DSM-5 DRILL DOWN PRESENTER: DIANA PALS, LCPC DEVELOPED BY: IDAHO-I MHCA 1 2 3 MAJOR CHANGES OF DSM5 1. Elimination of 5 Axis Diagnosis 1. 2. Inclusion of ICD 10 3. Addition of V Codes/ T & Z Codes 4. Consolidation of Aspergers, Autism, PDD 4 MAJOR CHANGES OF DSM5 5. Restructuring SUD into single disorder with varying severity 1. 6. Integration of emerging genetic & neuroimaging research 7. Symptom severity assessment 5 6 POSITIVES OF DSM5 1. Broad Collaboration 2. Inclusion of Cultural Considerations 3. More Descriptive Diagnosis 4. Reorganized to reflect etiology & shared factors 7 POSITIVES OF DSM5 5. Recognition of life span issues related to specific disorder. 6. Gender & cultural notes for individual diagnosis. 7. Removed diagnostic criterion not relevant across cultural groups. 8. 30% international in each work group 8 9 THREE MAJOR SECTIONS 1. The Basics 2. Diagnostic Criteria & Codes 3. Emerging Measures & Models - 10 INTRODUCTION: CODING & REPORTING PROCEDURES • Procedures • First list focus of treatment or reason for first visit • Exception: If a mental disorder is caused by a medical condition then list medical condition first (ICD coding rule). • Other diagnosis codes are listed in descending order of clinical importance including V/Z codes Sample Text V62.21 Problem Related to Current Military Deployment Status 301.89 Other Specified Personality Disorder (mixed personality features-dependent and avoidant symptoms) 327.26 Comorbid Sleep-Related Hypoventilation 300.4 Persistent Depressive Disorder (Dysthymia), With anxious distress, In partial remission, Early onset, With pure dysthymic syndrome, Moderate V62.89 Victim of Crime (state the crime) 278.00 Overweight or Obesity WHODAS: 63 11 WHODAS • World Health Organization Disability Assessment Schedule. • Can be self-administered by the client or proxy administered by the clinician. Download for free at: www.psyciatry.org/practice/dsm/dsm5/onlineassessmentmeasures (also in the back of the DSM 5, p 747) • Inventories cover the following aspects of functionality: • • Cognition • Mobility • Self-care • Getting along or socialization • Life activities and • Participation 12 GUIDELINES FOR ASSESSEMENT • • • • • • • • • • • • • • • • • Name of client: DOB: Pre-natal environment and conditions of delivery Age of mother during pregnancy Early infancy development Age of onset of symptoms Course of illness development Description of symptoms Severity of symptoms Cultural considerations School years development Temperamental status Genetic issues in the family History of mental illness in the family Full Medical history of client and family Areas of impairment Level of impairment severity Substance use /medication use history- assess which came first…the use or the disorder 13 14 SUBSTANCE-RELATED & ADDICTIVE DISORDERS Substance Use Disorders Inhalant-Related Disorders Substance-Induced Disorders Opioid-Related Disorders Substance Intoxication and Withdrawal Sedative, Hypnotic, or AnxiolyticRelated Disorders Substance/medication-Induced Mental Disorders Stimulant-Related Disorders Alcohol-Related Disorders *Kappa=.40 Tobacco-Related Disorders Caffeine-Related Disorders Other (or Unknown) SubstanceRelated Disorders Cannabis-Related Disorders Non-Substance-Related Disorders *Gambling Disorder Hallucinogen-Related Disorders 15 SUBSTANCE-RELATED & ADDICTIVE DISORDERS • Substance Use Disorders • No More Substance Abuse and Substance Dependence • *Critical* to Read & Follow Recording Procedures and Coding Notes • Few changes from the DSM-IV-TR with substance abuse and dependence criteria combined into one list • Nearly all substances are defined under the same overarching criteria • Criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders • Threshold Criteria= 2 of 11 symptoms • • • • Impaired Control (Criteria 1-4) Social Impairment (Criteria 5-7) Risky Use (Criteria 8-9) Pharmacological criteria (criteria 10-11) • *Removed: recurrent legal problems criterion • *Added: craving or a strong desire or urge to use a substance 16 SUBSTANCE-RELATED & ADDICTIVE DISORDERS Substance Use Disorders Specifiers & Severity Substance Use Disorder Changes Remission Specifiers • No more partial or full • Early remission=at least 3, but less than 12 months without substance use disorder criteria (except craving) • Sustained remission=at least 12 months without criteria (except craving) Removed • Polysubstance Abuse/Dependence • Amphetamine • Cocaine • Specifier for a physiological subtype • On agonist therapy Severity Ratings • 2-3 criteria indicate Mild Disorder • 4-5 criteria indicate Moderate Disorder • 6 or more indicate Severe Disorder Added • Caffeine Withdrawal • Cannabis Withdrawal • Tobacco-Related Disorder • Stimulant-Related Disorder • On Maintenance therapy 17 SUBSTANCE-RELATED & ADDICTIVE DISORDERS Gambling Disorder Gambling Disorder, cont. • “This change reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance abuse use disorders to a certain extent.” • Lowering of the pathological gambling threshold to 4 symptoms • Removed: the illegal acts criterion • Similar clinical expression, brain origin, comorbidity, physiology, and treatment • Not yet strong or pervasive research to support the inclusion of other disorders like: • Sex addiction • Relationships • Codependency • Cults • Performance • Compulsive Spending • Rage/violence • Media/entertainment 18 19 PREVALENCE OF AUTISM SPECTRUM DISORDERS 1 in 88 children 1 in 54 boys 1 in 252 girls 78% increase from 2002 20 PERVASIVE DEVELOPMENTAL DISORDERS (DSM-IV-TR) • PDD included • • • • • Autistic Disorder Rhett’s Disorder Childhood Disintegrative Disorder Asperger’s Disorder Pervasive Developmental Disorder, NOS 21 ASPERGER’S DISORDER (DSM-IV-TR) • Impairment in social interactions (at least 2) • Restricted repetitive and stereotyped patters of behavior, interest, and activities (at least one) • Significant impairment in social, occupational, or other important areas of functioning • No clinically significant language delay • No clinically significant delay in cognitive development or ADLs • Not better accounted for by another PDD or Schizophrenia 22 PERVASIVE DEVELOPMENTAL DISORDER, NOS (DSM-IV-TR) • Severe and pervasive impairment in reciprocal social interactions, and • Impairment