Diagnostic groupings in the DSM 5

In DSM-IV TR, the diagnostic groupings had a separate category for children and adolescents.

DSM 5 does not make a separate category for children and adolescents

In DSM-IV TR some of the categories had names that made no sense-such as somatoform disorders

DSM 5 attempts to simplify diagnostic category names DSM 5 organizes diagnostic categories into 20

chapters, starting with diagnostic categories that are seen earlier in life and progressing to those that are seen later in life

Diagnostic groupings in IV-TR and 5

Attention to severity assessment and specification of severity for each diagnosis

Inclusion of other specified disorder and unspecified disorder as a diagnosis for each group (Replaces that NOS) "Other specified disorder" permits clinician to

communicate sub threshold diagnoses and specific reasons why client did not meet criteria for other diagnoses within that group

Changes throughout DSMX

DSM 5 has 20 diagnostic groupings plus a group of other conditions that might be a focus clinically (V codes)

DSM 5 organizes these categories beginning with those that might be seen earlier in life and progressing to those later in life

DSM 5 changes in classification

Neuro developmental

Bipolar

Schizophrenia Depressive

Anxiety

Obsessive-compulsive and related

Trauma related

Dissociative

Somatic symptom related

Feeding and eating disorders

Sexual dysfunctions

Sleep wake disorders

Elimination disorders

Substance related and addictive disorders

Disruptive, impulse control disorders

Neurocognitive disorders

Personality disorder

Gender dysphoria

Paraphilia disorders

Others

Younger Older

The progression from younger to older in the DSM is general and there are specific disorders such as some early childhood feeding disorders that clearly occur later

1. Neurodevelopmental disorders2. schizophrenia spectrum and other psychotic disorders3. bipolar and related disorders4. depressive disorders5. anxiety disorders6. obsessive-compulsive and related disorders7. Trauma and related disorders8. dissociative disorders9. Somatic symptom and related disorders10. feeding and eating disorders11. elimination disorders12. sleep wake disorders13. sexual dysfunctions14. gender dysphoria15. disruptive, impulse control, and conduct disorders16. neurocognitive disorders17. paraphilia disorders

Which are your top 7 or 8

Neurodevelopmental disorders-1. mental retardation is removed intellectual disability

is put in.

2. Autism spectrum disorder is the new DSM 5 diagnosis encompassing autistic disorder. Aspergers and childhood disintegrative disorder as well as pervasive developmental disorder.

3. Several changes have been made to ADHD- specifiers = combined; inattententive type; hyperactive/impulsive type

Changes in the groupings: 1. Neurodevelopmental disorders

SUMMARY

Severity level

Conceptual domain Social domain Practical domain

Mild Preschool = no obvious differences. School-aged children and adults = academic skills involving reading writing math time or money. In adults abstract thinking planning cognitive flexibility are somewhat impaired impaired. Tendency toward concrete thinking

Immaturity and social interactions; some difficulty picking up social cues communication conversation in language more concrete than peers. Possible difficulties in emotional regulation and age-appropriate behavior. Perhaps impairment in risk assessment

Personal care may be age-appropriate, but more complex tasks might require support. For example grocery shopping, transportation home and childcare organization food prep banking and money management

Moderate Conceptual skills lag markedly language development and pre-academic skills slow to develop. School-age children = progress in reading writing mass understanding of time and money but slower than peers. Adults = academic skill development is at an elementary level. Ongoing assistance needed in conceptual decision-making

Marked differences in social and communication from peers. Spoken language is much less complex than peers. Capacity for relationships evident in familial friendship ties. Problems with perceiving social cues in social situations accurately. Social judgment and decision-making limited. Help is needed with life decisions

Personal care is okay in adulthood. Adults typically can participate in all household tasks with teaching. Can work with considerable support in the workplace

Severe Limited attainment of conceptual skills. Little or no understanding of written language math, time and money. Extensive support for problem solving is needed

Spoken language is limited in terms of vocabulary and grammar. Communication is focused on the here and now an everyday event. Relationships and relational ability is considerable.

Support needed for all activities of daily living. Supervision required at all times. We will not make responsible decisions regarding well-being .skill acquisition is very limited

Profound No concept of symbolic processes, perhaps some functional use of objects, although this might be limited by disturbance and motor

skills.

Might understand simple instructions and cues. Social expression is often nonverbal. Can respond and enjoy relationships with people who were well known to them. Can initiate limited social interaction with such people through gestures. Sensory and physical impairments may prevent social activities

Dependent on others for all aspects of daily physical care. Participation in these activities is limited.. Some simple concrete tasks such as carrying dishes to the table might be accomplished. Co-occurring physical and sensory impairments are often barriers to participation

MENTAL RETARDATION = INTELLECTUAL DISABILITYSeverity level for intellectual disability

SEVERITY DETERMINED BY ADAPTIVE FUNCTIONING NOT IQ

1. Expressive language disorder2. Receptive-expressive language disorder3. Phonological (articulation) disorder= speech sound disorder (315.39) In DSM 54. Stuttering AKA Childhood onset fluency disorder (315.35) In DSM 5

Combined into "language disorder" (315.39) in DSM 5

Includes deficits in language speech and communication

A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following;

deficits in using communication for searching purposesA.impairments of the ability to change communications to match the context or needs of the listenerB.difficulties following rules for conversation and storytelling such as taking turns in conversation , rephrasing and knowing how to use verbal and nonverbal to regulate interactionC.Difficulties in understanding what is not explicitly stated

B. Deficits result in functional limitations and effective communications. The onset is in the early developmental. (But deficits aren't fully noticeable until later in life)

C. Not attributable to another medical condition or neurological condition and not better explained by other neurodevelopmental disorders

Social pragmatic communication disorder 315.39

Differential diagnoses should always consider the possibility of autism spectrum disorder, in particular those with mild severity.Primary deficits of ADHD can cause some impairments in social communicationsocial anxiety disorder and social phobia can often appear with similar symptoms and again mild intellectual developmental disorder might also mask symptoms

DEFINED INDEPENDENT FROM GENERAL INTELLIGENCE

DIAGNOSED WHEN AN INDIVIDUAL’S ACHIEVEMENT ON INDIVIDUALLY ADMINISTERED STANDARDIZED TESTS IN READING, MATH OR WRITTEN EXPRESSION IS SUBSTANTIALLY BELOW THAT FOR EXPECTED AGE AND INTELLIGENCE

DSM IV Dyslexia – reading disorder Dyscalculia – math disorder Dysgraphia – written expression disorder

LEARNING DISORDERS

A. Difficulty learning and using academic skills indicated by the presence of at least one of the following symptoms for at least 6 months despite interventions.

1. Inaccurate or slow and effortful word reading2. Difficulty understanding the meaning of what is read3. Difficulties with spelling4. Difficulties with written expression5. Difficulties mastering number sense, number facts, or calculation6. Difficulty with mathematical reasoning

B. Affected academic skills are substantially and quantifiably below those expected for the individual's chronological age causing significant interference with performance (quantifiable suggest testing)

C. The learning difficulties begin during school way cheers but might not become apparent until those faculties require more regular use

D. Not better accounted for by intellectual disabilities visual or auditory deficits other mental or neurological disorders etc.

DSM 5 criteria – no separation

In DSM-IV TR, ADHD was grouped in the diagnostic domain of "disruptive behavior disorders seen in childhood and adolescence"

DSM 5 has moved it to neurodevelopmental disorders

DSM-IV TR separated ADHD into 2 subtypes: predominantly attention deficit predominantly hyperactivity impulsivity

DSM 5 has moved these two sub-types to specifiers

ADHDX

Must occur before age 7 years Present for at least 6 months Causes impairment in at least 2 settings

Meets 6 of 9 symptoms of inattention AND/OR 6 of 9 symptoms of

hyperactivity/impulsivity – Must be developmentally inappropriate levels

Diagnostic Criteria for ADHD(DSM-IV)

DSM 5 has moved onset age limit to 12!

Now requires “SEVERAL SYMPTOMS” across settings

X

A. Persistent pattern of inattention and or hyperactivity-impulsivity that interferes with functioning or development as characterized by inattention and or hyperactivity/impulsivity

1. Inattention: 6 or more of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic activities

A. Often fails to give close attention to details or makes careless mistakes in schoolworkB. Has difficulty sustaining attention in tasks or play activitiesAnd remaining focusedC. Often does notseem to listen when spoken to directlyD. Does not follow through on instructions and fails to finish schoolwork chores or

dutiesE. Has difficulty organizing tasks and activitiesF. Avoids dislikes or is reluctant to engage in tasks that require sustained mental effortG. Loses things necessary for tasks or activitiesH. Is easily distractedI. Is forgetful in daily activities

DSM 5 criteriaX

314.01 – combined presentation 314.00-predominantly inattentive presentation 314.01 predominantly hyperactive impulsive In partial remission Severity level (mild moderate severe)

Specifiers

ADHD can now be co-morbid with Autism spectrum Symptom threshold has been specified for adults Adults require a minimum of 5 symptoms – not 6 Developmentally appropriate example of symptoms

are offered

Other important changes ADHDX

Represents a new classification of several disorders that were considered different forms of autism

Previously, these were separate diagnoses. Autistic disorder Retts disorder Childhood disintegrative disorder Aspergers PDD NOS

Autism Spectrum disorderX

Autistic disorder Retts disorder Childhood disintegrative disorder Aspergers PDD NOS

PDDs in DSM IV TR

All characterized by severe deficits and pervasive impairment in multiple areas of development•Reciprocal social interaction•Communication impaired•Stereotyped behavior, interests and activities

With the new DSM 5. Those separate disorders have now been consolidated and ASD is evaluated in terms of severity rather than separate diagnosis

RETTS Disorder removed because it has been established as a physical disease

X

Three domains from the DSM IV-TR became two: 1Social interaction; 2 communication deficits; 3 repetitive behavior/fixated interest =

1)     Social interaction/communication deficits2)     Fixated interests and repetitive behaviors

Deficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms with contextual and environmental specificities

Delays in language are not unique nor universal in ASD and are more accurately considered as a factor that influences the clinical symptoms of ASD, rather than defining the ASD diagnosis

Requiring both criteria to be completely fulfilled improves specificity of diagnosis without impairing sensitivity

Providing examples for subdomains for a range of chronological ages and language levels increases sensitivity across severity levels from mild to more severe, while maintaining specificity with just two domains

Decision based on literature review, expert consultations, and workgroup discussions; confirmed by the results of secondary analyses of data from CPEA and STAART, University of Michigan, Simons Simplex Collection databases

major changes for ASDX

A.    Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:

1.     Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction,

2.     Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.

