Being a Good Diagnostician: Changes in Diagnosis

1. Being a Good Diagnostician: Changes in Diagnosis Rhoda Olkin, Ph.D. Distinguished Professor California School of Professional Psychology – SF rolkin@alliant.edu DZ

2. 7 Facts • DSM 5 (not V) to allow for numbering of revisions (5.1, 5.2, etc). • Was targeted for 2009, then 2011, now May 22, 2013. • Am Psychiatric Assocmtg in SF. • 2-year grace period for implementation. • Complete interface with ICD-11; codes in parentheses. • NIMH • Cost: $139 – $199 DZ

3. Pet Peeves? DZ

4. History • Each DSM has tried to resolve problems in previous versions. • Problems in DSM-IV-TR • Not very user friendly. • 9 categories for diagnostic uncertainty. • NOS predominated. • Insufficient on culture. • Index not as good. DZ

5. Guiding Principles for Changes to DSM • Research evidence should support any addition or substantive modification. • Continuity with the current manual should be maintained when possible. • No restraints should limit the degree of change between DSM-5 and past editions. (Contradiction) • Routine clinical practices must be able to implement any changes.

6. 6 Types of Changes • Structural changes. • Shifting criteria. • New diagnoses. • Reclassification of diagnoses. • Deleted diagnoses. • Code #s

7. Sections • Section 1: Intro to updates, how to use. • Section II: The diagnoses (22 chapters) • Section III: Conditions requiring further research; cultural formulations; glossary. RO

8. Overall Structural Changes • What is the order of chapters (chronology? Relatedness?). • No axes  info goes elsewhere. • Ego syntonic / dystonic (insight) specifiers: • Good or Fair (dystonic) • Poor insight (ambivalent) • Absent insight (syntonic) RO

9. Overall Structural Changes p. 2 • Some require direct knowledge over 12 mos. • Severity indicators (replaces Axis V: GAF). • Severity level is “over time & circumstances.” • Some diagnoses go up to severity level 2, some to 3. Rating scales. 0 = None (>70 GAF) 1 = Mild (>70 GAF) 2 = Severe 3 = Very severe (<31 GAF) RO

10. Changes • Axis III: Part of diagnosis on Axis I. • Axis IV: Make notation of psychosocial and contextual factors. • What happened to The Big 4 from DSM IV? • (GMC, substance use, malingering or factitious, normal)? RO

11. The Big 4 • GMC: • Not in index. • But evident throughout. • Often option of X Disorder Due to Another Medical Condition (e.g., Depressive Disorder Due to MS). • Sometimes not (e.g., Bipolar Dis Due to A.M.C.) RO

12. The Big 4 • Malingering  Factitious Disorder • In Somatic Symptom & Related Disorders chapter. • Factitious Disorder Imposed on Self • Factitious Disorder Imposed on Another (was “by proxy). • Single vs Recurrent Episodes • “Surreptitious actions to misrepresent, simulate, or cause signs or symptoms of illness or injury in absence of obvious external rewards.” (p. 325) • May co-occur with medical condition (e.g., manipulating blood sugar in person with diabetes).

13. The Big 4 • Substance Abuse: and Suicidality: • Elevated status. • Will always note the correlation. • Some disorders can be: “Substance/Medication-Induced.

14. The Big 4 • Normal: • Less of a concern? • Bereavement (V code). • Disruptive Mood Dysregulation Disorder (new). • ASD (increased stigma?). • “Saving normal” (Allen Francis, 2013)

15. Overall Structural Changes p. 3 • NOS  CNEC (conditions not elsewhere classified): • Only for 6 months. • Only for specific reasons: • Diagnosis unclear (e.g., psychotic disorder CNEC) • Clinician not trained to make the dx. • Clinician cannot get info (e.g., client uncooperative; records not available). • You do not have enough info. • Clinicians needs or is required to take more time of direct observation (e.g., 12 months). RO

16. Implications? • Positives: • More reliability? • Better treatment planning? • Longer therapy authorized? • More work & time in the diagnostic process. • Demand for outcome studies; clinicians to validate their treatments (Dept of Corrections) • Responsibilities of diagnostician. • Severity index. • Symptom scales for some disorders. RO