in either verbal or nonverbal communication skills or stereotyped behavior • Does not meet criteria for a specific PDD, schizophrenia, schizotypal PD, or Avoidant PD 23 WHY THE CHANGE IN DSM-5? • Improve accuracy of diagnosing • Describe specific symptoms • *No significant changes overall 24 AUTISM SPECTRUM DISORDER DSM-5 Criterion Described Part A • Persistent deficits in social communications and social interactions across multiple contexts, as manifested by the following, currently or by history Deficits in social-emotional reciprocity Deficits in nonverbal communicative behaviors used for social interactions • Deficits in developing, maintaining, and understanding relationships • • 25 AUTISM SPECTRUM DISORDER DSM-5 (CONT.) Part B • Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history • Stereotyped or repetitive motor movements, use of objects, or speech • Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior • Highly restricted, fixated interests that are abnormal in intensity or focus • Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment (*new criteria) **Both Part A & B must be present to diagnose 26 AUTISM SPECTRUM DISORDER DSM-5 (CONT.) Part C • Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capabilities, or may be masked by learned strategies in later life). Part D • Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning Part E • These disturbances are not better explained by intellectual disability or global developmental delay. 27 AUTISM SPECTRUM DISORDER SPECIFIERS/MODIFIERS • With or without accompanying intellectual impairment • With or without accompanying language impairment • Associated with a known medical or genetic condition or environmental factor • Associated with another neurodevelopmental, mental, or behavioral disorder • With catatonia 28 AUTISM SPECTRUM DISORDER LEVEL OF SEVERITY • Level 1: Requiring Support • Level 2: Requiring Substantial Support • Level 3: Requiring Very Substantial Support 29 FOCUS IS NOW ON HISTORY & OTHER ASSOCIATED FACTORS History & Associated Factors now considered in the diagnosis of Autism Spectrum Disorder include: Age of perceived onset Pattern of onset Culture-related issues Gender-related issues 30 AUTISM SPECTRUM DISORDER DIFFERENTIAL DIAGNOSIS Rhett’s Syndrome Selective mutism Language disorders Intellectual Disabilities without Autism Spectrum Disorder • Stereotypical movement disorder • Attention-deficit/hyperactivity disorder • Schizophrenia • • • • 31 MAJOR CHANGES IN THE DSM-5 • • • • • Spectrum of Disorders Focus on two key areas instead of three More focus on history Addition of Specifiers and Modifiers Social Communication Disorder (SCD) 32 IMPLICATIONS OF THE CHANGE • • • • • • Elimination of Asperger’s Disorder and PDD, NOS Better history screening Comorbid diagnoses Hopefully better services Intellectual Disability New Testing Measures 33 CONCERNS ABOUT THE NEW CRITERIA • • • • • Spectrum vs. Individual Diagnosis Too Stringent Social Communication Disorder Educational Needs Third Party Payers 34 TREATMENT FOR AUTISM • Team Approach • Medical Care-pediatrician, neurologist, psychiatrist, gastroenterologist • Early intervention/behavioral approaches • Speech Therapy • Occupational Therapy • Physical Therapy • Nutritionist 35 TYPES OF EARLY INTERVENTIONS FOR AUTISM SPECTRUM DISORDER • • • • • • • Applied Behavioral Analysis Pivotal Response Treatment Verbal Behavior Early Start Denver Model Floortime Relationship Development Intervention TEACCH 36 WHERE TO FIND SERVICES FOR AUTISM SPECTRUM DISORDER • • • • • • • • Screenings Local testing Children’s Hospitals Local Universities Community Mental Health Centers Private Practitioners Specializing in ASD Autismspeaks.org—Tool kits Support Groups 37 38 DSM-5 LAYOUT FOR MOOD DISORDERS • Divided into 2 sections designed to assist in diagnosing problems with mood. • 1. Criteria and description of all disorders, including diagnostic features, associated features, and differential diagnostic issues • 2. Definitions of Specifiers that provide greater description of the current or most recent mood episode. • Recognition is important: bipolar disorder is often missed; average time for non-MD to correctly diagnose is 8.9 years; for an MD it is 6.5 years (Ghaemi, as cited in Quinn, 2008). • TIPS: Always check for a mood disorder in any new client and NEVER assume mood disorder is client’s only diagnosis. 39 WHAT IS A MOOD EPISODE? • Mood episodes are building blocks of (most) mood disorders. • • • • • Quality of mood (high or low) Required time Required symptoms Degree of disability Exclusions not result of GMC or substance use 40 CLASSIC TRIAD OF MANIC EPISODE Heightened self-esteem Increased motor activity Pressured Speech 41 BUILDING BLOCKS OF MOOD DISORDERS: MANIC EPISODE • Must meet five (5) criteria • Mood that is abnormally elevated and expansive (sometimes irritable) • Heightened mood has existed for a minimum of one week. • Must meet 3 of the following criteria: • • • • • • • 1. increased self esteem 2. decreased sleep 3. Pressured speech 4. racing thoughts 5. increase in physical activity 6. goal agitation 7. risk taking behavior • Has resulted in significant social, personal, and/or occupational impairment • Does not violate exclusions of GMC & substance induced • At least one lifetime manic episode is required for the diagnosis of Bipolar I. 42 BUILDING BLOCKS OF MOOD DISORDERS: HYPOMANIC EPISODE • “Watered down” version of a manic episode • Quality of mood that is euphoric, but without the driven quality present in a manic episode • Mood must be qualitatively different from normal nondepressed mood • Disturbance in mood is observable by others • Is NOT severe enough to cause marked impairment • Client must have symptoms for a period of four (4) days • Same number of symptoms from the same list required for manic episode: At least three (3) symptoms must be present during previous four (4) days. If mood is irritable than four (4) symptoms are required. Hypomanic episodes are common in Bipolar I Disorder, but are not required for a diagnosis of Bipolar I Disorder. 