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Diagnostic groupings in the DSM 5

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Title: Diagnostic groupings in the DSM 5


1
Diagnostic groupings in the DSM 5
2
Diagnostic groupings in IV-TR and 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

3
Changes throughout DSM
X
  • 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

4
DSM 5 changes in classification
  • 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

5
Neurocognitive disorders
Neuro develop mental
Sexual dysfunctions
Disruptive, impulse control disorders
Somatic symptom related
Paraphilia disorders
Bipolar
Anxiety
Elimination disorders
Trauma related
Obsessive-compulsive and related
Schizophrenia
Depressive
Dissociative
Sleep wake disorders
Personality disorder
Others
Feeding and eating disorders
Substance related and addictive disorders
Gender dysphoria
Older
Younger
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
6
1. Neurodevelopmental disorders 2. schizophrenia
spectrum and other psychotic disorders 3. bipolar
and related disorders 4. depressive disorders 5.
anxiety disorders 6. obsessive-compulsive and
related disorders 7. Trauma and related
disorders 8. dissociative disorders 9. Somatic
symptom and related disorders 10. feeding and
eating disorders 11. elimination disorders 12.
sleep wake disorders 13. sexual dysfunctions 14.
gender dysphoria 15. disruptive, impulse control,
and conduct disorders 16. neurocognitive
disorders 17. paraphilia disorders
Which are your top 7 or 8
7
Changes in the groupings 1. Neurodevelopmental
disordersSUMMARY
  • Neurodevelopmental disorders-
  • mental retardation is removed intellectual
    disability is put in.
  • Autism spectrum disorder is the new DSM 5
    diagnosis encompassing autistic disorder.
    Aspergers and childhood disintegrative disorder
    as well as pervasive developmental disorder.
  • Several changes have been made to ADHD-
    specifiers combined inattententive type
    hyperactive/impulsive type

8
MENTAL RETARDATION INTELLECTUAL
DISABILITY Severity level for intellectual
disability
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
SEVERITY DETERMINED BY ADAPTIVE FUNCTIONING NOT IQ
9
Includes deficits in language speech and
communication
1. Expressive language disorder 2.
Receptive-expressive language disorder 3.
Phonological (articulation) disorder speech
sound disorder (315.39) In DSM 5 4. Stuttering
AKA Childhood onset fluency disorder (315.35) In
DSM 5
Combined into "language disorder" (315.39) in DSM
5
10
Social pragmatic communication disorder 315.39
  • Persistent difficulties in the social use of
    verbal and nonverbal communication as manifested
    by all of the following
  • deficits in using communication for searching
    purposes
  • impairments of the ability to change
    communications to match the context or needs of
    the listener
  • difficulties following rules for conversation and
    storytelling such as taking turns in
    conversation , rephrasing and knowing how to use
    verbal and nonverbal to regulate interaction
  • Difficulties in understanding what is not
    explicitly stated
  • 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)
  • Not attributable to another medical condition or
    neurological condition and not better explained
    by other neurodevelopmental disorders

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 communication social anxiety disorder and
social phobia can often appear with similar
symptoms and again mild intellectual
developmental disorder might also mask symptoms
11
LEARNING DISORDERS
  • DEFINED INDEPENDENT FROM GENERAL INTELLIGENCE
  • DIAGNOSED WHEN AN INDIVIDUALS 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

12
DSM 5 criteria no separation
  • 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.
  • Inaccurate or slow and effortful word reading
  • Difficulty understanding the meaning of what is
    read
  • Difficulties with spelling
  • Difficulties with written expression
  • Difficulties mastering number sense, number
    facts, or calculation
  • Difficulty with mathematical reasoning
  • Affected academic skills are substantially and
    quantifiably below those expected for the
    individual's chronological age causing
    significant interference with performance
    (quantifiable suggest testing)
  • The learning difficulties begin during school way
    cheers but might not become apparent until those
    faculties require more regular use
  • Not better accounted for by intellectual
    disabilities visual or auditory deficits other
    mental or neurological disorders etc.

