The DSM-5: Diagnosis for Psychological and Emotional Disorders in Children and Adolescents

Transcription

1 The DSM-5: Diagnosis for Psychological and Emotional Disorders in Children and Adolescents Registration Number:

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3 The DSM-5: Diagnosis for Psychological and Emotional Disorders in Children and Adolescents Written and Presented by: George Haarman, PsyD, LMFT Any opinions, findings, recommendations or conclusions expressed by the author(s)or speaker(s) do not necessarily reflect the views of Cross Country Education, LLC. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting or other professional service. If legal advise or other expert assistance is required, the services of a competent professional person should be sought. Copyright 2013 George Haarman & Cross Country Education, LLC. No part of this workbook may be reproduced in any manner without the expressed written consent of George Haarman & Cross Country Education, LLC. From a Declaration of Principles jointly adopted by a Committee of the American Bar Association and a committee of Publishers. 6465

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5 he DSM 5: Psychological and Emotional Disorders In Children and Adolescents George B. Haarman, Psy.D., LMFT Licensed Clinical Psychologist Licensed Marriage and Family Therapist To comply with professional boards/associations standards: I declare that I or my family do not have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally all Planner s involved do not have any financial relationship. I declare that I do not have any relevant non-financial relationships. Requirements for successful completion is attendance for the full day seminar, if not, amended CE will be granted accordingly based on your boards/associations requirements (rules) along with a completed evaluation form. Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. The DSM-5: Diagnos Psychological and Emotional Disorders in Children and Adolescents George Haarman, PsyD, LMFT Cross Country Education Leading the Way in Continuing Education and Professional Development. 1

6 h DSM 5: Diagnosi Psychological and Emotional Disorders in Children and Adolescents 8:00 8:30 8:30 9:45 9:45 10:00 10:00 11:30 11:30 12:30 12:30 2:00 2:00 2:15 2:15 2:45 2:45 3:15 3:15 3:30 Introduction Section I Overview and Major Changes Break Section II Changes: DSM-IV-TR to DSM5 Lunch Section III What Happened to My Old Disorders of Childhood and Adolescence Break Case Studies Section V What Happened to My Old Disorders of Adulthood Evaluation 3 History of Diagnostic and Statistical Manual (DSM) 1840 Census had one category - idiocy/insanity 1880 Seven categories - mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy Post WWII, VA nomenclature included 10 psychoses, 9 neuroses, and 7 disorders of character, behavior, and intelligence The American Psychiatric Association published Diagnostic and Statistical Manual: Mental Disorders (DSM-I) in 1952 reflecting a psychological view and included the term reaction. DSM-II was published in 1968 and was very similar to DSM-I, but eliminated the concept of reaction. Heavily criticized for lack of diagnostic reliability due to three or four sentence descriptions of Disorders 2

7 History of Diagnostic and Statistical Manual (DSM) Work began in 1974 that resulted in the publication of DSM-III in Major advances included the use of explicit diagnostic criteria, a multi-axial system, and a descriptive approach that was neutral to theories or etiology (eliminated terminology of neurosis and psychosis). The number of diagnoses in child section increased fourfold. Inconsistencies and unclear criteria resulted in a revision of DSM-III (DSM-III-R) being published in DSM-IV was published in 1994 containing 340 conditions, 120 more than contained in DSM-III-R. DSM-IV-TR published in 2001updates current research. Attempted to be more consistent with ICD-10. Criticisms included: artificial constructs, comorbid conditions blur boundaries, changes to criteria created false epidemics, dimensional vs. dichotomous approach would allow for age and gender variations. Diagnostic and Statistical Manual for Primary Care (DSM-PC) 2005 views symptoms in a developmental context, on a continuum from normal to mental disorders, and reflects stressful environmental situations History of Diagnostic and Statistical Manual Fifth Edition (DSM-5) Work began on DSM5 in 2000 under a grant from NIMH Series of meetings with WHO (ICD) 2006 Am Psychiatric announced Drs. Kupfer and Reiger as chair and vice chair 2007 Work Groups appointed and began meeting February 2010 draft was published for comment May 2010 Field Trials of proposed criteria Additional comment period Spring 2012 Final Drafts to printer December 2012 Publication date of May 18,