17. The Chapters • 22 chapters. • New order (?). • Some split (e.g., anxiety disorders). • Some renamed (e.g., neurodevelopmental disorders). • Some new (e.g., Trauma- & Stressor- Related Disorders) RO

18. 22 Chapters: RO

19. Neurodevelopmental • Not just a rename – • Etiology important; • Disorders here are considered genetic/biochemical; • Not responses to environment. • EliminatedRett’s Disorder (genetic). • Includes: ADHD, ID, ASD, Communication Disorders, Global Developmental Delay, Motor (Tic) Disorders, Specific LD. • May include specifier: “associated with known med/genetic condition or environmental factor.” • NO:Sensory Processing Disorder (SID) p. 31 RO

20. Neurodevelopmental MR  Intellectual Disability(ICD-11: IntDev Dis.) • PL 111-256, 2010, “ID.” • 3 criteria: Deficits in (a) intellectual functions, (b) adaptive functioning, (c) onset during develop. period. • Code 319 with severity specifier: Mild (F70), Moderate (F71), Severe (F72), Profound (F73). (Table for severity) • Severity is based on adaptive functioning, not IQ scores. • Functioning in Conceptual Domain, Social Domain, Practical Domain. • Usually IQ scores 70 + 5 (Mean = 100; s.d. = 15). • Requires testing with instruments “normed for individual’s sociocultural background and native language.” (p. 37)

21. Neurodevelopmental Autism Spectrum Disorder (ASD): (p. 50) • Now included as ASD: Autism, Aspergers, PDD NOS, Disintegrative Disorder. • 2 areas of disturbance: • Social Communication & Social Interaction; • Restricted repetitive patterns of behavior. • Diagnostic criteria are “illustrative, not exhaustive.” • Table for severity level, requiring: 1-support; 2-substantial support; 3-very substantial support. • M:F = 4:1 RO

22. Neurodevelopmental Communication Disorders: • Social Communication Disorder (new): • Language Disorders • Speech Disorders • Unspecified Communication Disorder • All of the following DSM IV disorders are subsumed under above: Language Emergence; Specific Language Impairment; Social Communication Disorder; Voice Disorder; Speech-Sound Disorder; Motor Speech Disorder; Child Onset Fluency Disorder. RO

23. Neurodevelopmental Social Communication Disorder: • Must have all of A. • A. Persistent difficulties in social use of verbal and nonverbal communication: • Social purposes: (greeting, sharing info). • Changing communication to match listener or context. • Difficulties following rules for conversation or storytelling (taking turns). • Difficulties understanding what is not explicitly stated, and nonliteral or ambiguous meanings (idioms, humor, metaphors).

24. DSM-IV-TR Aspergers Autism Overlap DSM 5 Social Communication Disorder Autism Spectrum Disorder RO

25. Neurodevelopmental ADHD(p. 59) • Inattention (>6/9) and/or hyperactivity-impulsivity (>6/9) that interferes with functioning or development. • Prior to age 12 (instead of 7). • 2 or more settings. • Specify: Combined (314.01), Predominantly inattentive presentation (314.00), Predominantly hyper/impulsive presentation (314.01). (Typo?) • Specify: Mild, moderate, Severe. • Prevalence: About 5% of children, 2.5% of adults. • M:F 2:1 RO

26. Neurodevelopmental Specific Learning Disorder: (p. 66) • Difficulties despite “provision of interventions” in: • A. 6 areas (no specified # to be met). • Specify and code: Reading; Written expression; Mathematics. • Specify: Mild, Moderate, Severe.

27. Neurodevelopmental Motor Disorders(p. 74) • Developmental Coordination Disorder. • Stereotypic Movement Disorder. • Tic Disorders (specify: Tourette’s; Persistent Motor or Vocal Tic disorder; Provisional Tic Disorder.) Other childhood disorders: • See other chapters.

