points)

Former DSM-IV-TR subtypes:

317 Mild Mental Retardation: IQ level 5055 to approximately70

318.0 Moderate Mental Retardation: IQ level 3540 to 5055

318.1 Severe Mental Retardation: IQ level 2025 to 3540

318.2 Profound Mental Retardation: IQ level below 20 or 25

Proposed DSM-5 levels of severity:

Mi ld, Moderate, and Severe levels of severi ty acrossConceptual, Practical, and Social domains

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NEW: Intellectual or Global Developmental

Delay Not Elsewhere Classified (NEC)

Clear evidence of s ignificant intellectual orgeneral developmental delay or disability, butcriteria for another specific disorder are not fullymet.

Why?

Additional clarifying data are required before one

can make a diagnosis of Intellectual Disability

The indiv idual is too young to fully manifest specific

symptoms

Individual is untestable

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Autism Spectrum Disorders Autism Spectrum Disorders (ASD) will be ONE single

diagnostic category: Autistic disorder (autism)

Asperger's Syndrome Childhood disintegrative disorder

Pervasive developm ental disorder (not o therwise specified)

Concentrates on required features: Social/communication deficits

Restricted, repetitive patterns of behavior, interests, activitieso Addition of sensory criteria

Under the new classification, clinicians would rate theseverity of cli nical presentation of ASD as: severe, moderate,or mild.

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Social Communication

Disorder

Not in DSM-IV-TR

May re-classifies students with PDD-NOS

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Attention Deficit/Hyperactivity Disorder (ADHD)

Age of onset (symptoms)

Changed from 7 to 12 years of age

Specifiers:

Hyperactive/Impulsive

Inattentive

Combined Type

Restrictive Inattentive

Multiple informants:

Information must be obtained from two differentinformants, preferably a (parent and teacher)

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Specific Learning Disorder (SLD)

SLDnot listed in DSM-IV

DSM-IV disorders subsumed under learning disabilityinclude: Disorder of Written Expression, Mathematics Disorder,

Reading Disorder, Learning Disorder Not OtherwiseSpecified

No previous general criteria for learning disorders.

These disorders affect individuals demonstrating at leastaverage abilities Learning Disorders are distinct from Intellectual

Developmental Disorder

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Implications of the DSM-5

Allows access to legal rights to non-discrimination and

accommodations (Section 504)

Access to Special Education Services through the

Individuals with Disabilities Education Act (IDEA)

Income support (Social Security Disability Insurance)

Medicaid-financed developmental disability services.

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The DSM-5 and Special Education

How will a change in diagnostic criteria impactinteractions with the school system?

Students with Aspergers or PDD-NOS?

Students with Social Communication Disorder?

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Questions?

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References First, M. B., Frances, A., & Pincus, H. A. (2004). Roo ts: A brief history of psychiatric

classification. In DSM-IV-TR Guidebook (pp. 3-11). Washington, DC: AmericanPsychiatric Press.

Gaines, A. (1992). From DSM-IIIto DSMIII-R; Voices of self, master y and the other: Acultural constructivist reading o f U.S. psychiatric classification. Social Science &Medicine, 35(1), 3-24.

Houts, A. C. (2000). Fifty years of p sychiatric nomenclature: Reflections on the 1943 WarDepartment Technical Bulletin, Medical 203. Journal of Clinical Psychology, 56(7),935-967.

Kutchins, H. & Kirk, S. A. (1995). DSM-IV: Does bigger mean better? Harvard MentalHealth Letter, 11(11), 4-7.

Malik, M. L. & Beutler, L. E. (2002). The emergence of dissatisfaction with the DSM. In L.E.Beutler & M. L. Ma lik (Eds.),Rethinking the DSM(pp. 3-16). Washington, DC:American Psychological Association.

Widiger, T.A. (2004). Classification and diagnosis: Historical development and contemporaryissues. In J. Maddux & B. Winstead (Eds.), Psychopathology: Foundations for a contemporar y

understanding(pp. 63-83). Lawrence Erlbaum Associates, Inc.

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Documents

Session 26 A NP Conference Handout - Session 5