43 BUILDING BLOCKS OF MOOD DISORDERS: MAJOR DEPRESSIVE EPISODE • One of the most common problems for why people seek help. • Must meet following criteria: • Depressed mood or loss of interest or pleasure • Existed most of the day, nearly every day, for at least 2 weeks. • Accompanied by at least five (5) symptoms, where one (1) symptom must be depressed mood or loss of pleasure • Death wishes/suicidal ideation • Mood disturbance cannot be due to a GMC or use of substances • Major Depressive episodes are common in Bipolar I Disorder, but are not required for a diagnosis of Bipolar I Disorder. 44 BIPOLAR I DISORDER CODING & RECORDING ISSUES • Big changes to coding & recording from the DSM-IV TR. • If you suspect a Bipolar I diagnosis, then you need to determine the following related to the current or most current episode • (a) severity, (b) if psychotic features are present, and (c) remission status • Note: Current severity and psychotic features are only indicated if full criteria are met for a manic or major depressive episode. 45 BIPOLAR I DISORDER: DIAGNOSTIC CODING Bipolar I disorder, Current or most recent episode manic Choose one of the following for coding purposes: • Mild, 296.41 (F31.11) • Moderate, 296.42 (F31.12) • Severe, 296.43 (F31.13) • With psychotic features, 296.44 (F31.2) • In partial remission, 296.45 (F31.73) • In full remission, 296.46 (F31.74) • Unspecified, 296.40 (F31.9) 46 BIPOLAR I DISORDER: DIAGNOSTIC CODING Bipolar I disorder, Current or most recent episode depressed Client’s current or most recent episode is depressed and criteria have been met for at least one manic episode Choose one of the following for coding purposes: • Mild, 296.41 (F31.31) • Moderate, 296.52 (F31.32) • Severe, 296.53 (F31.4) • With psychotic features, 296.54 (F31.5) • In partial remission, 296.55 (F31.75) • In full remission, 296.56 (F31.76) • Unspecified, 296.50 (F31.9) 47 BIPOLAR I DISORDER: DIAGNOSTIC CODING Bipolar I disorder, current or most recent episode hypomanic Client’s current or most recent episode is hypomanic and criteria have been met for at least one manic episode Choose one of the following for coding purposes: • Severity and psychotic specifiers do not apply, always code 296.40 (F31.0). • In partial remission: 296.45 (F31.73) • In full remission: 296.46 (F31.74) • Unspecified, 296.40 (F31.9) 48 BIPOLAR I DISORDER: DIAGNOSTIC CODING Bipolar I disorder, current or most recent episode unspecified Client’s current or most recent episode is unspecified and criteria have been met for at least one manic episode • Choose the following for coding purposes: Severity, psychotic, and remission specifiers do not apply, always code 296.7 (F31.9) 49 MAKING THE BIPOLAR I DISORDER DIAGNOSIS For Bipolar I Disorder, the symptoms must not be better accounted for by schizoaffective disorder, schizophrenia, schizophreniform, delusional disorder, or other psychotic disorder exclusions. The clinician has the option to add other specifiers that are not associated with a code (applies only to the current or most recent episode, except with rapid cycling). • With anxious distress • With mixed features • With rapid cycling (applies to course of disorder rather than to most recent episode) • With melancholic features • With atypical features • With mood-congruent psychotic features • With mood-incongruent psychotic features • With catatonia (coding note: Use additional code 293.89 (F06.1) • With peripartum onset • With seasonal pattern (applies only to current or most recent depressive episode 50 BIPOLAR I DIAGNOSIS, CONTINUED • In recording the Bipolar I diagnosis, start with the name of disorder, type of current or most recent episode, severity/psychotic features/remission specifiers, as many specifiers without codes that apply. • Some examples of diagnoses: • 296.52 (F31.32) Bipolar I disorder, current episode depressed, moderate, with atypical features • 296.44 (F31.2) Bipolar I disorder, most recent episode manic, with psychotic features, with anxious distress, with rapid cycling. 51 BIPOLAR II DISORDER: DIAGNOSTIC CODING • Criteria have been met for at least one hypomanic episode and at least one major depressive episode; no history of manic episode. • Choose the following for coding purposes: • Only one diagnostic code. 296.89 (F31.81) • Current severity, psychotic features (depressive episode only), course, and other specifiers cannot be coded, but can be expressed in writing. 52 MAKING THE BIPOLAR II DIAGNOSIS • Specify the following in writing if relevant to client’s symptoms: • Most recent episode is hypomanic or depressed • Any of these characteristics match the most recent episode? • With anxious distress • With mixed features • With rapid cycling (applies to course of disorder rather than to most recent episode) • With melancholic features • With atypical features • With mood-congruent psychotic features • With mood-incongruent psychotic features • With catatonia (coding note: Use additional code 293.89 (F06.1) • With peripartum onset • With seasonal pattern (applies only to current or most recent depressive episode) 53 BIPOLAR II DIAGNOSIS, CONTINUED • Additional specifiers: • If full criteria for mood episode are not currently met • In partial remission • In full remission • If full criteria for mood episode are currently met • mild, moderate, severe • Writing out the Bipolar II diagnosis should have the following pattern: • Name of disorder, current or most recent episode, additional specifiers, course specifiers, severity specifiers. • Example: • 296.89 (F31.81) Bipolar II disorder, current episode depressed, with seasonal pattern, moderate 54 OTHER BIPOLAR DISORDERS • Substance/Medication-Induced Bipolar and Related Disorder (coding depending on substance) • Bipolar and Related Disorder Due to a General Medical Condition (Coding follows ICD-10-CM and can get complicated). • 296.89 (F31.89) Other Specified Bipolar and Related Disorder • 296.80(F31.9) Unspecified Bipolar and Related Disorder 55 CYCLOTHYMIC DISORDER • Clients who are chronically both elated and depressed, but do not fulfill criteria for hypomanic or major depressive episodes. • Client has had hypomanic symptoms and low mood swings for at least two years (at least 1 year for children and adolescents). • Symptoms have been present for at least half the time; longest client has been free of mood swings during two year period is two months. • Client has never met criteria for major depressive, manic, or hypomanic episodes • Typical exclusions (not due to GMC or substance use) 56 KEY DIAGNOSTIC PRINCIPLES (QUINN, 2008) • Most critical task: is the depression unipolar or bipolar? • Always rule out medical disorders or substance abuse that may cause secondary depression or mania • Diagnostic assessment should search strategically for periods of hypomania in client’s history • Hypomania can “look like” normal happiness, but if it happens repeatedly without sleep, and the client has more energy but with less sleep, or these times are preceded/followed by rapid bouts of depression, think hypomania. • Assess multiple criteria • Symptoms are important, but also look at course of symptoms, family history, and client response to medication. 