28. Anxiety Disorders Split into 3 chapters: • Anxiety Disorders: • Fight or flight system (Amygdala). • Trauma- & Stressor-Related Disorders. • Greater focus on affective response to external stressors. • OCD & Related Disorders. • Based on imaging and genetic studies, and treatment response. • Basal ganglia – movement circuit – focus on urge and behavior, less on anxiety. DZ

29. Anxiety Disorders • Fear(fight or flight) +Anxiety(hyper-vigilance) +Behavior (avoidance). • Separation Anxiety. • Selective Mutism. • Specific Phobias (more specifiers). • Social Anxiety Dis. (in chldrn, not just w adults). • Panic Disorder (4/12 symptoms + worry + behav.). • Agoraphobia. • GAD (3/6 sxs for adults, 1/6 for children). • Substance/medication induced; Anxiety due to AMC • Also Panic Attack Specifier(p. 214) p. 189

30. Obsessive-Compulsive & Related Disorders • OCD. • Hoarding Disorder. • Excoriation (Skin Picking Disorder). • Hair Pulling Disorder. • Substance/Medication Induced. • Due to Another Medical Condition. p. 235 DZ

31. Obsessions vs Compulsions • Obsessions: Recurrent & persistent thoughts, urges, or images that are experiences as intrusive and unwanted. • Compulsions: Repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be rigidly applied.

32. Trauma- & Stressor-Related p. 265 • Exposure to traumatic or stressful event. • New grouping of disorders from various places in DSM • Adjustment Disorder. • Acute Stress Disorder. • PTSD. • 4 clusters of symptoms: Intrusion, Avoidance, Negative mood/cognitions, Arousal & reactivity. • Children: expanded definition; section for < 6 yo. • Specifiers: (a) dissociative sxs (depersonalization or derealization); (b) delayed expression. • Attachment disorders (next slide). DZ

33. Trauma- & Stressor-Related Attachment related disorders: • Common etiology: Absence of adequate caregiving during childhood. • Reactive Attachment Disorder: • Internalizing disorder: depression, withdrawal. • New criteria (4/5 sxs; onset between 9 mos. & 5 yrs.) • Disinhibited Social Engagement:(NEW). • Externalizing disorder: disinhibition, externalizing behavior. • 2/4 sxs; onset > 9 mos.

34. 5 Pathogenic Realms Some disorders are considered to arise from one or more of five pathogenic realms. This distinguishes them from disorders that are thought to be biochemical (e.g., bipolar disorder). • Persistent disregard of child’s emotional needs; &/or • Persistent disregard of child’s physical needs; &/or • Repeated changes in primary caregivers; &/or • Raised in settings with limited opportunities for stable attachments; &/or • Persistent harsh punishment or other types of grossly inept parenting. RO

35. Bipolar Disorders • 1974: Increased focus on distinguishing BP from schizophrenia. • Mid-1980s: Broadening the “BP spectrum” • Avoid antidepressant-induced mania • Treat the spectrum properly • Mid-1990s: Pediatric BD • Catch it early, avoid kindling p. 123 DZ

36. Bipolar Disorders • Late 1990s: Increased use of 2nd generation antipsychotics for BD. • Now: Narrowing the gate on Pediatric BD.

37. Bipolar Disorders • Bipolar I: no change (> 1 episode mania). (NB: suicide risk 15 x’s greater) • Bipolar II: no change (hypomania & MDD) (Lethality of suicide methods greater than Bipolar I) • Cyclothymia: (hypomanic episodes below criteria for hypomania + depression below threshold for MD); (minimum of 2 years for adults, 1 year in children/adolescents). DZ

38. Bipolar Disorders • Specifiers: • Anxious distress (mild, moderate, moderate-severe, severe). • Mixed features. • Rapid cycling (4 mood episodes in 12/ months. • With melancholic features. • With atypical features.