3.     Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and  in making friends  to an apparent absence of interest in people

B.    Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of  the following:

1.     Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases). 

2.     Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).

3.     Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).

4.     Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).

C.    Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

D.         Symptoms together limit and impair everyday functioning.E. Symptoms are not better explained by intellectual developmental disorder or global developmental

delay

DSM 5 criteria for all ASDX

With or without accompanying intellectual impairment

With her without accompanying language impairment

Associated with a known medical or genetic condition or environmental factor

With catatonia Specify severity level

SpecifiersX

severitySeverity level ASD

Social communication and interaction

Restricted interests and repetitive behaviors

3.Requires very substantial support

Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others.  

Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres.  Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly

2 requires substantial support Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others

RRBs and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts.  Distress or frustration is apparent when RRB’s are interrupted; difficult to redirect from fixated interest

I requires support Without supports in place, deficits in social communication cause noticeable impairments.  Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others.  May appear to have decreased interest in social interactions. 

Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts.  Resists attempts by others to interrupt RRB’s or to be redirected from

fixated interest.

X

STIGMA - aspergers made autism respectable! Will it continue to de-stigmatize or re-stigmatize

Will clinicians and insurance companies “control for” the intellectual disability bias? Prior co-morbid estimates with previous classification

= 25-75% Drops to negligible with PDD and Aspergers

ASD CONCERNSX

2. Schizophrenia spectrum

Schizophrenia spectrum and other psychotic disorders

1. The spectrum seems to emphasize degrees of psychosis

2. Change in criteria for schizophrenia now requires at least one criteria to be either a. Delusions, b. Hallucinations or c. Disorganized speech

3. Subtypes of schizophrenia were eliminated

4. Dimensional measures of symptom severity are now included

5. Schizoaffective disorder has been reconceptualized

6. Delusional disorder no longer requires the presence of “non-bizarre" in delusions. There is now specifier for bizarre delusions.

7. Schizotypal personality disorder is now considered part of the spectrum

X

Schizophrenia and other disorders related to schizophrenia are now grouped within a spectrum

Overall definition of schizophrenia has not changed that much Requirements that delusions must be bizarre and

hallucinations must be "first rank." (eg. Two or more voices conversing together) have been eliminated.

The four subtypes of schizophrenia (paranoid, catatonic, disorganized and chronic undifferentiated) have been eliminated.

Rating of symptom severity is most important

Overview of changes from DSM-IV TR to the DSM five

2: schizophrenia and the DSM 5X

‘Spectrum’ as it applies to mental disorder is a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits".[1]

In some cases, a spectrum approach joins together conditions that were previously considered separately.(wikipedia)

Spectrums

Spectrum suggests a progression from

Attenuated psychosis Syndromein conditions for further study

Schizotypal personality Disorder(Found in PD Section)

delusional disorder

Briefpsychotic disorder

Schizophreniform disorder

Schizoaffective disorder

Schizophrenia

Mild or brief Major or lengthyDebilitation DebilitationSeverity severity

In the following areas1.Delusions2.Hallucinations3.Disorganized thinking/speech4.Disorganized or abnormal motor behavior5.Negative symptoms

Attenuated psychosis syndrome

A. At least one of the following symptoms is present in attenuated form and with relatively intact reality testing. It is of sufficient severity or frequency to warrant clinical attention

1. Delusions2. Hallucinations3. Disorganized speech

B. Symptoms must have been present at least once per week for the last monthC. Symptoms have begun or worsened in the last yearD. Symptom is sufficiently distressing or disabling to the individualE. Symptom is not better explained by another mental disorder including a

depressive or bipolar disorder with psychotic features and is not caused by a substance

F. Criteria for any other psychotic disorder have never been met

Symptoms are psychosis like, but below the threshold for a full psychotic disorder. Typically the symptoms are less severe and more transient than in another psychotic disorder. Insight is relatively intact this condition might be stress related. Typically the individual realizes that these changes are taking place and something is wrong. Usually occurs in late adolescence or early adulthood

CRITERIA

DIAGNOSTIC FEATURES

Schizotypal personality disorder(Technically not in the spectrum)

A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduce capacity for close relationships as well as by cognitive or perceptual distortions and eccentric cities of behavior beginning by early adulthood and present in a variety of contexts as Indicated by 5 or more of the following:

1. Ideas of reference (excluding delusions of reference)2. Odd beliefs or magical thinking that influences behavior; i.e. belief in clairvoyance, astral projection telepathy etc.3. Unusual perceptual experiences, including bodily illusions4. Odd thinking and speech5. Suspicious or paranoid ideation6. Inadequate or constricted affect7. Behavior or appearance that is odd eccentric or peculiar8. Lack of close friends or confidants9. Excessive social anxiety that does not diminish

1. does not occur exclusively within the course of schizophrenia a bipolar disorder or depressive disorder with psychotic features or another psychotic disorder or autism spectrum disorder

Pervasive pattern of social and it interpersonal deficits as well as eccentricities of behavior and cognitive distortions. Such people usually have few close relationships and are considered odd. They may be fascinated or preoccupied with paranormal phenomena and/or superstitions they might believe that they have magical powers. They typically do not fit in and have difficulty matching the norms of consensual social interaction. Typically these people do not become psychotic and any psychotic symptoms are often transient and mild

Criteria

SchizophreniaDSM-5 Criteria and DSM-IV criteria are sameDSM-5 Criteria and DSM-IV criteria are same::

CRITERION A. 2 or more characteristic symptoms present

for 1-month period over a 6-month period:

1. Delusions2. Hallucinations3. Disorganized speech4. disorganized behavior5. Negative symptoms (personality

deterioration)

X

Requirement of “bizarre delusions”and/or schneidnerian 1st rank hallucinations is changed to

At least 1 of the two below need to be from core positive symptoms (delusions, hallucinations, disorganized speech)

1.Delusions

2. Hallucinations

3. Disorganized speech

4. disorganized behavior

5. Negative symptoms (personality

Except forX

B. Level of functioning in one or more areas-work, interpersonal relations, self care, vocation-is markedly below the level of functioning prior to the onset; social/ occupational dysfunction – cant work or relate

C. Continuous signs of the disturbance for at least 6 months (at east 1 month with symptoms from category A. Duration is the main factor in differentiating schizophrenia from similar illnesses

D. have successfully ruled out schizoaffective disorder and mood disorder (with psychotic symptoms) b/c no evidence of mania or depression

E. not due to substance abuse F. not due to Autism spectrum disorder

X

Specifiers

1st episode, currently in acute stage 1st episode currently in partial remission 1st episode in full remission multiple episodes, currently in acute episode multiple episodes currently in partial remission multiple episodes currently in full remission continuous with catatonia

X

Schizophrenia

Other symptoms outside the major diagnostic criteria include mood dysphoria, inappropriate affect sleep disturbance depersonalization, derealization somatic concerns, vocational impairments

Lack of insight or awareness or even denial about the existence of the illness is also a symptom that commonly occurs.

Aggression, sometimes associated with delusions is common in males, although not as a rule

Although there are many brain and genetic abnormalities that have been identified, there are no “absolute” biological markers

Schizophrenia is often overdiagnosed in the poor

There is a high rate of suicide among schizophrenics-6%. With a suicide attempt rate of close to 20%

Still thought to be a lifelong illness although the occurrence of "positive symptoms" seem to diminish with age

Depression often shows up over time

Diagnostic featuresX

Schizophreniform disorder

* At least one third of people who receive this diagnosis recover. However the other two thirds will eventually be diagnosed with schizophrenia

Meets all the diagnostic criteria for Schizophrenia, except duration

Diagnosed when duration is less than six months (Absence of criterion B) (this includes prodromal, active and residual phase)_ Make this diagnosis when someone is having an episode

longer than one month, but it has not yet lasted 6 months (call it ‘provisional)

The 'Tweener' disorder in terms of length. The period of active psychotic symptoms (delusions, hallucinations, disorganized thinking, disorganize motor behavior) is longer than a brief psychotic episode, but not as long as schizophrenia Make this diagnosis when an individual Has already

recovered And the episode lasted between 1 and 6 months

Diagnostic featuresX

Schizophreniform

A. 2 or more of the following present for a significant portion of time. At least one of these must be one 2 or 3

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Disorganized motor behavior

5. Negative symptoms

B. Lasts at least one month but less than 6 months. When diagnosis is made before recovery, specify "provisional“

C. Schizoaffective disorder, depressive disorder or bipolar disorder with psychotic features have been ruled out because either no major mood episodes have occurred with the psychotic symptoms or if they have occurred, their occurrence was infrequent

D. Not attributable to substances or another medical condition

Diagnostic criteria – 295.40X

Schizoaffective disorder

A. An uninterrupted. period which there is a major mood episode con current with criterion A of schizophrenia

1. Delusions2. Hallucinations3. Disorganized thinking4. Grossly abnormal motor behavior5. Negative symptoms of schizophrenia

B. In addition, Delusions or hallucinations must occur for two or more

weeks with an absence of a major mood episode during the lifetime duration of the illness

C. Symptoms that meet criteria for major mood episode be present for the majority of the duration of the Active, and residual portions of the illness

D. Not attributable to the effects of a substance medication or other medical condition

Diagnostic criteria295.70

The requirement that a major mood disorder must be present for the majorityOf the duration of illness AFTER criterion A is met, makes this alongitudinalIllness or bridge on spectrum

X

Specify whether:295.70-bipolar type295.70-depressive typeSpecify if:with catatonia1st episode currently in acute episode1st episode currently in partial remission1st episode currently in full remissionmultiple episodes currently in acute episodemultiple episodes currently in partial remissionmultiple episodes currently in full remissioncontinuousseverity level-use. Clinician related dimensions of psychotic symptoms

SubtypesX

PSYCHOTICISM

AFFECT

HIGH

HIGH

NONE

NONE

MOOD DISORDER

MOOD DISORDERWITH PSYCHOTIC FEATURES

SCHIZOPHRENIAACUTE

SCHIZOPHRENIAPARTIAL REMISSION

SCHIZO-AFFECTIVE

X

Diagnosis must now include both changes in mood and changes in activity/energy level

Some particular conditions can now be diagnosed under "other specified bipolar and related disorders“

An "anxiety" specifier has now been included Attempts made to clarify definition of 'hypomania".