57 THE BIPOLARITY INDEX (SACHS, 2004; WEGMANN, 2011) • Assesses the client on 6 dimensions: episode characteristics (hypomania or mania), age of onset, illness course, and other features, response to medications, and family history. • Clients are scored depending on where they “fall” related to each dimension. For example: A client who has experienced an episode characteristic of full blown manic symptoms would be assigned 20 points. If he or she had an age of onset of between 20-30, another 15 points would be scored, and so forth. • Most bipolar I patients score about 60, according to Sachs (2004). • Still needs to be fine-tuned, but can provide some quantitative sense of the likelihood and magnitude of bipolar disorder. • Note that even if a client has not had a manic episode, some characteristics are highly predictive of bipolar disorder (e.g., early onset of depression, brief depressive episodes). 58 59 TREATMENT OF BIPOLAR I&II CBT Family-focused treatment Interpersonal psychotherapy Psychoeducation about disorder Chart the precipitants, nature, duration, frequency, and seasonality of dysfunctional mood to avoid future episodes. • Medication • • • • • • Lithium • Anticonvulsants (Depakote, Tegretol, Lamictal) • Atypical Antipsychotics (Risperdal, Seroquel) 60 61 ANXIETY DISORDERS • Definition • Anxiety is defined as “a state of intense apprehension, uncertainty, and fear resulting from the anticipation of a threatening event or situation, often to a degree that normal physical and psychological functioning is disrupted” (American Heritage Medical, 2007, p. 38). • The American Psychiatric Association (APA) purports that each of the Anxiety Disorders share features of fear and anxiety. • “Fear is the emotional response to real or perceived threat, whereas, anxiety is anticipation of future threat” (APA, 2013, p. 189). 62 CHARACTERISTICS OF ANXIETY DISORDERS • Physiological symptoms include: • • • • • Muscle tension Heart palpitations Sweating Dizziness Shortness of breath • Emotional symptoms include: • • • • • Restlessness Sense of impending doom Fear of dying Fear of embarrassment or humiliation Fear of something terrible happening 63 PREVALENCE OF ANXIETY DISORDERS • Each year Anxiety Disorders impact approximately 18% (40 million) adults in the U.S. (NIMH, 2013b; NIMH, 2013c). • Anxiety disorders have a lifetime prevalence of approximately 30% (Kessler et al., 2005). • Close to 50% of individuals diagnosed with an Anxiety Disorder also meet the criteria for a Depressive Disorder (Batelaan, De Graaaf, Van Balkom, Vollebergh, & Beekman, 2012). 64 MAJOR CHANGES IN ANXIETY DISORDERS FROM DSM-IV TR TO DSM-5 • Includes Selective Mutism and Separation Anxiety • Changing the name of Social Phobia to Social Anxiety Disorder • Removing Panic Attack as a specifier for Agoraphobia. • Assigning Panic Attack as a specifier that may be applied to a wide array of DSM-5 diagnoses. 65 DIFFERENTIAL DIAGNOSIS OF ANXIETY DISORDERS & DEPRESSIVE DISORDERS • Challenging due to the high comorbidity (up to 50%) of Anxiety Disorders with Depressive Disorders • Depressive Disorders are sometimes viewed as “anxious-misery” with high incidences of sadness and anhedonia. • Anxiety Disorders often include “anxiety anticipation”, worry, uncertainty, and fear (Craske et al., 2009) • Sleep disturbance, overall fatigue, and difficulty with concentration can be symptoms of both (APA, 2013). 66 SEPARATION ANXIETY DISORDER • Separation Anxiety Disorder was moved from Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence (DSM-IV TR) to the Anxiety Disorders chapter in DSM-5. • The age-of-onset requirement (before age of 18 years) was dropped, thus allowing for diagnosis of Separation Anxiety Disorder in adults (Mohr & Schneider, 2013). 67 SEPARATION ANXIETY DISORDER DEFINITION & PREVELANCE • Required: • Duration of at least 6 months in adults (1 month in children). • Prevalence rates are as follows: children (4%); adolescents (1.6%), and adults (0.9%- 1.9%) • Separation Anxiety Disorder is the most prevalent Anxiety Disorder in children, with girls more susceptible than boys. • Functionality in school, work, or social settings is often impaired (APA, 2013). 68 SELECTIVE MUTISM • This is a new diagnosis in the Anxiety Disorders chapter of the DSM-5 due to the restructuring of the chapters and the removal of the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence (APA, 2013). • Selective Mutism is the voluntary refusal to speak (typically occurs outside of the home or immediate family). • Children with Selective Mutism will sometimes communicate with non-verbals such as nodding or grunting, and these children do not usually possess language deficits. • Selective Mutism usually has an age of onset of under 5 years and is often first noticed in school settings (APA, 2013). 69 SPECIFIC PHOBIA • Specific Phobias represent the existence of fear or anxiety in the presence of a specific situation or object. This is called the “phobic stimulus” (APA, 2013). • This fear or anxiety must be markedly stronger than the actual threat of the object or situation (i.e., likelihood of being stuck on a well-maintained elevator). • Specific Phobias were first identified as such in the DSM-III-R, carry a lifetime prevalence rate of 9.4% to 12.5% (Marques et al., 2011). 