13
ADHD
X
  • 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

14
Diagnostic Criteria for ADHD(DSM-IV)
X
DSM 5 has moved onset age limit to 12!
  • 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/impulsivit
    y
  • Must be developmentally inappropriate levels

Now requires SEVERAL SYMPTOMS across settings
15
DSM 5 criteria
X
  • Persistent pattern of inattention and or
    hyperactivity-impulsivity that interferes with
    functioning or development as characterized by
    inattention and or hyperactivity/impulsivity
  • 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
  • Often fails to give close attention to details or
    makes careless mistakes in schoolwork
  • Has difficulty sustaining attention in tasks or
    play activitiesAnd remaining focused
  • Often does notseem to listen when spoken to
    directly
  • Does not follow through on instructions and fails
    to finish schoolwork chores or duties
  • Has difficulty organizing tasks and activities
  • Avoids dislikes or is reluctant to engage in
    tasks that require sustained mental effort
  • Loses things necessary for tasks or activities
  • Is easily distracted
  • Is forgetful in daily activities

16
Specifiers
  • 314.01 combined presentation
  • 314.00-predominantly inattentive presentation
  • 314.01 predominantly hyperactive impulsive
  • In partial remission
  • Severity level (mild moderate severe)

17
Other important changes ADHD
X
  • 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

18
Autism Spectrum disorder
X
  • 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

19
PDDs in DSM IV TR
  • Autistic disorder
  • Retts disorder
  • Childhood disintegrative disorder
  • Aspergers
  • PDD NOS
  • All characterized by severe deficits and
  • pervasive impairment in multiple areas of
    development
  • Reciprocal social interaction
  • Communication impaired
  • Stereotyped behavior, interests and activities

20
X
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
21
major changes for ASD
X
  • Three domains from the DSM IV-TR became two
    1Social interaction 2 communication deficits 3
    repetitive behavior/fixated interest
  • 1)     Social interaction/communication deficits
  • 2)     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

22
DSM 5 criteria for all ASD
X
  • 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

23
Specifiers
X
  • 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

24
severity
X
Severity 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 RRBs 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 (RRBs) cause significant interference with functioning in one or more contexts.  Resists attempts by others to interrupt RRBs or to be redirected from fixated interest.
25
ASD CONCERNS
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

26
2. Schizophrenia spectrum
27
Schizophrenia spectrum and other psychotic
disorders
X
  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

28
Overview of changes from DSM-IV TR to the DSM
five
2 schizophrenia and the DSM 5
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

29
Spectrums
  • 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)

30
Spectrum suggests a progression from
Mild or brief Major or lengthy Debilitation
Debilitation Severity
severity
Attenuated psychosis Syndrome in conditions
for further study
Schizotypal personality Disorder (Found in PD
Section)
delusional disorder
Brief psychotic disorder
Schizophreniform disorder
Schizoaffective disorder
Schizophrenia
  • In the following areas
  • Delusions
  • Hallucinations
  • Disorganized thinking/speech
  • Disorganized or abnormal motor behavior
  • Negative symptoms

31
Attenuated psychosis syndrome
CRITERIA
  • 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
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Symptoms must have been present at least once per
    week for the last month
  • Symptoms have begun or worsened in the last year
  • Symptom is sufficiently distressing or disabling
    to the individual
  • 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
  • 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

DIAGNOSTIC FEATURES
32
Schizotypal personality disorder(Technically not
in the spectrum)
Criteria
  • 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
  • Ideas of reference (excluding delusions of
    reference)
  • Odd beliefs or magical thinking that influences
    behavior i.e. belief in clairvoyance, astral
    projection telepathy etc.
  • Unusual perceptual experiences, including bodily
    illusions
  • Odd thinking and speech
  • Suspicious or paranoid ideation
  • Inadequate or constricted affect
  • Behavior or appearance that is odd eccentric or
    peculiar
  • Lack of close friends or confidants
  • Excessive social anxiety that does not diminish
  • 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

33
Schizophrenia
X
  • DSM-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
  • Delusions
  • Hallucinations
  • Disorganized speech
  • disorganized behavior
  • Negative symptoms (personality deterioration)

34
Except for
X
  • Requirement of bizarre delusionsand/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)
  • Delusions
  • Hallucinations
  • Disorganized speech
  • disorganized behavior
  • Negative symptoms (personality

35
  • 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
36
Specifiers
X
  • 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

37
Schizophrenia
X
Diagnostic features
  • 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

38
Schizophreniform disorder
X
Diagnostic features
  • 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

39
Schizophreniform
X
Diagnostic criteria 295.40
  • 2 or more of the following present for a
    significant portion of time. At least one of
    these must be one 2 or 3
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Disorganized motor behavior
  • Negative symptoms
  • Lasts at least one month but less than 6 months.
    When diagnosis is made before recovery, specify
    "provisional
  • 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
  • Not attributable to substances or another medical
    condition

40
Schizoaffective disorder
X
Diagnostic criteria295.70
  • An uninterrupted. period which there is a major
    mood episode con current with criterion A of
    schizophrenia
  • Delusions
  • Hallucinations
  • Disorganized thinking
  • Grossly abnormal motor behavior
  • Negative symptoms of schizophrenia
  • 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
  • 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
  • Not attributable to the effects of a substance
    medication or other medical condition