However it was not successful Bipolar I mixed episode –no longer requires full criteria

for depressed and mania or hypomania New specifier is “mixed features”.

3. Bipolar and related disorderssummary

X

Some particular conditions can now be diagnosed under "other specified bipolar and related disorders”

These do not meet full criteria for bipolar diagnosis

1. No history of major depression with hypomanic episode05-

2. Short durations. Cyclothymic (less than 24 months).

3. Multiple episodes of hypomanic symptoms that do not meet criteria and multiple episodes of depressive symptoms that you might meet criteria

4. History of major depressive disorder• Hypomanic symptoms present but not of

sufficient duration (less than 4 days)• Insufficient number of hypomanic

symptoms

X

Severity Criteria are unclear "Severity is based on the number of criterion symptoms,

Francis severity of those symptoms and the degree of functional disability." (Page 154)

Dimensional measures for both mania and depression exist as level II crosscutting measures. These could be used to measure severity.

Problems

Bipolar I Coding for severityBipolar I disorder

Current or most recent episode-manic

Current or most recent episode-hypomanic

Current or most recent episode-depressed

Current or most recent episode-unspecified

Mild 296.41 Not applicable 296.51 Not applicable

Moderate 296.42 Not applicable 296.52 Not applicable

Severe 296.43 Not applicable 296.53 Not applicable

Mild = few if any symptoms in excess of those required to meet the diagnostic criteria are present. The intensity is distressing that manageable. Symptoms resulting minor impairment of social and occupational functioning

Moderate = number of symptoms and intensity and/or functional impairment are between those specified for mild and severe

Severe = number of symptoms is substantially in excess of those required to make DX. Intensity of symptoms is seriously distressing and unmanageable. Symptoms interfere markedly with social and occupational functioning.

The dimensional Alternative assessment

of mania and hypomania

DSM 5 offer some assistance Suggests 1st using the level I crosscutting

symptoms scale-PP.734 – 735. That the answers to question 9 and 10-increased

energy anddecreased need for sleepare positive then

Move to use of the Altman self rating mania scale (ASRM) - See next slide

Level 2 Dimensional Measure for Mania

Level II measures are more in-depth than level I measures. The level I measure shown in week 1 measured a number of different symptoms. Level II focuses in on only one subgroup. In this case mania

Instructions for the mania scale

Instructions: for client On the DSM-5 Level 1 cross-cutting questionnaire you just completed, you indicated that during the past 2 weeks you (theindividual receiving care) have been bothered by “sleeping less than usual, but still having a lot of energy” and/or “starting lots more projects than usual or doing more risky things than usual” at a mild or greater level of severity. The five statement groups or questions below ask about these feelings in more detail. 1. Please read each group of statements/question carefully.2. Choose the one statement in each group that best describes the way you (the individual receiving care) have been feeling for the past week.3. Check the box (P or x) next to the number/statement selected.4. Please note: The word “occasionally” when used here means once or twice; “often” means several times o more and frequently” means most of the time. 

Instructions to CliniciansThe DSM-5 Level 2—Mania—Adult measure is the Altman Self-Rating Mania Scale. The ASRM is a 5-item se rating mania scale designed to assess the presence and/or severity of manic symptoms. The measure is completed by the individual prior to a visit with the clinician. If the individual receiving care is of impaired capacity and unable to complete the form (e.g., an individual with dementia), a knowledgeable informant complete the measure. Each item asks the individual (or informant) to rate the severity of the individual’s manic symptoms during the past 7 days. Scoring and InterpretationEach item on the measure is rated on a 5-point scale (i.e., 1 to 5) with the response categories having differ anchors depending on the item. The ASRM score range from 5 to 25 with higher scores indicating greater severity of manic symptoms. The clinician is asked review the score on each item on the measure during th clinical interview and indicate the raw score for each item in the section provided for “Clinician Use”. The r scores on the 5 items should be summed to obtain a total raw score and should be interpreted using the Interpretation Table for the ASRM below: Interpretation Table for the ASRM- A score of 6 or higher indicates a high probability of a manic or hypomanic condition- A score of 6 or higher may indicate a need for treatment and/or further diagnostic workup - A score of 5 or lower is less likely to be associated with significant symptoms of mania  

Coding and recording procedures for bipolar one disorder

Coding is complicated Must specify the following in the order presented below

1. Bipolar I disorder2. Type of current episode (manic or depressive)3. Severity level 4. Current state of most recent episode (active, in partial

remission, in full remission, unspecified)5. Psychotic features present6. Presence of other specifiers (uncoded)

Bipolar I Coding for Current state of episode & psychosis

Bipolar I disorder

Current or most recent episode-manic

Current or most recent episode-hypomanic*

Current or most recent episode-depressed

Current or most recent episode-unspecified**

W/ psychotic features

296.44 Not applicable 296.54 Not applicable

In Partial remission

296.45 296.45 296.55 Not applicable

In full remission 296.46 296.46 296.56 Not applicable

Unspecified 296.40 296.40 296.50 Not applicabl

*Do not code severity and psychotic features if current or most recent episode is hypomanic. **Do not code severity and psychotic features if current or most recent episode = unspecified.

New diagnosis included = "disruptive mood dysregulation disorder-use for children up to age 18

New diagnosis included = "premenstrual dysphoric disorder“

What used to be called dysthymic disorder is now "persistent depressive disorder“

Bereavement is no longer excluded

4. Depressive disordersSUMMARY

X

MDD: Specifiers

SeverityWith anxious distressWith mixed featuresMelancholic Features Atypical Features Catatonic Postpartum SeasonalWith Psychotic Features(Mood congruent or

incongruent)

X

Depression is mainly coded by severity and recurrence

Severity/course specifier

Single episode Recurrent episode

Mild 296.21 296.31

Moderate 296.22 296.332

Severe 296.23 296.33

With psychotic features 296.24 296.34

In partial remission 296.25 296.35

In full remission 296.26 296.36

Unspecified 296.20 296.30Mild = few if any symptoms in excess of those required to meet the diagnostic criteria are present. The intensity is distressing that manageable. Symptoms resulting minor impairment of social and occupational functioning

Moderate = number of symptoms and intensity and/or functional impairment are between those specified for mild and severe

Severe = number of symptoms is substantially in excess of those required to make DX. Intensity of symptoms is seriously distressing and unmanageable. Symptoms interfere markedly with social and occupational functioning.

Severity Criteria are unclear "Severity is based on the number of criterion symptoms,

Francis severity of those symptoms and the degree of functional disability." (Page 154)

Dimensional measures for both mania and depression exist as level II crosscutting measures. These could be used to measure severity.

Problems with severity

LEVEL ii CROSS-CUTTING MEASURE FOR DEPRESSION. The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking ( or x) one box per row.

Instructions to Clinicians The DSM-5 Level 2—Depression—Adult measure is the 8-item PROMIS Depression Short Form that assesses the pure domain of depression in individuals age 18 and older. The measure is completed by the individual prior to a visit with the clinician. If the individual receiving care is of impaired capacity and unable to complete the form (e.g., an individual with dementia), a knowledgeable informant may complete the measure as done in the DSM-5 Field Trials. However, the PROMIS Depression Short Form has not been validated as an informant report scale by the PROMIS group. Each item asks the individual receiving care (or informant) to rate the severity of the individual’s depression during the past 7 days.

Scoring and Interpretation Each item on the measure is rated on a 5-point scale (1=never; 2=rarely; 3=sometimes; 4=often; and 5=always) with a range in score from 8 to 40 with higher scores indicating greater severity of depression. The clinician is asked to review the score on each item on the measure during the clinical interview and indicate the raw score for each item in the section provided for “Clinician Use.” The raw scores on the 8 items should be summed to obtain a total raw score. Next, the T-score table should be used to identify the T-score associated with the individual’s total raw score and the information entered in the T-score row on the measure.