70 SPECIFIC PHOBIAS • Specific Phobias can develop after a traumatic event or from witnessing traumatic events. • Individuals with Specific Phobia will avoid situations of exposure to the stimulus. • The fear or anxiety happens every time the person is exposed to the stimulus and may include symptoms of a panic attack. • The median age of onset for a diagnosis of Specific Phobia is 13 years (APA, 2013). 71 SPECIFIC PHOBIA CODING • Approximately 75% of individuals diagnosed with Specific Phobia fear more than one object. When this occurs, more than one diagnosis is given. • 300.29 (F40.228) Animal • 300.29 (F40.228) Natural Environment • 300.29 (F40.228) Blood-injection injury • • • • F40.230 Fear of blood F40.231 Fear of injections and transfusions F40.232 Fear of other medical care F40.233 Fear of injury • 300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed spaces) • 300.29 (F40.298) Other (situations that may lead to choking or vomiting; in children, e.g., loud sounds or costumed characters). • In cases where individuals experience panic attacks in response to their phobia, clinicians should add with panic attacks to the diagnosis. 72 73 SOCIAL ANXIETY DISORDER (SAD) • Social Phobia was originally classified as a mental disorder in the DSM-III and has been renamed Social Anxiety Disorder (SAD) in the DSM-5. • The main feature of SAD is ongoing fear and worry surrounding myriad of social situations (Kerns, Corner, Pincus, & Hofmann, 2013). • It is one of the most common mental disorders with a lifetime prevalence rate of slightly greater than 10%. • The majority of diagnoses are made during childhood or early adolescence (Kerns, et al., 2013; Marques et al., 2013). • SAD is often seen in conjunction with Major Depressive Disorders, other Anxiety Disorders, and Substance Use Disorders (APA, 2013). 74 SOCIAL ANXIETY DISORDERS (SAD), CONTINUED • Individuals with SAD often fear negative evaluation (e.g., being humiliated, embarrassed, or rejected) by others, either unfamiliar or familiar, in performance, interaction, or observation situations. • New: A Performance only specifier has been added for SAD in the DSM-5 and includes a minimum duration of 6 months. • Children, adolescents, and adults now share the same criteria for duration, and the criterion for adult insight has been dropped (Mohr & Schneider, 2013). 75 SAD • The Performance only specifier is given if anxiety is specific to speaking or performing in public. • Individuals diagnosed with the Performance only specifier are mainly impaired in regard to their occupational environments. They may also display difficulty in school situations where public speaking is a requirement. 76 77 PANIC DISORDER • Panic Disorder is defined as recurrent, unexpected panic attacks and was initially classified in the DSMIII. • There is a median age of onset ranging from 20 to 24 years with a small percentage of individuals first diagnosed in childhood. • Panic Disorder is not usually first seen in individuals over the age of 45. • There is an annual U.S. prevalence rate of 2.1% to 2.8%; this is one of the highest prevalence ratings in the world (Marques, et al., 2011). 78 PANIC DISORDER DEFINED • Essential features of Panic Disorder • Persistent fear or concern of inappropriate fear responses with recurrent and unexpected panic attacks • Includes physiological changes such as accelerated heart rate, sweating, dizziness, trembling, and chest pain. Panic Disorder has physical and cognitive symptoms and involves numerous, unexpected panic attacks (although it is important to note that individuals with Panic Disorder can have expected panic attacks, too). 79 PANIC DISORDER, CONTINUED • Common differential diagnoses for Panic Disorder: • • • • Other specified or Unspecified Anxiety Disorder Anxiety Disorder Due to Another Medical Condition Substance/Medication-Induced Anxiety Disorder Other mental disorders with panic attacks as an association feature (specifier). • Illness Anxiety Disorder, formerly known as hypochondriasis, often shares features with an/or is comorbid with Panic Disorder (Starcevic, 2013). 80 PANIC ATTACK SPECIFIER • Panic Attack is not classified as a mental disorder and does not have a diagnostic code. • Panic attacks are abrupt surges of intense fear; they can occur with other mental disorders such as Depressive and Anxiety Disorders and also be extant with physical disorders. • Panic attack is a specifier for both mental and physical disorders; however, the elements of panic attack are contained within the criteria for Panic Disorder so it is not a specifier for that diagnosis. • An example of panic attack used as a specifier is Social Anxiety Disorder, with Panic Attack (APA, 2013). 81 PANIC ATTACK SPECIFIER • Essential Features • Panic Attacks represent intense fear or discomfort that occurs abruptly and peaks rapidly. • Physical symptoms are predominate and must include a minimum of four out of the thirteen identified symptoms, listed on page 214 of the DSM5. • Panic Attacks have an 11.2% annual prevalence rate in the general U.S. population (APA, 2013). 82 AGORAPHOBIA • Agoraphobia is a newly codeable disorder in the DSM-5 and represents an intense fear resultant from real or imagined exposure to a wide range of situations. • There is a 1.7% prevalence rate for the diagnosis of Agoraphobia for adolescents through middle-aged adults. • Agoraphobia lends to moderate to severe impairment in functioning with over 33% of individuals diagnosed with Agoraphobia restricted to home environments (APA, 2013). 83 AGORAPHOBIA: ESSENTIAL FEATURES • Agoraphobia represents fear of situations where escape from bad things is difficult. This response happens almost every time an individual is exposed to the situations or event (it is not Agoraphobia if the response occurs only some of the time). Avoidance of the event or situation must also be present and can include cognitive or behavioral aspects (APA, 2013). • Acute stress disorder and Posttraumatic Stress Disorder can be distinguished from Agoraphobia in that the avoidance occurs only from situations that trigger a memory of the traumatic event, such as driving or riding in a car after a motor vehicle accident (APA, 2013). 