The requirement that a major mood disorder must
be present for the majority Of the duration of
illness AFTER criterion A is met, makes this
alongitudinal Illness or bridge on spectrum
41
Specify whether295.70-bipolar
type295.70-depressive typeSpecify ifwith
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
  • Subtypes

X
42
PSYCHOTICISM
X
HIGH
SCHIZO- AFFECTIVE
SCHIZOPHRENIA ACUTE
MOOD DISORDERWITH PSYCHOTIC FEATURES
AFFECT
HIGH
NONE
SCHIZOPHRENIA PARTIAL REMISSION
MOOD DISORDER
NONE
43
(No Transcript)
44
3. Bipolar and related disorderssummary
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.

45
Some particular conditions can now be diagnosed
under "other specified bipolar and related
disordersThese do not meet full criteria for
bipolar diagnosis
X
  • 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

46
Problems
  • 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.

47
Bipolar I Coding for severity
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
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.
48
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

49
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
50
Instructions for the mania scale
Instructions to Clinicians The DSM-5 Level
2ManiaAdult 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 individuals manic
symptoms during the past 7 days.   Scoring and
Interpretation Each 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
 
  • Instructions for client
  • On the DSM-5 Level 1 cross-cutting questionnaire
    you just completed, you indicated that during the
    past 2 weeks you (the
  • individual 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.
  •  

51
Coding and recording procedures for bipolar one
disorder
  • Coding is complicated
  • Must specify the following in the order presented
    below
  • Bipolar I disorder
  • Type of current episode (manic or depressive)
  • Severity level
  • Current state of most recent episode (active, in
    partial remission, in full remission,
    unspecified)
  • Psychotic features present
  • Presence of other specifiers (uncoded)

52
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.
53
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54
4. Depressive disordersSUMMARY
X
  • 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

55
MDD Specifiers
X
  • Severity
  • With anxious distress
  • With mixed features
  • Melancholic Features
  • Atypical Features
  • Catatonic
  • Postpartum
  • Seasonal
  • With Psychotic Features(Mood congruent or
    incongruent)

56
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 296.20 296.30
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.
57
Problems with severity
  • 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.

58
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.
59
Instructions to Clinicians The DSM-5 Level
2DepressionAdult 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
individuals depression during the past 7 days.
Scoring and Interpretation Each item on the
measure is rated on a 5-point scale (1never
2rarely 3sometimes 4often and 5always)
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 individuals total raw score and the
information entered in the T-score row on the
measure.
60
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 55.059.9 Mild
60.069.9 Moderate 70 and over Severe
Note If more than 25 of the total items on the
measure are
61
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

62
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

63
Persistent depressive disorder 300.4 Formerly
known as dysthymic disorder
X
  • In The DSM-IV TR, dysthymia was considered a
    depressive disorder that that was
  • long-lasting (chronic) and
  • did not meet the full criteria for a major
    depressive episode- a milder form of depression

64
Persistent depressive disorder in the DSM
5Combines dysthymia and a chronic form of major
depressive disorder (without certain symptoms
X
Persistent depressive disorder
Chronic major depressive disorder- Must last for
2 or more years with little or no abatement no
suicidal ideation, or anhedonia Chronic
depression meet full criteria for major
depressive episode/Disorder
Dysthymia-2 or more years Chronic low-level
depression never meet full criteria for major
depressive episode
65
Dysthymia vs MDD
X
  • 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
66
Dysthymic Disorder and Chronic major depressive
disorder
X
  • 2 or more of the following associated Symptoms
    Along with depressed mood
  • Change in appetite
  • Change in sleep
  • Decreased energy
  • Decreased self worth
  • Poor concentration
  • Hopelessness
  • .