Note: This look-up table works only if all items on the form are answered. If 75% or more of the questions have been answered; you are asked to prorate the raw score and then look up the conversion to T-Score. The formula to prorate the partial raw score to Total Raw Score is: (Raw sum x number of items on the short form) Number of items that were actually answered If the result is a fraction, round to the nearest whole number. For example, if 6 of 8 items were answered and the sum of those 6 responses was 20, the prorated raw score would be 20 X 8/ 6 = 26.67. The T-score in this example would be the T-score associated with the rounded whole number raw score (in this case 27, for a T-score of 64.4). The T-scores are interpreted as follows: Less than 55 = None to slight 55.0—59.9 = Mild 60.0—69.9 = Moderate 70 and over = Severe Note: If more than 25% of the total items on the measure are

Explanation of other specifiers With anxious distress = 1. Tense, 2. Restless 3. Excessive worry 4. Fear of catastrophe 5. Fear of losing control

If present, Code severity of anxiety Mild = 2 symptoms moderate = 3 symptoms moderate- severe = 4 or 5 symptoms

With mixed features = prominent dysphoria or depressed mood, diminished interest or pleasure, psychomotor retardation and/or other symptoms found in depressive episodes

With melancholic features = loss of pleasures and all activities, lack of reactivity to pleasurable experiences. 3 or more of the following; depressed mood that is worse in the morning, early-morning awakening mark psychomotor agitation or retardation, significant weight loss, excessive guilt

With atypical features = mood improves in response to positive events (mood reactivity) 2 or more of the following; weight gain or increase in appetite, hypersomnia, heavy feeling in arms or legs heightened sensitivity to interpersonal rejection

Mood congruent psychotic features = with depression, delusions and hallucinations are often punitive, self punishing and rejecting. Perhaps delusions of persecution or annihilation.

Mood incongruent psychotic features = delusions and hallucinations are not consistent with mood being displayed

With postpartum onset = onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery. Depressive episodes are far more common than manic episodes

Seasonal pattern = regular temporal correlation between the onset of manic, hypomanic or depressive episodes and a particular time of year, usually without the presence of psychosocial stressors

With anxiety Anxiety is very common with depression

anxious distress =

1. Tense 2. RelentlessRestlessness 3. Excessive worryOr concern that is

unwarranted 4. Excessive concern regarding the

occurrence of a major negative event- 5. Fear of losing control

If present, Code severity of anxiety Mild = 2 symptoms moderate = 3 symptoms moderate- severe = 4 or 5 symptoms

Persistent depressive disorder 300.4 Formerly known as dysthymic

disorder

• In The DSM-IV TR, dysthymia was considered a depressive disorder that that was

A. long-lasting (chronic) and B. did not meet the full criteria for a major depressive

episode- a milder form of depression

X

Persistent depressive disorder in the DSM 5

Combines dysthymia and a chronic form of major depressive disorder (without

certain symptomsPersistent depressive disorder

X

Dysthymia vs MDD

Chronic sense of inadequacy Depression is not as intense as with MDD Symptoms are typically not as “acute” as

with MDD MDD = depressed mood, most of day, nearly every

day for two weeks Dys = depressed mood more days than not over a

period of 2 years

Seems more like a personality disorder “dissatisified personality”

N

X

Dysthymic Disorder and Chronic major depressive disorder

2 or more of the following associated Symptoms Along with depressed mood

1. Change in appetite

2. Change in sleep

3. Decreased energy

4. Decreased self worth

5. Poor concentration

6. Hopelessness

.

X

Please note that there are 3 major symptoms missing from this list that are included in major depressive disorder;

1. Absence of pleasure (anhedonia) 2. Recurrent thoughts of suicide 3. Psychomotor retardation or agitation

This suggests that only a particular type of major depressive disorder-1 without suicidal ideation, anhedonia and lethargy qualify for this diagnosis

X

PDD: Specifiers Severity With anxious distress With mixed features Melancholic Features Atypical Features Psychosis-mild (mood congruent or incongruent) Postpartum Partial remission Full remission Late onset-21 or older Early onset

With pure dysthymic syndrome-criteria for major depression is not been met

With persistent major depressive episode-full criteria have been met, excluding anhedonia, psychomotor retardation and suicidal ideation

Intermittent major depressive episodes with or without current episode

X

In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons. The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. Second, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section III. Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes. Finally, the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression.

The bereavement exclusion is goneX

Disruptive mood dysregulation disorder296.99

The purpose of this diagnosis was to provide a category for children that created an alternative to the diagnosis of bipolar disorder

Evidence for such a diagnosis has long been available. Earlier proposals were "severe mood dysregulation“

Evidence suggests that children with this type of mood dysregulation will not go on to be bipolar, but more likely suffer from major depression

X

Diagnostic criteriaA. Severe recurrent temper outburst manifested verbally or

behaviorally; grossly out of proportion to the situation to the situation

B. Outbursts are inconsistent with developmental levelC. Outbursts occur 3 or more times a weekD. Mood between temper outburst is persistently irritable or angry

most of the day, nearly every day.

E. Criterion a through D have been present for 12 or more months

F. Criteria a through D are present in at least 2 or more settingsG. Initial Diagnosis can be made between the ages of 6 to 18

H. Age of onset-established her history or observation-must be before the age of 10

I. No presence of manic or hypomanic episode

J. These behaviors do not occur during an episode of major depression and are not better explained by another mental disorder

K. Symptoms are not attributable to the effects of a substance, another medical or neurological condition

Diagnostic features

Chronic, severe persistent irritability with the following: Frequent temper outbursts in response to frustration

over a sustained period of time and are developmentally inappropriate

Anger and irritability remains constant even after temper outbursts of stopped

X

Prevalence estimates range between 2% and 5% Affects males more than females such children seem to be extremely temperamental

in prodromal manifestation sometimes diagnosed as oppositional defiant

disorder

X

5. Anxiety disorders, 6. obsessive-compulsive disorder and 7. trauma-related disorders

SUMMARY

Anxiety disorders

Panic disorderAgoraphobiaGeneralized anxiety disorderSocial phobiaSpecific phobiaPTSDAcute Stress disorder

Stress and trauma related disorders

Adjustment disordersPTSDAcute stress disorder

Reactive attachment disorderDisinhibited social engagement dis.Reactive attachment disorder

Specified anxiety disorderUnspecified anxiety disorder

Obsessive-compulsive related disorders

Obsessive compulsive disorderocd w/ poor insightHoarding disorderHair-pulling disorderSkin-picking disorderBody dysmorphic disorderMedication-induced ocdOther specified/unspecified ocd

Obsessive compulsive disorderSeparation anxiety disorderselectivemutism

Obsessive-compulsive disorder has been moved out of this category

PTSD has been moved out of this category Acute stress disorder has been moved out of

this category Panic attacks can now be used as a specifier

within any other disorder in the DSM Separation anxiety disorder has been moved to

this group Selective mutism has been moved to this group

5. Anxiety disorders

Criteria for specific phobia, and social anxiety disorder that requires that individuals over 18 recognize that their anxiety is excessive or unreasonable has been deleted

I don't know I don't see it in here. I don't know. I had a lot of awareness requirement is now that anxiety must be out of proportion to the actual danger or threat in a situation after a cultural context is considerED

Panic disorder and agoraphobia are unlinked in the DSM 5 THE “generalized” specifier for social anxiety disorder has

been deleted and replaced with her “performance only” specifier

Other changes and anxiety disorders

A completely new diagnostic grouping category Hoarding disorder-new diagnosis Excoriation (skin picking) disorder-new diagnosis Substance induced obsessive-compulsive disorder-new

diagnosis Tic specifier has been added Muscle dysphoria is now a specifier within body dysmorphic

disorder Obsessive-compulsive disorder-refined to allow distinction

between individuals with good to fair poor or “absent/delusional”

6. Obsessive-compulsive and related disorders

X

OCD Specifiers

In DSM-IV TR a requirement for the diagnosis was that the person suffering realized that the worries and behaviors were excessive

Now insight is a specifier With good or fair insight-individual recognizes that

beliefs and behaviors are not true and will not work With poor insight-individual believes that behaviors and

beliefs will help With absent insight/delusional beliefs-individual is

zealous in thinking that thoughts and behaviors must happen

Hoarding disorder 300.3A. Persistent difficulty discarding her, parting with possessions,

regardless of their actual valueB. Difficulty is due to perceived need to save the items and due to

distress associated with discarding themC. To difficulty discarding results in the accumulation of

possessions that congest and clutter active living areas and compromise their intended use

D. Causes clinically significant distress or impairment in social, occupational or other Areas of functioning

E. Not attributable to another medical conditionF. Not better accounted for by….

With excessive acquisition-in addition to keeping things, this type actively seeks out more(80 to 90% of all hoarders)

With good or fair insight With poor insight With absent insight and delusional beliefs – this would

trump delusional disorder

Specifiers

X

Excoriation (skin picking) disorder 698.4

A. Recurrent skin picking resulting in lesions

B. Repeated attempts to stop or decrease behavior

C. Causes clinically significant distress or impairment in social, occupational…

D. Not attributable to the effects of a substance or medication

E. Not better explained by…

Substance/medication induced obsessive-compulsive and related

disorder

A. Obsessions, compulsions, skin picking, hair pulling or other body focused repetitive behaviors occur

B. Evidence that symptoms began during or soon after substance use, withdrawal or medication exposure. Substance or medication is capable of producing obsessive-compulsive symptoms

C. Not better accounted for by OCD that is not substance/medication induced

D. Does not occur exclusively during deliriumE. Causes clinically significant distress

X

OCD due to another medical condition 294.8

A. Obsessions, compulsions, skin picking, hair pulling or other body focused repetitive behaviors occur

B. Evidence that symptoms began during or soon after Another medical condition that could cause the symptomsNot better accounted for by OCD that is not substance/medication induced

C. Does not occur exclusively during delirium

D. Causes clinically significant distress

Specify if•With the possessive compulsive disorder like symptoms•With appearance. Preoccupation•With hoarding symptoms•With hair pulling symptoms•With skin picking symptoms

Other specified obsessive-compulsive and related disorder

300.3

Use when OCD symptoms are there and cause clinically significant distress, but do not meet full criteria for an OCD related diagnoses

Specify Body dysmorphia with actual flaws Body dysmorphia without repetitive behaviors Body dysmorphia with repetitive behaviors obsessional jealousy

Substance Use Disorders Substance Dependence Substance Abuse

Substance-Induced Disorders Substance Intoxication Substance Withdrawal Substance induced mental disorder

Substance-Related Disorders

: The distinction between Dependence and abuse disorders has been eliminated in the DSM 5

X

Substance use disorders maladaptive pattern leading to clinically significant

impairment or distress for at least 12 monthsMust have at least 2 of the following11:

1. Substance taken in larger amount (need more for increased effect)

2. Persistent desire or efforts to quit3. Time spent to obtain, use, recover from effects4. Cravings Or urges to use5. Failure to fulfill significant roles6. Continued use despite persistent and recurrent

problems7. Important social/occupational activities are

reduced8. Recurrent use in physically hazardous situations9. Use continues despite knowledge of impact of

the problem10. Tolerance, as defined by a. Increased amounts

needed to achieve intoxication or b. Diminished effect

11. Withdrawal

X

Substance-related disorders

Substance use dis. Substance induced dis.