84 GENERAL ANXIETY DISORDER (GAD) • GAD has been in existence since the DSM III • GAD is one of the most common of all mental disorders with an annual prevalence rate of 2.9% among adults in U.S. • Excessive worry or anxiety about a number of events is the key feature of GAD with the experience of the anxiety or worry in discord with the actual or expected event. • Although the DSM-5 Task Force proposed changes to GAD that would have resulted in a lowered diagnostic threshold, this disorder remains largely unchanged from the DSM-IV TR. 85 GAD, CONTINUED • Essential features include anxiety or worry that takes place across a number of settings and more days than not for at least six month. • The individual experiences at least three characteristic symptoms including (as defined by the APA, 2013): • Restlessness or feeling keyed up or on edge • Being easily fatigued • Difficulty concentrating or mind going blank • Irritability • Muscle tension • Sleep disturbance Many of the Anxiety Disorders outlined in this chapter along with Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, Adjustment Disorders, Depressive Disorders, and psychotic disorders possess similar features to GAD. 86 SUBSTANCE-INDUCED ANXIETY DISORDER • Anxiety caused by substance utilization is the primary criterion for the diagnosis of substance/medication induced Anxiety Disorder. • Panic or anxiety must have developed during or soon after substance/medication usage and be in excess of what would be expected to be associated with intoxication or withdrawal from that specific substance. • Prevalence rates for this disorder are low (.002%). • It is important for clinicians to tease out substances used to self-medicate anxious symptoms with anxiety resultant from substance usage or withdrawal. 87 ANXIETY DISORDER DUE TO ANOTHER MEDICAL CONDITION • Medical conditions can cause the development of an Anxiety Disorder, but they must cause clinically significant distress. • APA reports are “unclear” about prevalence of Anxiety Disorder Due to Another Medical Condition resultant from the extreme difficulty with differential diagnosis for this category (APA, 2013). • It is especially important for clinicians to carefully rule out differential diagnosis and consult with a physician before using the diagnosis of Anxiety Disorder Due to Another Medical Condition. 88 ANXIETY DISORDER DUE TO ANOTHER MEDICAL CONDITION • Essential Features • Marked anxiety attacks occur and can be directly attributed to an existing medical condition. The development of the anxiety can parallel the course of the illness. • Examples of medical conditions that can cause Anxiety Disorder Due to Another Medical Condition: endocrine disease, cardiovascular disorders, respiratory illness, metabolic disturbance, and neurological illness (APA, 2013). • The key to discernment regarding Anxiety Disorder Due to Another Medical Condition is that the anxiety symptoms must be attributed to the physiological effects of the medical condition. 89 TREATMENT • Although tending towards chronicity, Anxiety Disorders are responsive to psychotherapeutic treatment modalities. • It is important for counselors to note that severe anxiety is a risk factor for suicide (Fawcett, 2013). • Additionally, Anxiety Disorders are the most common disorders in youth (Sood, Mendez, & Kendall, 2012) and have a median age of onset of 11 years. 90 IMPLICATIONS FOR COUNSELORS • Due to the prevalence of Anxiety Disorders in the general population, these diagnoses are frequently the focus of clinical attention for counselors and are often diagnosed within counseling settings (ADAA, 2013). • Individuals with Anxiety Disorders generally respond well to clinical intervention with effective treatments including Cognitive-Behavioral Therapy (CBT), Behavior Therapy (BT), and relaxation training (AADA, 2013). • Numerous research studies reveal that positive treatment outcomes for Anxiety Disorders are maintained longer for individuals, including children and adolescents, who have participated in CBT and BT (Hausmann et al., 2007; Hofmann & Smits, 2008; Silverman, Pina, & Viswesvaran, 2008). 91 92 DEPRESSIVE DISORDER IN DSM-5 Organization of Chapter • Disruptive Mood Dysregulation Disorder • Major Depressive Disorder • Persistent Depressive Disorder • Premenstrual Dysphoric Disorder • Substance/Medication Induced Depressive Disorder • Depressive Disorder Due to Another Medical Condition • Other Specified Depressive Disorder • Unspecified Depressive Disorder 93 DISRUPTIVE MOOD DYSREGULATION DISORDER (DMDD) • Rationale for adding new disorder • Essential feature: Severe temper outbursts with underlying persistent angry or irritable mood • Temper Outburst Frequency: Three or more times in a week • Duration: Temper outbursts and the persistently irritable mood between outbursts lasts at least 12 months. • Severity: Present in two settings and severe in at least one • Onset: Before age 10, but do not diagnose before age 6. Cannot diagnose for the first time after age 18. • Common rule-outs: • Bipolar disorder, intermittent explosive disorder, depressive disorder, ADHD, autism spectrum disorder, separation anxiety disorder, substance, medication, or medical condition • If ODD present, do not diagnose DMDD. 94 ISSUES WITH DMDD • • • • • More common in males No empirically supported treatments yet. Need more research Avoid bipolar medications Consider CBT treatments used for depression in children: • Coping skills for thoughts, feelings, and behavior • Parent training • Parent support group 95 MAJOR DEPRESSIVE EPISODE • Essential features: Either depressed mood OR loss of interest or pleasure plus four other depressive symptoms • Duration: At least two weeks • Common rule-outs: medical condition, medications, substance use, bipolar disorder, or a psychotic disorder. • Note: Be careful about diagnosing major depression following a significant loss, because normal grief “may resemble a depressive episode.” 