Why worry about the DSM V in IB Psychology

2. DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders. The American Psychological Association (APA) published DSM-5 in 2013, culminating a 14-year revision process.

3. Why worry about the DSM Vin IB Psychology • Enhances our knowledge of the concepts of normality and abnormality • Highlights problems of validity and reliability of diagnosis. If the manual changes, how certain can we be of its credibility • Highlights the role cultural and ethical considerations in diagnosis. Some changes in DSM 5 are societal driven

4. Why worry about the DSM – 5?A summary of the changes specific to our IB course • move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V). • Changes in the way culture is addressed • Changes to classification of PTSD (enhanced position) • Changes to consideration of bereavement in Major Depression.

5. Where did it all start?Diagnostic Classification History • Emil Kraeplin (1856-1926) – created a medical model based on symptoms and grouped them based on a pattern of symptoms • Realised that the same symptom could occur across disorders abut that different disorders have different patterns of symptoms

6. Various iterations of DSM

7. A Short History of the DSM • The DSM-1 (1952), 106 disorders across several major categories, reflecting a psychodynamic perspective on etiology • DSM II (1968), 182 disorders, similar framework as DSM-1; like DSM-1, it lacked specification of specific symptoms of many disorders; distinguished among disorders at broader levels of neurosis, psychosis, and personality disturbance • DSM-III (1980) and DSM-III-R (1987), which focused on standardization of diagnostic categories by categorising illnesses based on symptoms, but to this day does not reflect an understanding of causes. Included 265 diagnoses in DSM-III and 292 in DSM-III-TR

8. DSM-IV (1994) •  Effort to develop a consistent worldwide system of classification that would be compatible with the ICD-10 (1993) •  Huge review of all research on psychopathology to update the classification system •  Distinction between organically based disorders and psychologically based disorders was eliminated •  Increased considerations of cultural factors

9. DSM-IV CLASSIFICATION 1. Disorders usually first diagnosed in infancy, childhood or adolescence 2.  Delirium, Dementia & amnestic, & other cognitive disorders 3.  Mental disorders due to a general medical condition 4.  Substance related disorders 5.  Schizophrenia & other psychotic disorders 6.  Mood disorders

10. DSM-IV CLASSIFICATION 7. Anxiety disorders 8. Somatoform disorders 9. Factitious disorders 10. Dissociative disorders 11. Sexual & Gender identity disorders 12. Eating disorders

11. DSM-IV CLASSIFICATION 13. Sleep disorders 14. Impulse control disorders not elsewhere classified 15. Adjustment disorders 16. Personality disorders 17. Other conditions that may be a focus of clinical attention

13. Axis I • Are features of one or more DSM IV disorders present

14. Axis II • Personality disorders • Mental retardation • Personality traits & disorders • Habitual maladaptive defense mechanisms

15. Axis III • Current general medical conditions that are relevant to understanding and treatment of mental disorder

16. Axis IV • Psychosocial or environmental problem that effects diagnosis, treatment and prognosis of mental disorder: • Problems with primary support group • Problems related to social environment • Educational and occupational problems • Housing and other economic problems • Problems with access to health care services • Problems related to interaction with legal system / crime • Other psychosocial and environmental problems

17. AXIS V: • Global assessment of functioning (GAF) • Used to plan treatment, measure its impact and predict its outcome • GAF= 0 to 100 • Only rate with respect to psychological, social and occupational functioning • Do not include impairment due to physical or environmental limitations

18. Limitations of DSM IV Makes unjustified categorical distinctions between disorders, and between normal and abnormal (what about behaviour that falls behind the threshold, is behaviour a continum) Requires judgements can be subjective and open to cultural bias Too many diagnoses? 300 acute stress disorder a natural reaction? Represents increasing medicalization of human nature Relies on a biological model Disease mongering driven by drug companies Demonstrates lack of understanding between causes and illness – focus on treatments Scientific doubt about validity & reliability of diagnostic categories and criteria used

19. Problems with DSM classification: • Cultural considerations: • Culture determines how a disorder is expressed. May not be reflected in the diagnostic system (e.g. somatic expression of depression) • Western-based classification system may have questionable validity in a different cultural context (e.g.neurasthenia) • DSM IV has attempted to be more culturally sensitive by: • Provides a general framework for evaluating the role of culture and ethnicity • Decribes the role of cultural factors and ethnicity for each disorder • Lists culture bound syndromes in appendix

20. Problems with DSM classification: Labelling: • Tends to be reductionistic • May lead to stigmatization, or person taking on the sick role and identifying with the label •  Labels are “sticky” •  Instrument of social control: gives mental health professionals control over people’s lives

21. LIMITATIONS of DSMDSM demonstrates the link between diagnosis and treatment is relative weak • Eg Prozac: • Prescribed as anti-depressannt • But also helps: • Panic disorder • OCD • Builimia • Social phobia

22. Limitations continued • Many patients meet several diagnostic definitions at once • Eg adults with clinical depression often fit the definition of an anxiety disorder • Patients diagnosed with the same dysfunction aren’t necessarily the same • Based on consensus of experts, not scientific evidence

23. Assessment techniques • Behavioural observation • Appearance • Speech • Mood & affect • Thought processes • Intelligent functioning • Sensorium