Pathological pattern of behaviors related to use of the substance1.Impaired control2.Social impairment3.Risky use

4. Pharmacological effectsIncreased tolerance

SubstanceIntoxicationRecent ingestion.Reversible symptoms related to ingestion

SubstanceWithdrawalPhysiological and psychological symptoms due to decreased use or cessation

Delirium; persisting dementia; persisting amnesia;Psychotic disorder; mood dis; anxiety dis; sexual dys; sleep dis.

= does occur also

=

SubstanceInducedMental disorder.Recent ingestion followed by symptoms of another M.D.

X

1. Substance taken in larger amount (need more for increased effect)2. Persistent desire or efforts to quit3. Time spent to obtain, use, recover from effects4. Cravings Or urge to use5. Failure to fulfill significant roles6. Continued use despite persistent and recurrent problems7. Important social/occupational activities are reduced8. Recurrent use in physically hazardous situations9. Use continues despite knowledge of impact of the problem10. Tolerance, as defined by a. Increased amounts needed to achieve

intoxication or b. Diminished effect11. Withdrawal

11 criteria four areas – USE DxImpairedControl

socialImpairment

Risky use

Pharmacologicaleffects

X

A. A maladaptive pattern of substance use leading to impairment or distress, as seen in 2 of the following in the same 12-mo. period:

1. Substance taken in larger amount (need more for increased effect)

2. Persistent desire or efforts to quit3. Time spent to obtain, use, recover from effects4. Cravings Or urges to use5. Failure to fulfill significant roles6. Continued use despite persistent and recurrent problems7. Important social/occupational activities are reduced8. Recurrent use in physically hazardous situations9. Use continues despite knowledge of impact of the problem10.Tolerance, as defined by a. Increased amounts needed to

achieve intoxication or b. Diminished effect11.Withdrawal

1. Criteria for Substance Use disorderX

DSM IVAbuse = 1 or more 1Failure to fulfill major role obligations at work, school, home such as repeated absences or poor work performance related to substance use; #5 DSM 5

2. Frequent use of substances in situation which iis physically hazardous #8 dsm 5

3Frequent legal problems (e.g. arrests, disorderly conduct) for substance abuse removed

4. Continued use despite having persistent or recurrent social or interpersonal problems #6 dsm 5

Dependence = 3 or more5. Tolerance or markedly increased amounts of the substance to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount of substance #10 DSM 5

6 Withdrawal symptoms or the use of certain substances to avoid withdrawal symptoms #11 DSM 5

7. Use of a substance in larger amounts or over a longer period than was intended #1 DSM 5

8.persistent desire or unsuccessful efforts to cut down or control substance use #2 DSM 5

9. Involvement in chronic behavior to obtain the substance, use the substance, or recover from its effects #3 DSM 5

10. .Reduction or abandonment of social, occupational or recreational activities because of substance use #7 DSM 5

11. Use of substances even though there is a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance #9 DSM 5

DSM 5 use = 2 or more crit.

SeverityMild = presence of 2-3 symptoms moderate = presence of four – five symptomssevere = presence of six or more symptoms

Course specifiersIn early remission = after full criteria were previously met

none of the criteria have been met for at least three months but less than 12 (with the exception of craving)

In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more

Specifiers for use disordersX

Simple substance dxMental disorders that can be induced by substances

I/W

I

I/W

Can also diagnose intoxication, withdrawal and induced mental disordersX

For diagnosis of acute stress disorder, it must be specified whether the traumatic events were experienced directly or indirectly

Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress

Major changes in the criteria for the diagnosis of PTSD

7. Trauma and stress related disorders

X

Diagnostic criteria has gotten more detailed and specific = more

complicated diagnosisThe basics

A. Exposure to trauma-direct or indirect

B. Presence of intrusive thoughts, memories, flashbacks, dreams, triggers that cause distress, or other external cues that remind one of the trauma

C. Avoidance of stimuli associated with the traumatic event

D. Changes (usually increased sensitivity) in thought processes and emotions associated

E. Increased arousal or reactivity associated with the traumatic event with the traumatic event

Traumatic events

Subsequent reactions

X

Criterion A - the stressor criterion is more explicit with regard to how an individual experienced “traumatic” events.

Criterion A2 (subjective reaction) has been eliminated. Three major symptom clusters in DSM-IV—reexperiencing,

avoidance/numbing, and arousal— Now four symptom clusters in DSM-5, because the

avoidance/numbing cluster is divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood. This latter category, which retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as persistent negative emotional states. The final cluster—alterations in arousal and reactivity—retains most of the DSM-IV arousal symptoms. It also includes irritable or aggressive behavior and reckless or self-destructive behavior. Posttraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder.

Reactive Attachment

PTSD changesX

PTSD 309.81 A . Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways

1. Directly experiencing the traumatic events

2. Witnessing in person. The event is it occurred to others3. Learning that the traumatic events occurred to a close family member or close friend

4. Experiencing repeated or extreme exposure to aversive details of the traumatic events; a form of Vicarious exposure experienced by police officers or 1st responders

B. Presence ofone or more of the following intrusion symptoms associated with the traumatic events beginning after the event occurred

1. Recurrent, involuntary and intrusive distressing memories of the event

2. Recurrent distressing dreams in which the content is related to the event3. Dissociative reactions (flashbacks) where individual feels or acts as if the event were recurring

4 intense-prolonged psychological distress when exposed to internal or external cues5. Marked physiological reactions to internal or external cues

C. Persistence avoidance of stimuli associated with the traumatic events beginning after the event occurred1. Avoidance or efforts to avoid distressing memories, thoughts or feelings associated with the event2. Avoidance or efforts to avoid external reminders-people, places, conversations that might arouse distressing memory starts her feelings associated with the event

D. Negative alterations in cognitions and mood associated with the events beginning or worsening after the events

1. Inability to remember an important aspect of the traumatic event. This is not caused by a head injury help call or drugs, but dissociative amnesia related to the event2. Persistent exaggerated negative beliefs or expectations about oneself, Others and the world-I am bad, No one can be trusted, the world sucks3. Distorted cognitions that lead to self blame where the blame of others.

4. Persistent negative emotional state5. Diminished interest or participation in significant activities

6. Feelings of detachment or estrangement from others7. Persistent inability to experience positive emotions

X

PTSD 309.81-Continued E. Significant alterations in arousal and reactivity associated with the traumatic event

1. Irritable behavior in angry outbursts with little or no provocation-started after the event, usually directed toward people or objects2. Reckless or self-destructive behavior

3. Hypervigilance4. Exaggerated startle response

5. Problems with concentration6. Sleep disturbance

F. Duration of the disturbance is longer than one monthG. Causes clinically significant distress or impairment

H. The disturbance is not attributable to the physiological effects of a substance or another medical condition

Please note the presence of anxiety, fear and avoidance. 3 conditions that we find in generalized anxiety disorder

Specifiers Specify whether: Dissociative symptoms are present

Depersonalization = experience of feeling detached from, and disconnected from one self. Often described as feeling as if one were outside observing oneself or as though in a dream.A sense or feeling of unreality

regarding oneself-with the knowledge that this is not trueDerealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her

distorted. However, one realizes this is not true

Specify ifExpression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or

more after the event

X

PTSD In children-6 or youngerAvoidance and alterations in cognition collapsed into one criterion

group A . Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways

1. Directly experiencing the traumatic events

2. Witnessing in person. The event is it occurred to others3. Learning that the traumatic events occurred to a close family member or close friend

B. Presence ofone or more of the following intrusion symptoms associated with the traumatic events beginning after the event occurred

1. Recurrent, involuntary and intrusive distressing memories of the event

2. Recurrent distressing dreams in which the content is related to the event3. Dissociative reactions (flashbacks) where individual feels or acts as if the event were recurring4 intense-prolonged psychological distress when exposed to internal or external cues

5. Marked physiological reactions to internal or external cues C. One or more of the following symptoms involving either avoidance or negative alterations in cognition are made - must be Present

1. Avoidance or efforts to avoid distressing memories, thoughts or feelings associated with the event2. Avoidance or efforts to avoid external reminders-people, places, conversations that might arouse distressing memory starts her feelings associated with the event3. Increase of negative emotional states4. Diminished interest or participation in significant activities5. Socially withdrawn Behavior

6. Reduction in expression of positive emotions D. alterations in arousal and reactivity associated with the traumatic event

1. Irritable behavior in angry outbursts with little or no provocation-2. Hypervigilance

3. Exaggerated startle response4. Problems with concentration

5. Sleep disturbance E.. Duration of the disturbance is longer than one month

F. Causes clinically significant distress or impairmentG.. The disturbance is not attributable to the physiological effects of a substance or another medical condition