8 Broad Controversies Allen Frances (Chair of DSM-IV) resigned due to lack of scientific integrity Assumption that all disorders stem from biological brain and neurological disorders ( medicalization of mental disorders) 70% of committee members have economic ties to pharmaceutical industry Critics fear that many ordinary reactions to life (grief, anger, angst) will be labeled as illnesses and people will be prescribed unnecessary medications. One of the raps against psychiatry is that you and I are the only two people in the US without a psychiatric diagnosis Chicago Tribune Interview12/27/08 with David Kupper, MD International members of the personality disorders work group resigned in protest over lack of scientific integrity May, 2013 NIMH withdraws support from DSM5 and advocates a biological approach based on their own system, RDoC (Research Domain Criteria) Negative Valence Systems, Positive Valence Systems, Cognitive Systems, Systems for Social Processes, Arousal/Modulatory Systems. DSM5 Philosophy Traditional approaches look at diagnosis of disorders from a Categorical Model or Dimensional Model Categorical Model geared toward separating phenomena (observed behavior) into discrete categories. DSM-II, IV, and IV-TR Presence or absence Relatively separate phenomena Dimensional Models view behavior on a continuum Adaptive to dysfunctional Absent to severe Achenbach: Internalizing vs. Externalizing 4

9 DSM-5 Philosophy Disorders were distributed along an internalizing/externalizing continuum based on genetic markers and underlying mechanisms Shift towards a more dimensional approach to diagnosis than categorical. Some authors have criticized this as a hybrid approach Disorders were distributed on developmental and lifespan considerations Cultural Issues were given special attention under the construct of culture bound syndromes Both DSM and WHO attempt to separate mental disorder from Disability (impairment in social, occupational, and relational functioning) Cautionary statements about using DSM in Forensics DSM5 and ICD-10 and 11 Congress and Health and Human Services have continued to delay the implementation of ICD -10 for insurance. (October 1, 2014) ICD-11 is due to be released by WHO in 2015 Some question the wisdom of switching twice in a short time period Agreement between ICD Committee and DSM for consistency was a priority for DSM Work Groups Some ICD disorders are not in DSM and vice versa Results in some situations where two DSM Disorders have same number Under HIPAA, insurance companies are only required to accept ICD May require conversion of DSM codes to ICD codes Crosswalk to convert DSM to ICD is included as Appendix in DSM5 DSM5 contains both ICD-9(DSM-TR-IV) and ICD-10 codes in parenthesis The World Health Organization Disability Assessment Schedule (WHO-DAS 2.0) is included in Section III and is the same as used for medical disability. 5

10 Cross-Cutting Dimensional Assessment in DSM-5 In addition to categorical diagnoses, dimensional assessments are proposed The goal is to provide additional information for the purpose of assessment, treatment planning, and treatment evaluation A full range of dimensional assessments (from paper-based self report to computerized assessment) were considered and field tested (DSM-5 trials) Each diagnosis may comment on attitude considerations. Ego Syntonic (absent insight) vs. Ego Dystonic (good insight) May be specific to disorders or more global Severity scales are proposed for most disorders. An initial evaluation is used to establish a base-line Cross-Cutting crosses the boundaries of single disorders Cross-Cutting Dimensional Assessment in DSM-5 Criteria for Assessment System Useful in clinical practice Are brief, simple to read, and simple to evaluate Can be completed by a patient or informant, rather than clinician Provide coverage suitable for most patients in most clinical settings Use ratings on a 5-point scale, with 0 indicating the absence of the problem DSM-5 Self-Rated Level 1 Cross Cutting Symptom Measure-Adult and Parent/Guardian-Rated DSM-5 Level 1Cross Cutting Symptom Measure- Child Age 6-17 are contained in Section III p.738 Clinically significant items on Level 1 Assessment (rating above 2) trigger a Level 2 Assessment (Disorder Specific) Level II Assessment tools can be found at 6