67
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

68
PDD Specifiers
X
  • 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

69
X
The bereavement exclusion is gone
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 12 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 nonbereavement-related major
depressive episodes. Finally, the depressive
symptoms associated with bereavement-related
depression respond to the same psychosocial and
medication treatments as nonbereavement-related
depression.
70
Disruptive mood dysregulation disorder 296.99
X
  • 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

71
Diagnostic criteria
  1. Severe recurrent temper outburst manifested
    verbally or behaviorally grossly out of
    proportion to the situation to the situation
  2. Outbursts are inconsistent with developmental
    level
  3. Outbursts occur 3 or more times a week
  4. Mood between temper outburst is persistently
    irritable or angry most of the day, nearly every
    day.
  5. Criterion a through D have been present for 12 or
    more months
  6. Criteria a through D are present in at least 2 or
    more settings
  7. Initial Diagnosis can be made between the ages of
    6 to 18
  8. Age of onset-established her history or
    observation-must be before the age of 10
  9. No presence of manic or hypomanic episode
  10. These behaviors do not occur during an episode of
    major depression and are not better explained by
    another mental disorder
  11. Symptoms are not attributable to the effects of a
    substance, another medical or neurological
    condition

72
Diagnostic features
X
  • 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

73
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

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75
5. Anxiety disorders, 6. obsessive-compulsive
disorder and 7. trauma-related disordersSUMMARY
76
Stress and trauma related disorders Adjustment
disorders
Anxiety disorders Panic disorder Agoraphobia Gene
ralized anxiety disorder Social phobia Specific
phobia
Disinhibited social engagement dis. Reactive
attachment disorder
Reactive attachment disorder
PTSD Acute stress disorder
PTSD Acute Stress disorder
Obsessive-compulsive related disorders Obsessive
compulsive disorder ocd w/ poor insight Hoarding
disorder Hair-pulling disorder Skin-picking
disorder Body dysmorphic disorder Medication-induc
ed ocd Other specified/unspecified
ocd
Specified anxiety disorder Unspecified anxiety
disorder
Obsessive compulsive disorder
Separation anxiety disorder selectivemutism
77
5. Anxiety disorders
  • 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

78
Other changes and 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

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80
6. Obsessive-compulsive and related disorders
X
  • 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

81
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

82
Hoarding disorder 300.3
X
  • Persistent difficulty discarding her, parting
    with possessions, regardless of their actual
    value
  • Difficulty is due to perceived need to save the
    items and due to distress associated with
    discarding them
  • To difficulty discarding results in the
    accumulation of possessions that congest and
    clutter active living areas and compromise their
    intended use
  • Causes clinically significant distress or
    impairment in social, occupational or other Areas
    of functioning
  • Not attributable to another medical condition
  • 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
83
Excoriation (skin picking) disorder 698.4
  1. Recurrent skin picking resulting in lesions
  2. Repeated attempts to stop or decrease behavior
  3. Causes clinically significant distress or
    impairment in social, occupational
  4. Not attributable to the effects of a substance or
    medication
  5. Not better explained by

84
Substance/medication induced obsessive-compulsive
and related disorder
X
  1. Obsessions, compulsions, skin picking, hair
    pulling or other body focused repetitive
    behaviors occur
  2. Evidence that symptoms began during or soon after
    substance use, withdrawal or medication exposure.
    Substance or medication is capable of producing
    obsessive-compulsive symptoms
  3. Not better accounted for by OCD that is not
    substance/medication induced
  4. Does not occur exclusively during delirium
  5. Causes clinically significant distress

85
OCD due to another medical condition 294.8
  1. Obsessions, compulsions, skin picking, hair
    pulling or other body focused repetitive
    behaviors occur
  2. 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
  3. Does not occur exclusively during delirium
  4. 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

86
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

87
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88
Substance-Related Disorders
X

The distinction between Dependence and abuse
disorders has been eliminated in the DSM 5
  • Substance Use Disorders
  • Substance Dependence
  • Substance Abuse
  • Substance-Induced Disorders
  • Substance Intoxication
  • Substance Withdrawal
  • Substance induced mental disorder

89
Substance use disorders maladaptive pattern
leading to clinically significant impairment or
distress for at least 12 months
X
  • Must have at least 2 of the following11
  • Substance taken in larger amount (need more for
    increased effect)
  • Persistent desire or efforts to quit
  • Time spent to obtain, use, recover from effects
  • Cravings Or urges to use
  • Failure to fulfill significant roles
  • Continued use despite persistent and recurrent
    problems
  • Important social/occupational activities are
    reduced
  • Recurrent use in physically hazardous situations
  • Use continues despite knowledge of impact of the
    problem
  • Tolerance, as defined by a. Increased amounts
    needed to achieve intoxication or b. Diminished
    effect
  • Withdrawal

90
Substance-related disorders
X
Substance induced dis.
Substance use dis.
  • Pathological pattern of behaviors related to use
    of the substance
  • Impaired control
  • Social impairment
  • Risky use

4. Pharmacological effects Increased tolerance
Substance Induced Mental disorder. Recent
ingestion followed by symptoms of another M.D.
Substance Withdrawal Physiological and
psychological symptoms due to decreased use or
cessation
Substance Intoxication Rec
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