X

PTSD 309.81-Children

Specifiers Specify whether: Dissociative symptoms are present

Depersonalization = experience of feeling detached from, and disconnected from one self. Often described as feeling as if one were outside observing oneself or as though in a dream.A sense or feeling of unreality

regarding oneself-with the knowledge that this is not trueDerealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her

distorted. However, one realizes this is not true

Specify ifExpression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or

more after the event

Specifiers are the same

X

In DSM-IV RAD was divided into subtypes

Subtypes = inhibited type and disinhibited type (criterion A),

Inhibited = Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g. the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit "frozen watchfulness", hypervigilance while keeping an impassive and still demeanor). Such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain "proximity", an essential element of attachment behavior

Disinhibited = Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures). There is therefore a lack of "specificity" of attachment figure

Disinhibited = 313.89 disinhibited social engagement disorder

A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of the following

1. Reduced or absent reticence in approaching and interacting with unfamiliar adults

2. Overly familiar verbal or physical behavior that is not consistent with age-appropriate social boundaries

3. Diminished or absent "checking back" behaviors4. Willingness to go with an unfamiliar adult with minimal or no hesitation

B. Behaviors in criterion a are not limited to impulsivity such as that seen in ADHD

C. The child has experienced a pattern of extremes of insufficient care, as evidenced by at least one of the following

1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort stimulation and affectation met by caregivers

2. Repeated changes of primary caregivers that limit opportunities for stable attachment

3. Rearing in unusual settings

D. The criterion C is presumed to be responsible for the disturbed behavior in criterion AE. The child has a developmental age of at least 9 months

313.89 RADA. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult

caregivers manifested by both of the following

1. The child rarely or minimally seeks comfort when distressed

2. The child rarely or minimally responds to comfort. When distressedB. A persistent social and emotional disturbance characterized by at least 2 of the

following1. Minimal social and emotional responsiveness to others

2. Limited positive affect

3. Episodes of unexplained irritability, sadness or fearfulness that are evident even during nonthreatening interactions with caregivers

C. The child has experienced the pattern of extremes or insufficient care, as evidenced by at least one of the following

1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort stimulation and affection met by caregiving adults

2. Repeated changes a primary caregivers that limit opportunities to form stable attachment

3. Rearing in unusual settings that severely limit opportunities to form attachments

D. To carry in criterion C is presumed to be responsible for the disturbed behavior in criterion a

E. Criterion are not met for autism spectrum disorderF. Disturbance is evident before age 5

G. Child has a developmental age of at least 9 months

Adjustment Disorders

In DSM-5, adjustment disorders are reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event, rather than as a residual category for individuals who exhibit clinically significant distress without meeting criteria for a more discrete disorder (as in DSM-IV ). DSM-IV subtypes marked by depressed mood, anxious symptoms, or disturbances in conduct have been retained, unchanged.

•Stressor can be of any severity or type (unlike PTSD Criterion A)•Much more flexible diagnosis then PTSD or acute stress disorder•Diagnose adjustment disorder when:

• PTSD criteria are not met• Criterion A for PTSD stressors not met• Subthreshold for acute stress disorder & PTSD• Symptoms do not last longer than 6 months after stressor.-

A transitional state that is longer than acute stress disorder, but typically not as intense

Depersonalization disorder has been relabeled “Depersonalization/Derealization disorder“

Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of "dissociative amnesia“

Changes in criteria for the diagnosis of "dissociative identity disorder"

8. Dissociative disordersSUMMARY

Criterion A has been expanded to include certain possession-form phenomena and functional neurological symptoms to account for more diverse presentations of the disorder.

Criterion A now specifically states that transitions in identity may be observable by others or self-reported.

Criterion B, individuals with dissociative identity disorder may have recurrent gaps in recall for everyday events, not just for traumatic experiences. Other text modifications clarify the nature and course of identity disruptions.

DID

Diagnostic criteria – DSM 5 300.14

A. Presence of two or more distinct Personality states, which may be described in some cultures as an experience of possession. This disruption and identity involves marked discontinuity in sense of self and personal agency. This is accompanied by alterations (often sudden) in affect, behavior, consciousness, memory, perception and/or sensorimotor functioning. These signs and symptoms may be observed by others or reported by the individual

B. Inability to recall important personal information Or gaps in recall of everyday events. Important personal information or traumatic events. AKA dissociative amnesia

C. Cause clinically significant distress , And/or impairment D. Not a part of broadly accepted cultural or religious practiceE. Not due to a substance or general medical condition

Note the difference in the Diagnostic criteria –IV TR

A. Presence of two or more distinct identities, each with its own relatively stable pattern of personality traits

B. At least two of these ‘alters’ take control of the person’s behavior

C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness

D. Not due to a substance or general medical condition

This is a new name for what was previously called "somatoform disorders“

The number of diagnoses in this category has been reduced. The diagnoses of somatization disorder, hypochondriasis, pain disorder and undifferentiated somatoform disorder have all been removed

"Illness anxiety disorder" has been an added diagnosis and replaces hypochondriasis

Factitious disorder is now included in this group

9. Somatic symptom and related disorders

X

Factitious disorder: conscious and intentional feigning or production of symptoms, because of a psychological need to assume the sick role to obtain emotional gain

Malingering: conscious and intentional production or exaggeration of symptoms for material gain, such as money, lodging, food, drugs, avoidance of military service, or escape from punishment

Somatization: recurrent and multiple symptoms (eg, pain, GI, sexual, pseudoneurological) with no organic basis, believed to be due to unconscious expressions of suppressed emotional conflict or stress; unlike factitious disorders, the symptoms are not created by voluntary, conscious behavior

Hypochondriasis: obsession with fears that one has a serious, undiagnosed disease, presumably based on misinterpretation of bodily sensations - See more at: http://www.psychiatrictimes.com/articles/factitious-disorder-detection-diagnosis-and-forensic-implications#sthash.trRTuLQM.dpuf

Some definitionsX

Individuals with somatic symptoms plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed medical condition.

The relationship between somatic symptoms and psychopathology exists along a spectrum.

high symptom count required for DSM-IV somatization disorder did not accommodate this spectrum.

The diagnosis of somatization disorder was essentially based on a long and complex symptom count of medically unexplained symptoms.

Individuals previously diagnosed with somatization disorder will usually meet DSM-5 criteria for somatic symptom disorder, but only if they have the maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to their somatic symptoms.

In DSM-IV, the distinction between “undifferentiated somatoform disorder” had been created in recognition that “somatization disorder” would only describe a small minority of “somatizing” individuals, but this disorder did not prove to be a useful clinical diagnosis.

They are merged in DSM-5 under somatic symptom disorder, and no specific number of somatic symptoms is required.

Somatic Symptom DisorderX

Somatic Symptom Disorder300.82

Diagnostic Criteria:

A.One or more somatic symptoms that are distressing and result in significant disruption of daily life

B.Excessive thoughts, feelings or behaviors related to the symptoms or associated health concerns, as manifested by at least one of the following:1. Disproportionate and persistent thoughts about the seriousness

of symptoms2. Persistently high level of anxiety about health or symptoms3. Excessive time and energy devoted to the symptoms or health

concerns

C.The state of being symptomatic is persistent (typically more than 6 months)

X

Specifiers

Specify if: with predominant pain (previously classified as pain disorder and DSM-IV)

Specify if: persistent: severe symptoms lasting longer than 6 months

Specify current severity: mild = only one of the symptoms specified in criterion B is the filled moderate = 2 or more of the symptoms in criterion beer for filled Severe = 2 or more of the symptoms are fulfilled. Plus, there are multiple

other somatic complaints

300. 7 Illness anxiety disorder criteria

Previously hypochondriasisA. Preoccupation with having or acquiring a serious illness

B. No evidence of somatic symptoms or extremely mild symptoms present

C. High anxiety about health and health statusD. Excessive health related behaviors or avoidant

health related behaviorsE. Illness preoccupation present for at least 6

monthsF. not better explained by another disorder

Specify whether:care seeking type: medical care, including physician visits frequently usedcare avoidant type: medical care is rarely if ever used

X

DSM-IVpain disorder diagnoses assume that some pains are associated solely with psychological factors, some with medical diseases or injuries, and some with both. lack of evidence that such distinctions can be made with

reliability and validity, and a large body of research has demonstrated that psychological factors influence all forms of pain.

individuals with chronic pain attribute pain to a combination of factors, including somatic, psychological, and environmental influences-not either/or

DSM-5 some individuals with chronic pain could be DXd having somatic symptom disorder, with predominant pain 316.0psychological factors affecting other medical

conditions adjustment disorder

Pain Disorder removed from DSM 5

X

Psychological factors affecting other medical conditions is a new mental disorder in DSM-5, having formerly been included in the DSM-IV chapter “Other Conditions That May Be a Focus of Clinical Attention.” This disorder and factitious disorder are placed among the somatic symptom and related disorders because somatic symptoms are predominant in both disorders, and both are most often encountered in medical settings. The variants of psychological factors affecting other medical conditions are removed in favor of the stem diagnosis.

Psychological Factors Affecting Other Medical

Conditions

A. Medical symptom or condition is present B. psychological or behavioral factors adversely affect the

medical condition in one of the following ways The factors that influence the course of the medical condition as

shown by a close temporal association between a psychological factors and the development or exacerbation of medical condition

The factors interfere with the treatment of the medical condition The factors constitute additional well-established health risk for

the individualThe factors influence the underlying psychopathology precipitating or exacerbating symptoms or necessitating medical attention

C. psychological and behavioral factors in criterion B are not better explained by another mental disorder

Psychological Factors Affecting Other Medical

Conditions

300.19 Factitious disorder criteria

Self-imposedA. Falsification of physical or psychological signs or symptoms or induction of injury or disease. In order to deceiveB.Individual present self to others, as if impaired or injured

C.No apparent or obvious external rewardsD., Not better accounted for by…

Imposed on othersA. Falsification of physical or psychological signs or symptoms or induction of injury or disease. In order to deceiveB.Individual presents another individual to others as you know, impaired or injuredC.No apparent external rewardsD.Not better accounted for by…

E.When imposed on others. Diagnosis is given to the perp

Specify ifsingle episoderecurrent episodes

X

Somatic symptoms – major focus on symptoms experienced as well as anxiety- symptoms can have a physical cause, but the pt. experiences no relief

Illness anxiety – major focus on anxiety and what “might” happen. Symptoms might or might not be present- but are mild if there.