96 GRIEF VS. A MAJOR DEPRESSIVE EPISODE IN DSM-5 Grief Major Depression Dominant affect is feelings of emptiness and loss Dominant affect is a depressed mood Dysphoria occurs in waves, vacillates with exposure to reminders and decreases with time Persistent dysphoria that is accompanied by self-critical preoccupation and negative thoughts about the future Capacity for positive emotional experiences Limited capacity to experience happiness or pleasure Self-esteem preserved Worthlessness clouds esteem Fleeting thoughts of joining deceased Suicidal ideas about escaping life versus joining a loved one. 97 DIAGNOSING MAJOR DEPRESSIVE DISORDER • Essential Features: • Meets criteria for a Major Depressive Episode • No history of a Manic or Hypomanic Episode • Coding Steps: • 1. Start with noting whether it is a single episode or recurrent (see columns on pg 162). • 2. The code # indicates the type of episode (single or recurrent) as well as the severity, presence of psychotic features and remission status (partial or full). Find the correct code number by dropping down your selected episode column to locate the applicable severity, psychosis, or remission term. For a recurrent episode that is moderate severity you would use this code: • 296.32 Major Depressive Disorder, Recurrent episode 98 DIAGNOSING MAJOR DEPRESSIVE DISORDER, CONTINUED • 3. Now state the severity, psychosis, or remission status term right after single or recurrent episode: • 296.32 Major Depressive Disorder, recurrent episode, moderate severity • 4. Finally, add any of the specifiers that apply • With anxious stress, with mixed features, with melancholic features, with atypical features, with mood-congruent psychotic features or with mood-incongruent psychotic features, with catatonia (code separately), with peripartum onset, or with seasonal pattern • 296.32 Major Depressive Disorder, recurrent episode, moderate severity, with peripartum onset 99 PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA) • Essential Feature: Depressed mood plus at least two other depressive symptoms • Duration: The symptoms persist for at least two years (one year for children and adolescents). • May include periods of major depressive episodes (double depression). • Rule outs: Be sure it is not due to another psychotic disorder, substance, medication, or medical condition. 100 SPECIFIERS FOR PERSISTENT DEPRESSIVE DISORDER Severity: Mild, moderate, or severe Remission status: In partial or full remission (if applicable) Onset: Early (before 21), or late (21 or older) Specify mood features: With anxious distress, mixed features, melancholic features, atypical features, moodcongruent or mood-incongruent psychotic features, and peripartum onset • Course specifiers: with pure dysthymic syndrome, with persistent major depressive episode, with intermittent major depressive episodes with current episode, with intermittent major depressive episodes without current episode. • • • • 101 102 PREMENSTRUAL DYSPHORIC DISORDER (PMDD) • Essential Feature: Significant affective symptoms that emerge in the week prior to menses and quickly disappear with the onset of menses. • Symptoms threshold: At least five symptoms which include marked affective lability, depressed mood, irritability, or tension. • Duration: Present in all menstrual cycles in the past year and documented prospectively for two menstrual cycles. • Impairment: Clinically significant distress or impairment • Rule outs: An existing mental disorder (e.g., MDD), another medical condition, (e.g., migraines that worsen during the premenstrual phase) or substance or medication use. 103 PMDD UPDATE • What’s the difference between PMDD and PMS? • Why is it clinically significant to note from a mental health stand-point? • • • • • Increased risk of postpartum depression Increased risk of suicidal thinking, planning, and gestures Impact on the individual’s quality of life Impact on psychosocial functioning Treatments: • Diet • SSRI’s • CBT 104 FINAL THOUGHTS • Depressive Disorders are common and treatable • Be sure your diagnosis is part of an overall case formulation • Remember, to understand the disorder, you need to understand the person (Hippocrates). 105 106 PERSONALITY DISORDER: HISTORY OF THEIR INCLUSION IN DSM-IV-TR • Each personality disorder included in the DSM-IV TR was the subject of a literature review performed by Work Group members and advisors. • The reviews revealed that antisocial/psychopathic, borderline, and schizotypal personality disorders had the most extensive empirical evidence of validity and clinical utility. • Almost NO empirical research backed paranoid, schizoid, or histrionic personality disorders explicitly. • And, there was NO significant co-morbidity. 107 PERSONALITY DISORDERS IN DSM-5 THE PROPOSAL • Original draft of DSM-5 eliminated 4 Personality Disorders: • 1. Paranoid Personality Disorder • 2. Schizoid Personality Disorder • 3. Histrionic Personality Disorder • 4. Dependent Personality Disorder *An earlier draft also eliminated Narcissistic Personality Disorder & Borderline Personality Disorder. Very controversial topic! 108 PERSONALITY DISORDERS: RESEARCH • Personality Disorders with the most research behind them: • 1. Anti-social Personality Disorder • 2. Borderline Personality Disorder • 3. Schizotypal Personality Disorder These could not be eliminated in good conscience. Personality Disorders with the least research behind them: • 1. Paranoid Personality Disorder • 2. Histrionic Personality Disorder • 3. Schizoid Personality Disorder 109 PERSONALITY DISORDERS IN DSM-5 • No significant co-morbidity was found between the disorders…so a compromise was made: TO ELIMINATE NOTHING! ORGANIZATION OF PERSONALITY DISORDERS became the focus for DSM-5. Personality disorders do not fall along a developmental continuum, as the rest of the DSM-5 had been organized. Personality Disorders was tacked on to the end of the manual. 110 PERSONALITY DISORDER: ORGANIZATION IN THE MANUAL The cluster arrangement of these disorders remains the same. The beginning of the chapter discusses the features that are present in all of the personality disorders. Each disorder is more specifically discussed under their own heading. Common features among all disorders: 1. Cognition-ways of perceiving and interpreting self, others, and events 2. Affectivity-the range, intensity, lability, and appropriateness of emotional response 3. Interpersonal functioning 4. Impulse control issues 111 10 PERSONALITY DISORDERS Paranoid Personality Disorder Cluster A Schizoid Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Borderline Personality Disorder Cluster B Histrionic Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder Cluster C 112 DEFINITION OF PERSONALITY DISORDER “A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has onset in adolescence or in early adulthood, is stable over time, and leads to distress or impairment.” (APA, 2013, p. 645). 