24. Assessment techniques • Clinical Interview • P.88 table

26. Assessment techniques cont… 2. Psychological Testing • Projective testing • Use ambiguous stimuli & ask people to describe them • e.g. Rorschach Inkbolt, T.A.T, MMPI (personality inventory) • Intelligence testing • Intelligent quotient (IQ) • e.g. WAIS-III, WISC, SSAIS-R

27. Assessment techniques cont… • Physiological Tests Neurological Testing • Locates brain dysfunction • receptive & expressive language, attention, memory & motor skills • More sophisticated technology • Computerised Axial Tomography (CAT-Scan) • Electroencephalograph (EEG) • Magnetic Resonance Imaging (MRI)

29. Alternative Classification System • International Classification of Diseases (ICD 10) • Chinese Classification of Mental Disorders (CCMD – 3)

30. International Classification of Diseases • International Statistical Classification of Diseases and Related Health Problems • Published by WHO

31. ICD • Gives unique category and code to all diseases • Currently in 10th ediction (ICD-10) • New edition planned for 2015

32. Chinese Classification of Mental DisordersCCMD

34. The Chinese Classification of Mental Disorders (CCMD), published by the Chinese Society of Psychiatry (CSP), is a clinical guide used in China for the diagnosis of mental disorders. It is currently on a third version, the CCMD-3, written in Chinese and English. It is intentionally similar in structure and categorisation to the ICD and DSM, the two most well-known diagnostic manuals, though includes some variations on their main diagnoses and around 40 culturally-related diagnoses.

35. CHINESE CLASSIFICATION OF MENTAL DISORDERS • First published by the Chinese Society of Psychiatry, 1979 • A clinical guide for diagnosis of mental disorders • Currently CCMD-3 • Published in Chinese and English • Intentionally similar in structure and categories to DSM and ICD • Includes some variations on main diagnosis of about 40 culturally related disroders.

36. Advantages (according to Chinese psychiatrists) • Simplicity (Chinese Translation of the ICD- 10 was linguistically complicated) • Stability • Inclusion of culture-distinctive categories • Exclusion of certain Western diagnostic categories

37. What are the practical and ethical implications of diagnostic classification?

38. Depression in CCMD-3 • Similar to DSM • Concept of neurasthenia (nervous system disorder) called ‘shenjing shairu’, which emphaises somatic (bodily) complaints as well as fatigue

39. Schizophrenia • Included • Applied readily and broadly in Chinese psychiatry

40. Diagnoses specific to Chinese or Asian culture • Retains ‘ego-systonic homosexuality’ • Mental disorder due to Quigong (a Chinese method of mediation/posture/exercise (linked to psychosis) • Koro • Mental disorders due to superstiion or witchcraft

42. USE of CCMD-3 in China* used domestically. * in international collaborative research use ICD-10* in research with American colleagues use DSM-IV.

43. Culture bound syndromes

44. Classifying Abnormal Behavior Culture and Classification • The DSM-IV-TR encourages clinicians to consider the influence of cultural factors in both the expression and recognition of symptoms of mental disorders. • People express extreme emotions in ways that are shaped by the traditions of their families and other social groups to which they belong.

45. Classifying Abnormal Behavior Culture and Classification (continued) • The diagnostic manual attempts to sensitize clinicians to cultural issues by including a glossary of culture-bound syndromes. • These are patterns of erratic or unusual thinking and behavior that have been identified in diverse societies around the world and do not fit easily into the other diagnostic categories that are listed in the main body of DSM-IV-TR.

46. Classifying Abnormal Behavior Culture and Classification (continued) • Culture-bound syndromes have also been called idioms of distress. • In other words, they represent a manner of expressing negative emotion that is unique to a particular culture and cannot be easily translated or understood in terms of its individual parts.

47. Classifying Abnormal Behavior Culture and Classification (continued) • These dimensions include: • emotional expressions (an explosion of screaming and crying, coupled with overwhelming feelings of anxiety, depression, and anger), • bodily sensations (including trembling, heart palpitations, weakness, fatigue, headache, and convulsions), • actions and behaviors (dramatic, forceful gestures that include aggression toward others, suicidal thoughts or gestures, and trouble eating or sleeping), and • alterations in consciousness (marked feelings of “not being one’s usual self,” accompanied by fainting, loss of consciousness, dizziness, and feelings of being outside of one’s body).

48. Some important general facts on DSM 5 • DSM 5 (not V) to allow for numbering of revisions (5.1, 5.2, etc). • Was targeted for 2009, then 2011, finally May, 2013. • 2-year grace period for implementation. • Complete interface with ICD-11; codes in parentheses. DZ

49. Some key changes • Elimination of multiaxial system and GAF • Establishes 20 diagnostic classes or categories of mental disorders • Introduction of new diagnostic category of Neurodevelopmental Disorders to include Autism Spectrum Disorder and ADHD and other disorders reflecting abnormal brain development • Removes obsessive-compulsive disorder from category of Anxiety Disorders and places it in new category of Obsessive-Compulsive and Related Disorders: • More on that later!!!

50. The 20 diagnostic categories of the DSM - 5