Conversion disorder – symptoms present. Of a neuro-perceptual type; blindness paralysis

Factitious – symptoms intentionally produced – no apparent gain-assess motivation

Malingering (v code)– intentional gain can be documented-assess motivation

X

Somatic symptomsInauthentic –authentic illnesses

Psychogenic illness – the mind causes symptoms that are experienced by the patient but have no “real” presence

Unconscious Somatic symptom Illness anxiety conversion

Conscious Factitious malingering

Diagnosed in part by LACK of evidence

Diagnosed by evidence

X

The person's medical history doesn't make sense No believable reason exists for the presence of an

illness or injury The illness does not follow the usual course There is a lack of healing for no apparent reason,

despite appropriate treatment There are contradictory or inconsistent symptoms

or lab test results The person is caught in the act of lying or causing

his or her injury

When to suspect factitious disorder

X

http://www.psychiatrictimes.com)The Case of Factitious Disorder Versus Malingering (2009] Courtney B. Worley,MPH ; Marc D. Feldman, MD and James C. Hamilton, PhD

X

Without detailing the full DSM diagnostic criteria sets for these disorders and their relations, thefollowing is a summary of how DSM instructs psychiatrists to diagnose cases of inauthentic illnessbehavior:

1. In the absence of overwhelming affirmative evidence of intentional medical deception (eg, caughton video, evidence from a room search), diagnose a somatoform disorder.

2. If there is traditional forensic evidence of overt medical deception, diagnose malingering orfactitious disorder.

3. If there is any significant material or instrumental benefit from the intentional medical deception(eg, financial settlement, disability determination, access to narcotic medicine), diagnose malingering.

http://www.psychiatrictimes.com)The Case of Factitious Disorder Versus Malingering (2009] Courtney B. Worley,MPH ; Marc D. Feldman, MD and James C. Hamilton, PhD

X

"Binge eating disorder' is now included as a separate diagnosis

also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter "disorders usually 1st diagnosed during infancy childhood and adolescence“.

Pica and rumination disorder are 2 examples

10. Feeding and eating disorders

Originally classified in chapters on childhood and infancy. Now have separate classification

Primary insomnia renamed "insomnia disorder« Narcolepsy now distinguished from other forms of

hypersomnia Breathing related sleep disorders have been broken into

3 separate diagnoses Rapid eye movement disorder and restless leg syndrome

are now independent diagnoses within this category

11. Elimination disorders

12. Sleep wake disorders

Some gender related sexual dysfunctions have been outed

Now only 2 subtypes-acquired versus lifelong and generalized versus situational

New diagnostic class and the DSM 5 Include separate classifications for children adolescents

and adults The construct of gender has replaced the construct of

sex

13. Sexual dysfunctions

14. GENDER DYSPHORIA DSM 5

Attempted to eliminate the stigma involved in the previous diagnosis of gender identity disorder

Likely that more research is needed. Prevalence is remarkably low

Gender Dysphoria in Adolescents and adults

A. Mark incongruence between one's experienced/expressed gender and assigned gender. At least 6 months duration, as manifested by at least 2 of the following1. Marked incongruence between one's experienced/expressed gender and primary

and/orsecondary sex characteristics2. Strong desire to be rid of one's primary and/or secondary sex characteristics because of

marked incongruence with one's experienced/expressed gender3. Strong desire for the primary and/or secondary sex characteristics of the other gender4. Strong desire to be of the other gender5. Strong desire to be treated as the other gender6. Strong conviction that one has the typical feelings and reactions of the other gender

B. Condition is associated with clinically significant distress or impairment

Specify if "post-transition“ = the individual has transition to full-time living in the desired gender (with or without legalization of gender change), and has undergone or is preparing to have at least one cross-section medical procedure or treatment regimen

New diagnostic grouping and DSM 5 Combines a group of disorders previously included in disorders

of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified

Oppositional defiant disorder now has 3 subtypes Intermittent explosive disorder no longer requires physical

violence but can include verbal aggression

Disruptive, impulse control and conduct disorders

X

15. Disruptive, impulse control, and conduct disorders

Disruptive onesoppositional defiant disorderconduct disorderIntermittent explosive disorder

Impulsive onesIntermittent explosive disorderpyromaniakleptomania

Gambling disorder

X

Major dynamic in all ICDs

Tension and stressBegins to build

Spike (steep rise)In tension immediatelyBefore the act

Impulsive act

Immediate release in tension,Experience of pleasure or gratification

ODD 313.81A. Pattern of angry/irritable mood, argumentative/defiant behavior, Vindictiveness, lasting at

least 6 months; evidenced by at least 4 symptoms for many of the following categories and exhibited during interaction with at least one individual, not a sibling.

Angry, irritable mood1. Often loses temper2. Is often touchy or easily annoyed.3. Often angry and resentful

Argumentative, defiant behavior4. Often argues with authority figures.5. Actively defies or refuses to comply with requests from authority figures.6. Deliberately annoys others.7. Blames others for his or her mistakes

Vindictive behavior8. Has been spiteful or vindictive at least twice within the past 6 months

B. Causes distress in person, and others Does not occur during the course of another disorder

X

Changes from DSM IVODD & conduct disorder are not mutually exclusive3 symptom type groupingsguidance re: how to distinguish from developmental normsseverity measure included

Specifiers

Mild Moderate Severe

Severity can be measured through intensity, frequency, or pervasiveness. For example, if the behavior occurs in more than one setting, it is more pervasive and thus more severe. Usually occurs in the home and not across settings

X

Dimensional severity assessment for ODD

Instructions to clinicians for ODDThe Clinician-Rated Severity of Oppositional Defiant Disorder assesses the severity of the OPPOSITIONAL DEFIANT symptoms for the individual based on their pervasiveness across settings. The measure is intended to capture meaningful variation in the severity of symptoms, which may help with treatment planning and prognostic decision-making. The measure is completed by the clinician at the time of the clinical assessment. The clinician is asked to rate the severity of oppositional defiant problems as experienced by the individual in the past seven days.

Scoring and interpretation for ODD scaleThe Clinician-Rated Severity of Oppositional Defiant Disorder is rated on a 4-point scale (Level 0=None; 1=Mild; 2=Moderate; and 3=Severe). The clinician is asked to review all available information for the individual and, based on his or her clinical judgment, select ( ) the level that most accurately describes the severity of the individual’s condition.

Frequency of use for ODD scaleTo track changes in the individual’s symptom severity over time, the measure may be completed at regular intervals as clinically indicated, depending on the stability of the individual’s symptoms and treatment status. Consistently high scores on a particular domain may indicate significant and problematic areas for the individual that might warrant further assessment, treatment, and follow-up. Your clinical judgment should guide your decision.

X

ODD dimensional assessmentX

Problems with diagnosis

Differentiating this from developmental and/or environmental stress related behavior

Differentiating from other diagnoses such as bipolar 2

Biased reporting or reporting based on reputation Expectation induced disruptive behaviors Behavior is often confined to one way one setting

(for example, the home) Little or no insight is present on the part of the

suffer. See self is victim

X

Conduct disorder unchanged

Diagnostic criteriaA. Repetitive and persistent pattern of behavior in which the basic rights of others or

major age-appropriate societal norms and rules are violated, as manifested by the presence of at least 3 of the following 15 criteria in the past 12 months. For many of the categories below, with at least one criteria present in the last 6 months

Aggression to people or animals1 bullies, threatens or intimidates2 often initiates physical fights3 used weapons that can cause serious physical harm4. been physically cruel to people5. Been physically cruel to animals6. Has stolen while confronting a victim7. Forced someone into sexual activity

destruction of property8. Has deliberately engaged in fire setting with intent of causing damage9. Deliberately destroyed others property

deceitfulness or theft10. Broken into someone else's home building car11. lies or deceives to obtain goods or favors12. Has stolen nontrivial items without confronting victim – shoplifting etc.

serious violation of rules13. Stays out at night. Despite parental prohibitions. Begins before 1314. Has run away from home at least twice15. Often truant, beginning before age 13

B. Causes clinically significant impairmentC. If age 18 or over, not attributable to antisocial personality disorder

X

New diagnostic group Dementia and amnestic disorder are included in

this new group Mild NCD is a new diagnosis

16. Neuro-cognitive disordersX

Term "dementia" has been deemphasized done to lessen stigma Deemphasize irreversibility Broadens category in a more neutral way (see The following

points below)

Mild neurocognitive disorder has been added Distinguished from Major (severe) neurocognitive disorder

X

Diagnostic criteria for delirium unchanged

A. disturbance Inattention (reduced ability to direct, focused, sustain and shift attention and awareness); reduced orientation to environment

B. . develops over a short period of time and fluctuates during the day

C. Add a disturbance in cognition (usually marked) – such as memory deficit, disorientation, agitation, language or perceptual disturbance

D. The criteria from A&C are Not better explained by a preestablished neurocognitive disorder or evolving neurocognitive disorder

E. evidence from the history, physical examination or lab findings thate disturbances are direct consequence of another medical condition, substance, intox or w/drawal

X

Specifiers Substance intoxication delirium = when criteria in A and C

predominate during a period of intoxication Substance withdrawal delirium = should be made it instead of

substance withdrawal when the symptoms in criterion a and C predominate in the clinical picture