11 Level 1 Assessment Level I Assessment I. Depression Mild or greater LEVEL 2 Depression Adult (PROMIS Emotional Distress Depression Short Form)1 II. Anger Mild or greater LEVEL 2 Anger Adult (PROMIS Emotional Distress Anger Short Form)1 III. Mania Mild or greater LEVEL 2 Mania Adult (Altman Self-Rating Mania Scale) IV. Anxiety Mild or greater LEVEL 2 Anxiety Adult (PROMIS Emotional Distress Anxiety Short Form)1 V. Somatic Symptoms Mild or greater LEVEL 2 Somatic Symptom Adult (Patient Health Questionnaire 15 Somatic Symptom Severity [PHQ-15]) VI. Suicidal Ideation Slight or greater None VII. Psychosis Slight or greater None VIII. Sleep Problems Mild or greater LEVEL 2 Sleep Disturbance - Adult (PROMIS Sleep Disturbance Short Form)1 IX. Memory Mild or greater None X. Repetitive Thoughts and Behaviors Mild or greater LEVEL 2 Repetitive Thoughts and Behaviors Adult (adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B]) XI. Dissociation Mild or greater None XII. Personality Functioning Mild or greater None XIII. Substance Use Slight or greater LEVEL 2 Substance Abuse Adult (adapted from the NIDA-modified ASSIST 7

12 Level I Assessment Cultural Considerations in the DSM-5 Cultural Definition of the Problem: the presenting issues that led to the current illness episode, cast within the patient s worldview. In this section, the patient describes the problem and focuses on its most troubling aspects. Cultural Perceptions of Cause, Context, and Support: the patient s explanations for the circumstances of illness, including the cause of the problem. The patient also clarifies factors that improve or worsen the problem, with particular attention to the role of family, friends, and cultural background. Cultural Factors Affecting Self Coping & Past Help Seeking: the strategies employed by the patient to improve the situation, including those that have been most and least helpful. The patient also identifies past barriers to care. Current Help Seeking: the patient s perception of the relationship with the clinician, current potential treatment barriers, and preferences for care. In this section, the patient specifies how the clinician may facilitate current treatment and what may interfere with the clinical relationship. DSM5 appendix Glossary of Cultural Concepts of Distress Dhat Southeast Asia (semen) Maladi Moun Hatian sending of illness through thoughts, to another evil eye Nervios Latin America somatic and thought influence brain aches Nerves Appalachian Culture p.833 The Cultural Formulation Interview is available at or in Section III of the DSM-5, p

13 Module II: Major Differences Between DSM-IV-TR and DSM5 Cliff Notes Version Differences Between DSM-IV and DSM5 (Cliff Notes Version) General Changes No Longer Numeric System, but Alphanumeric to be consistent with ICD-10 e.g. OCD was now will be (F42) Removal of the Multiaxial System Only one axis with notations and descriptors Axis I, II, and III combined in a descriptive fashion. Medical issues should continue to be listed as part of diagnosis i.e (F32.0) Major Depressive Disorder, Single Episode, Severe, HIV positive, Z59.5 Extreme Poverty Dimensional Assessments emphasize severity and course of a category of disorders Axis IV decision to use ICD-9 and ICD-10 V Codes and Z Codes Axis V as a measure of functioning is covered by using Disability Assessment Schedule (WHODAS) found in Section III 9

14 Differences Between DSM-IV and DSM5 (Cliff Notes Version) Coding and Reporting Procedures Subtypes and specifiers (coded in the 4 th, 5 th, or 6 th digit) increase specificity are reflected in specify whether (subtype) and specify or specify if (specifier) NOS (Not Otherwise Specified) is eliminated and replaced by two terms: Other Specified Disorder and Unspecified Disorder Other Specified Disorder allows communicating the specific reason that it does not meet criteria: Other Specified Depressive Disorder, insufficient symptoms and less than two weeks. Unspecified Depressive Disorder DSM-5 allows multiple diagnoses to be assigned, if both criteria are met Principal Diagnosis is the focus of treatment and listed first (or designated) Provisional Diagnosis can be used when there is an assumption that full criteria will eventually be met Differences Between DSM-IV and DSM5 (Cliff Notes Version) Specific Disorders While most people focus on diagnostic criteria, the DSM5 has for each disorder a compilation of the current thinking on prevalence, development and course, risk and prognostic factors, culture-related diagnostic issues, gender-related diagnostic issues, suicide risks, functional consequences, differential diagnoses, and comorbidity. Autism Spectrum Disorders Autistic Disorder, Asperger s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder combined into a new diagnosis of Autism Spectrum Disorder with specifiers and severity Binge Eating Disorder Moved from further study to classification to Disorder status Conduct Disorder with Limited Prosocial Emotions Specifier guilt, empathy, performance, and affect 10

