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. X Changes throughout DSM • 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 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 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 • 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

11. LEARNING DISORDERS DEFINED INDEPENDENT FROM GENERAL INTELLIGENCE DIAGNOSED WHEN AN INDIVIDUAL’S ACHIEVEMENT ON INDIVIDUALLY ADMINISTERED STANDARDIZED TESTS IN READING, MATH OR WRITTEN EXPRESSION IS SUBSTANTIALLY BELOW THAT FOR EXPECTED AGE AND INTELLIGENCE DSM IV Dyslexia – reading disorder Dyscalculia – math disorder Dysgraphia – written expression disorder

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! Now requires “SEVERAL SYMPTOMS” across settings • Must occur before age 7 years • Present for at least 6 months • Causes impairment in at least 2 settings • Meets 6 of 9 symptoms of inattention • AND/OR 6 of 9 symptoms of hyperactivity/impulsivity • – Must be developmentally inappropriate levels

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

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. X severity

25. X ASD CONCERNS • 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 The spectrum seems to emphasize degrees of psychosis Change in criteria for schizophrenia now requires at least one criteria to be either a. Delusions, b. Hallucinations or c. Disorganized speech Subtypes of schizophrenia were eliminated Dimensional measures of symptom severity are now included Schizoaffective disorder has been reconceptualized Delusional disorder no longer requires the presence of “non-bizarre" in delusions. There is now specifier for bizarre delusions. Schizotypal personality disorder is now considered part of the spectrum

28. 2: schizophrenia and the DSM 5 Overview of changes from DSM-IV TR to the DSM five 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 DIAGNOSTIC FEATURES • 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

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 delusions”and/or schneidnerian 1st rank hallucinations is changed to At least 1 of the two below need to be from core positive symptoms (delusions, hallucinations, disorganized speech) Delusions Hallucinations Disorganized speech disorganized behavior Negative symptoms (personality

35. X • 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

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. X Schizophrenia 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. X Schizophreniform 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. X Schizoaffective disorder Diagnostic criteria295.70 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 • 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

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

42. PSYCHOTICISM X HIGH SCHIZO- AFFECTIVE SCHIZOPHRENIA ACUTE MOOD DISORDERWITH PSYCHOTIC FEATURES AFFECT NONE HIGH SCHIZOPHRENIA PARTIAL REMISSION MOOD DISORDER NONE

44. X 3. Bipolar and related disorderssummary • 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. X Some particular conditions can now be diagnosed under "other specified bipolar and related disorders”These do not meet full criteria for bipolar diagnosis • 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 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 2—Mania—Adult measure is the Altman Self-Rating Mania Scale. The ASRM is a 5-item se rating mania scale designed to assess the presence and/or severity of manic symptoms. The measure is completed by the individual prior to a visit with the clinician. If the individual receiving care is of impaired capacity and unable to complete the form (e.g., an individual with dementia), a knowledgeable informant complete the measure. Each item asks the individual (or informant) to rate the severity of the individual’s manic symptoms during the past 7 days. Scoring and 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 weeksyou (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.