Medication induced delirium = should be made when the symptoms in criteria a and C arises a side effect of the medication taken as prescribed

Delirium due to another medical condition = evidence that the disturbance is attributable to the physiological consequences of another medical condition

Delirium due to multiple etiologies = evidence that the delirium has more than one cause or causal condition

Course =acute: lasting a few hours or dayspersistent: lasting weeks or months

Diagnostic criteria for Major NCDAKA DEMENTIA

A. Evidence of significant decline from her previous level of performance in one or more cognitive domains.: (Cognitive attention, Memory impairment, Learning, attention, recognition (Aphasia, agnosia), apraxia , Language, perceptual/motor problems , Social cognition and/or other disturbance of executive functions)

B. cause significant impairment in social, vocational functioning; is a marked decline from previous functioning And require assistance, and activities. If daily living, because they interfere with independence in every day activities

C. Are not caused or related to by delirium

D. Not better explained by…

X

Mild neurocognitive disorder

A. Evidence of modest cognitive decline for previous data performance in one or more cognitive domains-cognitive attention, executive function, learning and memory, language, perceptual motor or social cognition. Evidence based on

1. Concern of individual, a knowledgeable informant or the clinician that there is been a mild decline in cognitive function and

2. Modest impairment in cognitive performance preferably documented by standardized neuropsychological testing or another quantified clinical assessment

B. The cognitive deficits do not interfere for capacity with independence in every day activities, but greater effort compensatory strategies or accommodations may be required

C. The cognitive deficits do not occur exclusively in the context of a delirium

D. Not better accounted for by another mental disorder (major depression, schizophrenia

X

Specifiers whether (Sub-types) of Mild NCD (dementia) are classified by etiology

in DSM Alzheimer’s type Frontotemporal deterioration Lewy body disease Vascular (multi-infarct) dementia Related to HIV Head trauma Or TBI Substance medication induced Huntington’s disease Parkinson’s diseases Pick’s disease Prions disease Multiple etiologies Unspecified

X

17. Difference between paraphilia's and paraphilia

disorders Paraphilia describes the experience of intense Sexual arousal to atypical objects, situations, or individuals.

Paraphilic behavior (such as Pedophilia, zoophilia, voyeurism and exhibitionism and may be illegal in some jurisdictions, but may also be tolerated.

A paraphilia is NOT a paraphilic disorder Paraphilia disorder requires the generation of

clinically significant distress, impairment or acting them out with the nonconsenting person. (Criterion B)

Personality disordersNothing changes

X

DSM 5 promised major changes in criteria

Promised dimensional focus Promised reduction in number of personaliity

disorders to five Changes did not occur Dimensional focus for personality disorders was

moved to section 3

X

Primary Criteria in DSM 5(Unchanged from DSM-IV TR)

A. Enduring pattern of inner experience & behavior that deviates markedly from expectations of the culture. This pattern is manifested in 2 or more of the following areas

A. Cognition; B. Affect; C. Interpersonal; D. Impulse control

B. Inflexible & pervasive across situationC. Distress or impairment in social, occupational

interpersonal..…D. Long-standing (back to adolescence or early

adulthood)

X

DSM IV & 5 and personality clusters

Cluster AOdd/eccentric

ParanoidSchizoidschizotypal

Cluster BDramatic, erraticSelf-involved

Anti-socialHistrionicNarcissisticBorderline

Cluster CAnxious/fearful

DependentAvoidantObsessive-compulsive

X

Dimensional classification of personality disorders

Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders

They plan to reduce personality disorders from 10 to 5

This changed in a closed-door meeting Dimensional measures are now in section 3

X

ANTI_SOCIAL

A) There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three or more of the following:

1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;

2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;

3. impulsiveness or failure to plan ahead; 4. irritability and aggressiveness, as indicated by repeated physical fights or assaults; 5. reckless disregard for safety of self or others; 6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work

behavior or honor financial obligations; 7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated,

or stolen from another;

B) The individual is at least age 18 years. C) There is evidence of conduct disorder with onset before age 15 years. D) The occurrence of antisocial behavior is not exclusively during the

course of schizophrenia or a manic episode.

X

OR Mnemonic: “CALLOUS MAN”Diagnostic Criteria for Antisocial PD

Conduct disorder before age 15; current age at least 18 Antisocial activities; commits acts that are grounds for arrest Lies frequently Lacunae—lacks a superego Obligations not honored (financial, occupational etc.) Unstable—can’t plan ahead Safety of self and others is ignored

Money– recklessness with money; spouse and children are not supported because he bought a motorcycle

Aggressive, Assaultive Not occurring during schizophrenia or mania

X

Antisocial signs

Glibness, shallow emotion Requires constant stimulation Criminal versatility Promiscuity Poor impulse control Avoids responsibility for actions

X

Millon identified five subtypes of Anti-Social Personality Disorder covetous antisocial – variant of the pure

pattern where individuals feel that life has not given them their due – including paranoid features.

reputation-defending antisocial – including narcissistic features

risk-taking antisocial – including histrionic features

nomadic antisocial – including schizoid, avoidant features

malevolent antisocial – including sadistic, paranoid features.

X

BORDERLINE PD

A. A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-injuring behavior covered in Criterion 5

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex,

excessive spending, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5

5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars or picking at oneself (excoriation) .

6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).

7. Chronic feelings of emptiness 8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper,

constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

X

OR Mnemonic for Diagnostic Criteria: “I RAISED A PAIN”

Identity disturbance

Relationships are unstable Abandonment is frantically avoided Impulsive Self-mutilation, suicidal threats/attempts; splitting - as a predominant

defense mechanism is used Emptiness is a description of their inner selves Dissociative symptoms

Affective instability

Paranoid instability Anger is poorly controlled Idealization of others, followed by devaluation (splitting – person is either all

good or all bad) Negativistic—undermine their own efforts and those of others

X

First called “as if” personality because or changes in direction or interest

Term “borderline” is unfortunate. Originally referred to being on the ‘border’ between psychotic and neurotic

Label is often used pejoratively among mental health professionals

Misunderstood and mis-labeled as “manipulative”

X

Borderline Themes

Parental neglect and abuse Impulsivity Fears of abandonment Frequent suicide ideation or gestures Substance abuse or dependence Legal difficulties Disrupted education relationships, vocations,

vacations

X

Propose general criteria for personality disorder

A. Moderate or greater impairment in personality (self interpersonal functioning)

B. One or more pathological personality traits

C. The impairments in personality functioning are inflexible and pervasive across a broad range of personal and social situations

D. The impairments in personality functioning are relatively stable across time

E. The impairments in personality function are not better explained by another medical condition or substance

F. Impairments in personality functioning are not better understood as normal for individuals developmental stage, or sociocultural environment

X

Dimensional classification of personality disorders

Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders

They plan to reduce personality disorders from 10 to 5

This changed in a closed-door meeting Dimensional measures are now in section 3

X

Proposed changes in assessment Two broad dimensions

Overall personality functioning

5 BroadPathological Trait Domains

self Interpersonal

IdentitySelf direction

Empathy Intimacy

Negative affectivity

Detachment Antagonism Disinhibition Psychoticism

X

How to deal with uncertainty

2 dimensions required for all DSM diagnosis

1. Clarity of symptoms

2. Specified length of time for symptoms

4 basic levels of diagnostic warrant

Sym

pto

m

clarity

symptom pattern over time

High

low

Clearstable

Unclearunstable

Diagnostic certainty

Diagnostic uncertainty orDiagnostic confusion

Diagnostic plausibility

Diagnostic possibility

Diagnostic certainty

The likelihood that a “plausible” diagnosis is “probable” Clinicians often diagnoses based on “clinical

hunches”, which are a form of bias They select one or 2 salient characteristics –rather

than the complete 7 to 9- and make assumptions (Paris, 2013)

This is a form of “fast thinking” or quick judgment that leads to “framing effects” (Kahneman, 2011) sometimes called the “clinicians illusion”.

Easy for clinicians to conflate probability with plausibility

Plausibility = the likelihood that an event or events are representative of something more; clinicians tend to focus on this

Probability = the statistical likelihood of an event; researchers focus on this

Kahneman, 2011

2 conditions necessary for Diagnostic certainty

When symptoms are clear and stable over time When the relationship between plausibility and

probability has been considered

Plausibility- these symptoms represent X

Probability – the likelihood of X occurring

Sym

pto

m

clarity

symptom pattern over time

High

low

Clearstable

Unclearunstable

Diagnostic certainty

Diagnostic uncertainty orDiagnostic confusion

Diagnostic plausibility

Diagnostic possibility

probability

Progression of domains of diagnostic certainty over time

Diagnosticuncertainty

Diagnosticpossibilities

Diagnosticprobabilities

Diagnosticcertainty

Ethical issues arise here when:•Clinician unknowingly or unwittingly is in the wrong domain (incompetence)•Clinician knowingly chooses the wrong domain

Diagnosticplausibility

Progression of diagnostic certainty over time

Diagnosticuncertainty

Diagnosticpossibilities

Diagnosticprobabilities

Diagnosticcertainty

Documentation can help

What leads me to be unsure?Do I know What don’t I Know?

Why are theseThe possibilities? How do I know that other DXs are not poss.

Why am I certain? How do I know that I know?

What makes this a probability and others not? Where is my prevalence data?

Diagnosticplausibility

What am I seeing that is so compelling?What am I missing? Why am I missing?

Progression of diagnostic certainty over time

Diagnosticuncertainty

Diagnosticplausibility

Diagnosticprobabilities

Diagnosticcertainty

The more uncommon or unusual a diagnosis is, the more time and care one must take in differentiating or excluding other – more common - (statistically) diagnoses

Diagnosticpossibilities