15 Differences Between DSM-IV and DSM5 (Cliff Notes Version) Disruptive Mood Dysregulation Disorder (once called TDD Temper Dysregulation Disorder) To address concerns about over-diagnosis of bipolar disorder in children Excoriation (skin-picking) Disorder New to DSM and in Obsessive-Compulsive Chapter Hoarding Disorder New - Supported by extensive research Pedophilic Disorder Simply name change from Pedophilia Disinhibited Social Engagement Disorder RADS broken down into two disorders Differences Between DSM-IV and DSM5 (Cliff Notes Version) Personality Disorders Maintains a categorical model and criteria for the 10 personality disorders (abandoned the proposed five trait theory classification) New trait methodology for assessment is included in Section III (Further Study) Posttraumatic Stress Disorder (PTSD) Four distinct diagnostic clusters re-experiencing, avoidance, cognitions and mood, and alterations in arousal and reactivity Developmentally sensitive (Preschool Criteria <6) and childhood examples Specific Learning Disorder Broadens criteria and reduces to one disorder Premenstrual Dysphoric Disorder Adopted after extensive research 11

16 Differences Between DSM-IV and DSM5 (Cliff Notes Version) Bereavement Exclusion Removes the two month grief criteria Views bereavement as a severe psychosocial stressor precipitating major depressive episode Substance Use Disorder Combines abuse and dependence categories Requires greater number of symptoms Gambling Disorder viewed as addiction Did Not Make The Cut For Further Study Attenuated Psychosis, Internet Use/Gaming Disorder, Non-suicidal Self Injury, Suicidal Behavior Disorder Not Accepted for DSM Anxious Depression, Hypersexual Disorder, Parental Alienation Syndrome, Sensory Processing Disorder Module III: Highlights of Changes in DSM-5 12

17 Highlights of Changes DSM-IV-TR to DSM -5 Chapter Structure 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 Stressor-Related Disorders 8. Dissociative Disorders 9. Somatic Symptoms 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. Substance-Related and Addictive Disorders 17. Neurocognitive Disorders 18. Personality Disorders 19. Paraphilic Disorders Highlights of Changes DSM-IV-TR and DSM -5 Chapter 1. Neurodevelopmental Disorders Intellectual Disability Communication Disorders Autism Spectrum Disorder Attention Deficit Hyperactivity Disorder Specific Learning Disorder Motor Disorders 13

18 Highlights of Changes DSM-IV-TR and DSM -5 Intellectual Disability (Intellectual Developmental Disorder) Removal of the terminology of mental retardation Consistent with advocacy groups and PL Severity is based on adaptive functioning and IQ Requires deficits in both cognitive, social and adaptive behaviors (comprehensive assessment) Intellectual Developmental Disorder included in parenthesis to prepare for ICD-11 Does not include a specific IQ score in criteria but text reflects IQ of 2sd below, or about 70 The new criteria includes severity measures (mild, moderate, severe, and profound intellectual disability) Highlights of Changes DSM-IV-TR and DSM -5 Communication Disorders Restructured to include three disorders with appropriate subtypes Language Disorders Expressive Speech Disorder Expressive-receptive Disorder Speech Disorder Speech Sound Disorder (Phonological Disorder) Motor Speech Disorder Childhood-Onset Fluency Disorder (Stuttering) Voice Disorder Resonance Disorder 14

19 Highlights of Changes DSM-IV-TR and DSM -5 NEW Social (Pragmatic) Communication Disorder Difficulties in narrative, expository and conversational discourse. Difficulties using verbal and nonverbal communication for social purposes, leading to social, occupational, or academic problems Not explained by low cognitive ability Under DSM-IV was often diagnosed as PDD(NOS) No restricted, repetitive behaviors ASD must be ruled out to diagnose SCD Highlights of Changes DSM-IV-TR and DSM -5 Autism Spectrum Disorder Reflects a scientific consensus, but enormous controversy Combines four disorders as a single disorder on a continuum with levels of symptom severity (Autism, Asperger s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder NOS) Both deficits in social communication and interaction and restrictive repetitive behaviors, interests, and activities Both are required for a diagnosis of ASD, Social Communication Disorder is diagnosed if no RB s are present Allows for a number of specifiers (intellectual, genetic/medical, acquired, etc.) Three Levels of Severity (requiring support, requiring substantial support, requiring very substantial support) Symptoms present in early developmental period <24 months 15