113 GENERAL PERSONALITY DISORDER DIAGNOSIS CRITERIA There are no significant changes to the diagnosis criteria in the DSM-5! NEW: Culture Related Diagnostic Issues More predominantly culturally aware in the DSM-5. Examples in Personality Disorders: • Schizotypal: Voodoo, speaking in tongues, belief in an afterlife. • Antisocial: tends to be over-diagnosed in clients from lower SES. • Avoidant: Acculturation issues • Dependent: Some cultures foster this • OCPD: Work and productivity in some cultures vary 114 115 NO CHANGES YET…BUT, • The present system is not sufficient. • Not enough empirical support for many of the personality disorders. (We need more research!) • Frustration with an overarching organizational system • Does the system go far enough? 116 PERSONALITY DISORDERS: DSM-5 • The task force wanted to move to a dimensional model vs. a categorical model for personality disorders. • Section III includes the “new approach” that addresses many of the major shortcomings of the current approach. • Criterion A includes assessment of personality functioning towards self (identity, self-direction), and interpersonally (empathy, intimacy). • Criterion B includes Pathological Personality Traits • 5 Broad Traits: negative affectivity, detachment, antagonism, disinhibition, and psychotic features (and 25 trait facets). 117 PERSONALITY DISORDERS: DSM-5, CONTINUED • Criterion C & D includes the assessment of pervasiveness (different areas of life) and stability (going back to adolescence). • Criterion E, F, & G is an assessment of alternative explanations for personality pathology (Differential Diagnosis). Includes not better explained by another mental illness, not attributable to substances or medical condition, or not better understood by an individual’s developmental stage or sociocultural environment. 118 PROPOSAL CONTINUED, ICD-11 • ICD-11 is proposing an even more radical approach (2015-16) that would abolish all individual categories of personality disorder and replace by 4 severity levels qualified by trait domains that have no age limits. • Trait domains proposed: • Internalizing (neurotic), Externalizing (sociopathic), Schizoid, Anankastic (obsessive/compulsive in some way). • Severity Categories: No Personality Disturbance Personality Difficulty (not coding) Personality Disorder (1st level of clinical severity) Complex Personality Disorder (more difficulty with interpersonal functions) • Severe Personality Disorder • • • • 119 EXAMPLE DIAGNOSIS: AVOIDANT PERSONALITY DISORDER • A. Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas: • 1. Identity: low self-esteem associated with self-appraisal as socially inept, personally unappealing or inferior; excessive feelings of shame • 2. Self-Direction: unrealistic standards for behavior associated with reluctance to pursue goals, take personal risks, or engage in new activities involving interpersonal contact. • 3. Empathy: Preoccupation with, and sensitivity to criticism or rejection, associated with distorted inferences. • 4. Intimacy: Reluctance to get involved with people unless being certain of being liked. B. Three or more of the four pathological personality traits, one of which must be anxiousness: 1. Anxiousness; 2. Withdrawal; 3. Anhedonia; 4. Intimacy Avoidance 120 POTENTIAL NEW GROUPINGS OF DISORDERS ACCORDING TO SCIENTIFIC VALIDATORS: • • • • • • • • • • • Shared neural substrates Family traits Genetic risk factors Specific environmental risk factors Biomarkers Temperamental antecedents Abnormalities of emotional or cognitive processing Symptom similarity Course of illness High comorbidity Shared treatment response 121 FUTURE CHANGES • Clustering diagnoses according to “internalizing” vs. “externalizing” groups. Internalizing: disorders with prominent anxiety, depressive and somatic symptoms. Characterized by depressed mood, anxiety and related physiological and cognitive symptoms. Externalizing: disorders with prominent impulsive disruptive conduct, substance use symptoms. Characterized by anti-social behavior, conduct disturbances, addictions, and impulse control disorder. 122 123 AREAS FOR FURTHER STUDY • 1. Attenuated Psychosis Syndrome • 2. Depressive Episodes with Short-Duration Hypomania • 3. Persistent Complex Bereavement Disorder • 4. Caffeine Use Disorder • 5. Internet Gaming Disorder • 6. Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure • 7. Suicidal Behavioral Disorder • 8. Non-suicidal Self Injury 124 WHAT DID APA GET RIGHT IN DSM-5? • APA listened, to a degree, especially about Personality Disorders. • Advanced the place of culture in diagnosis • Made some thoughtful changes to the organization and diagnosis criteria that may end up being very beneficial • Sparked conversations among professionals that needed to happen (and those conversations must continue). • Identified 8 areas professionals can focus their passions in research 125 WHAT SHOULD COUNSELORS DO? • Get a copy, start with the basics! p.5 to 25 • & highlights of changes p 809 to 816 • Study the new sections of DSM-5 that are used most in your practice or profession. • Study the cultural interview and WHODAS assessment. • Learn the ICD-10 well (and prepare for the ICD-11). • Advance “counseling science” to contribute to the field. We need more empirical data and counselors can be a huge contributor to that research base. 126 WHAT SHOULD COUNSELORS DO? • MOST IMPORTANT- Actively engage clients in collaborative discussion about diagnosis and mental health so that it becomes a hopeful and proactive force in promoting changes desired by the client. Diagnosis is a useless exercise if it does not assist in the change process. 127 128 FINAL THOUGHTS? 129 REFERENCES • Cross cutting and diagnostic severity measures go to: www.psychiatry.org/dsm5 • Thorough summary of changes go to: http://tnicholson2013.files.wordpress.com/2013/09dsm-5changes.pdf • For the WHODAS 2.0 and many assessment measures go to: • www.psyciatry.org/practice/dsm/dsm5/onlineassessmen tmeasures they are also in the back of the DSM 5 • ACA Webinar • Idaho Mental Health Counselors Webinar • You Tube –free 4 hour seminar 130 131