39. What about Pediatric Bipolar? • Increasing diagnosis, over-diagnosis, wrong medication interventions, inaccurate prediction, heterogenousdisorder. • There may be two types of currently diagnosed PBD: • a narrow definition that looks like adult BD > still BD. • a different form that includes explosive emotional outbursts that don’t look like mania (no grandiosity, delusions) and are not so cyclical. • Looks a little like ADHD, but there may be more aggression. Looks like disruptive behavior disorder, but more emotional lability. • Believed that they will not grow up with BD and should perhaps be treated with antidepressants and/or Ritalin. • Many will now be diagnosed with Disruptive Mood Dysregulation Disorder (under Depression). DZ

40. p. 155 Depressive Disorders Disruptive Mood Dysregulation Disorder: • New disorder. • Older than 5yrs; • Persistent irritability; • Frequent episodes of behavior outbursts > 3 a week for more than 1 year; • Intended to address concerns about potential over-dx & over-trmntof bipolar disorder in children; • First diagnosis between ages 6-18;onset <10. • Cannot coexist with ODD or bipolar disorder. • Children with this dx typically develop unipolar depression or anxiety, not bipolar disorder. RO

41. Depression Disorders Major Depressive Episode– • Need 5/9 symptoms. • In children/adol mood may be irritable. • Table of codes for severity and single vs recurrent Dysthymia  Persistent Depressive Disorder • Still 2 years (adults); 1 yr children/adol • Five specifiers. (p. 169) • Nixed Mixed Anxiety Depression Section 3. RO

42. Depression Disorders Premenstrual Dysphoric Disorder • 5 sxs in week before menses. • Improvement few days after onset of menses. • A: 1/4 mood symptoms + B: 1/7 behavior symptoms = combined to equal 5 sxs.

43. Bereavement “Responses to a significant loss (e.g., bereavement…) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in the Criterion A [for MDE], which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a MDE in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and cultural norms for the expression of distress in the context of loss.” (p. 125-126) {V Code} • See footnote p. 126; same footnote p. 161

44. Schizophrenia & Other Psychotic Disorders • Schizophrenia: • Eliminated subtypes (paranoid, hebephrenic, disorganized, residual, catatonic). • 2/5 sxs (a. delusions, b. hallucinations, c. disorganized speech, d. disorganized or catatonic behavior, e. negative symptoms); 1 sx must be a, b, or c; 1 month. • What are negative sxs? “diminished emotional expression or avolition”). • Functional impairment. • Disturbance persist for >6 months. p. 87 RO

45. Schizophrenia & Other Psychotic Disorders Delusional Disorders:Few changes. • Subtypes: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified. • Specifier: w. bizarre content (implausible, not within ordinary experience). Brief Psychotic Disorder: • 1 day to 1 month. • Specifiers: w./w-o stressors; postpartum; with catatonia, severity (0-4 for each symptom). RO

46. Schizophrenia & Other Psychotic Disorders • Schizophreniform Disorder. • 1 to 6 months. • Specifiers: good/w-o good prognostic features, with catatonia, each sxs severity 0-4 • Schizoaffective Disorder: • Major Mood Episode + Criterion A of schizophrenia. • >2 weeks of delusions or hallucinations w-o mood. • Some discussion of Schizotypal PD here.

47. Substance-Related & Addictive Disorders • No “abuse” or “dependence”; now “use.” • Chapter reorganized by substance. • 10 classes of drugs: Alcohol; Caffeine; Cannabis; Hallucinogens; Inhalants; Opioids; Sedatives, hypnotics & anxiolytics; Stimulants; Tobacco; Other. • Two groups of disorders: (a) Substance use disorders, (b) Substance-induced disorders. p. 481

48. Substance-Related & Addictive Disorders • Substance use disorder: continued use of substance despite significant substance-related problems. 4 sets of criteria: • Impaired control (4 criteria). • Social impairment (3 criteria). • Risky use (2 criteria). • Pharmacological criteria (2 criteria: tolerance & withdrawal).

49. Substance-Related & Addictive Disorders • Severity levels: • Mild (2-3 symptoms) • Moderate (4-5 symptoms) • Severe (> 6 symptoms) • Remission: • Early vs Sustained; • Maintenance therapy • Controlled environment Example: Moderate Valium use disorder; Mild alcohol use disorder; Secobarbital withdrawal.

50. Substance-Related & Addictive Disorders • New language: “All drugs that are taken in excess have in common direct activation of the brain reward system…. Individuals with lower levels of self-control, which may reflect impairments of brain inhibitory mechanisms, may be particularly predisposed to develop substance use disorders, suggesting that the roots of substance use disorders for some persons can be seen in behaviors long before the onset of actual substance use itself.” (p. 481)