20 Highlights of Changes DSM-IV-TR and DSM -5 Attention-Deficit/Hyperactivity Disorder Same 18 symptoms are used (9 Inattention and 9 Hyperactivity/Impulsivity), but examples added across the life span Cross-situational requirement strengthened to include several symptoms in each setting Onset criteria has been increased to age 12 Subtypes are replaced with presentations Comorbid diagnosis with Autism Spectrum is allowed Symptom threshold is different for older adolescents and adults (5 vs. 6) Placed in neurodevelopmental category Subtypes remained the same despite earlier drafts Combined Presentation: Both Criteria 1 & 2 are met for six months Predominately Hyperactive/Impulsive Presentation: Criteria 2 is met, and Criteria 1 is not met for past six months Predominately Inattentive Presentation: Criteria 1 is met, but Criteria 2 is not met and 3 or more symptoms from 2 have been present for six months Severity specifiers: mild, moderate, severe Highlights of Changes DSM-IV-TR and DSM -5 Specific Learning Disorder Combines three former diagnoses into one category (broadening the category) Specifiers identify type of learning disorder Text acknowledges the international diagnoses of dyslexia and dyscalculia One of six symptoms for six months The learning difficulties begin in school-age period, but may not manifest until later Motor Disorders Slight wording changes for existing diagnoses of Developmental Coordination Disorder, Stereotypic Movement Disorder, Tourette s Disorder, Persistent Vocal or Motor Tic Disorder, and Provisional Tic Disorder 16

21 Highlights of Changes DSM-IV-TR and DSM -5 Chapter 2. Schizophrenia Spectrum and Other Psychotic Disorders o Schizophrenia o Two criterion A symptoms are required rather than one: hallucinations, delusions, negative symptoms (lack of affect, will, speech), and disorganized speech o Additional requirement of at least one symptom of delusions, hallucinations, and disorganized speech o Subtypes (paranoid, disorganized, catatonic, undifferentiated, and residual) are eliminated and instead a dimensional approach to severity (First Episode, Multiple Episodes, Continuous Highlights of Changes DSM-IV-TR and DSM -5 oschizoaffective Disorder o Primary Change is that major mood episode is present for majority of disorder s total duration o Based on conceptual and psychometric data o Both psychotic and mood symptoms are longitudinal over course of disorder 17

22 Highlights of Changes DSM-IV-TR and DSM -5 o Delusional Disorder o No longer require that delusions are non-bizarre. Can be covered by specifier: With Bizarre Content o Erotomanic, grandiose, persecutory, somatic subtypes o Symptoms cannot be better explained by Obsessive-Compulsive or Body Dysmorphic Disorder o No longer separates shared delusional (Folie a Deux) Highlights of Changes DSM-IV-TR and DSM -5 Chapter 3:Bipolar and Related Disorders obipolar I and II o Criterion A emphasizes a change in activity and energy as well as mood o The requirement that full criteria for both mania and depressed mood be fully met is removed by a new specifier, with mixed features. Do not have to meet full criteria for manic episode or depressive episode o A specifier for anxious distress is intended to cover those with anxiety symptoms, not a part of bipolar criteria 18

23 Highlights of Changes DSM-IV-TR and DSM -5 Chapter 4. Depressive Disorders omajor Depressive Disorder (wording changes) onew Disruptive Mood Dysregulation Disorder onew Premenstrual Dysphoric Disorder ocombined Dysthymia and Major Depressive Disorder, Chronic into Persistent Depressive Disorder Highlights of Changes DSM-IV-TR and DSM -5 Major Depressive Disorder o No major Changes in symptoms or duration o Addition of a with mixed features with the presence of at least three manic/hypomanic symptoms, but has never reached manic or hypomanic state. o Specifier with anxious distress - poorer prognosis oremoval of Bereavement Exclusion o Major Controversy Pathologization of Normal Human Experience 1. Implication that bereavement lasts only two months data implies 1 to 2 years 2. A severe stressor that can precipitate or complicate a Major Depressive Episode 3. Bereavement-related depression occurs more frequently in individuals with personal or family history of Major Depression 4. Symptoms associated with bereavement respond to the same psychosocial and medication treatments as Major Depression 5. Complex Bereavement Disorder Criteria in Section III 19

24 Highlights of Changes DSM-IV-TR and DSM -5 odisruptive Mood Dysregulation Disorder o Designed to address the concerns about over diagnosis of bipolar disorder in children. Originally Temper Dysphoria Disorder (TDD) o Up to age 18, persistent irritability, non-episodic behavioral dyscontrol o Extreme irritability without the mood changes that dominate the clinical picture of Bipolar o Episodes of behavioral dyscontrol are not necessarily mania o Brain imaging can distinguish BPD from DMDD (amygdala) o Most of the children who meet criteria for Disruptive Mood Dysregulation Disorder will also meet criteria for Oppositional Defiant Disorder, since the two disorders have overlapping symptoms. Diagnosis of Disruptive Mood Dysregulation Disorder will supersede and be utilized Highlights of Changes DSM-IV-TR and DSM -5 o Premenstrual Dysphoric Disorder o Graduated from the Further Study Category of DSM-IV- TR o A history of depressed mood, anxiety, affective lability, irritability, or loss of interest during the last week of the luteal phase (post ovulation) o Symptoms include lethargy, appetite change, sleep difficulties, overwhelmed and out of control, weight gain, and bloating o Approximately 2% of women will meet criteria o Concerns about the pathologization of women o Fears of implication that women are not capable of performing functions during premenstrual cycle 20

25 Highlights of Changes DSM-IV-TR and DSM -5 Persistent Depressive Disorder NEW Combines Dysthymia and Major Depressive Disorder, Chronic Chronicity is a significant factor in treatment outcome First step to conceiving mood disorders as a spectrum of severity and chronicity (Dimensional Model) rather than arbitrary categories (cleaving meatloaf) Highlights of Changes DSM-IV-TR and DSM -5 Chapter 5. Anxiety Disorders Obsessive Compulsive Disorder, Posttraumatic Stress Disorder, and Acute Stress Disorder are no longer considered anxiety disorders. They are moved to their own chapters Panic Attacks Removal of the requirement that recognition that anxiety is excessive Different types (cued and uncued) are now replaced by expected and unexpected. Panic Attacks can also be listed as a specifier for all DSM5 Disorders 21

26 Highlights of Changes DSM-IV-TR and DSM -5 Panic Disorder and Agoraphobia Panic Disorder and Agoraphobia are uncoupled in DSM5 Three categories are reduced to two: 1) Panic Disorder and 2) Agoraphobia Co-occurrence of Panic Disorder and Agoraphobia is coded with two diagnoses Changed to require two or more agoraphobic situations. Robustness to distinguish agoraphobia vs. specific phobias Duration of six months or more Highlights of Changes DSM-IV-TR and DSM -5 Specific Phobia Essentially the same criteria, but duration of recognition has time criteria Duration criteria (6 months) also applies to all ages Types are now referred to as specifiers (animal, environmental, blood/injection, situational) Social Anxiety Disorder Essentially the same criteria, but duration of recognition has time criteria Duration criteria (6 months)also applies to all ages Generalized specifier deleted and replaced by performance only. 22

27 Highlights of Changes DSM-IV-TR and DSM -5 Separation Anxiety Disorder Moved from Chapter on Infancy, Childhood, and Adolescence to Anxiety Criteria are essentially unchanged, but wording is modified to reflect adults who also have disorder Onset prior to age 18 is removed Duration criteria (6 months) added for adults to prevent over-diagnosis of transient fears Selective Mutism Essentially unchanged, but moved from Chapter on Infancy, Childhood, and Adolescence to Anxiety Highlights of Changes DSM-IV-TR and DSM -5 Chapter 6. Obsessive-Compulsive and Related Disorders (New Chapter) NEW Disorders include Hoarding Disorder, Excoriation (skin picking) Disorder, Substance/medication-induced Obsessive-Compulsive Disorder, and Obsessive-Compulsive Disorder Due to a Medical Condition Trichotillomania moved to this Chapter 23

28 Highlights of Changes DSM-IV-TR and DSM -5 Obsessive-Compulsive and Related Disorders Specifiers for level of insight have been refined to distinguish insight. absent (feel compelled), good (probably will happen) delusional convinced Improve differential diagnosis of obsessive-compulsive versus a schizophrenia spectrum Tic Related specifier identifies a high co-morbidity factor at work. Body Dysmorphic Disorder Moved from Somatoform Chapter Respond better to SSRI s than antipsychotics Should not be coded as a Delusional Disorder, but with specifiers with muscle dysmorphia and absent insight/delusional beliefs added Highlights of Changes DSM-IV-TR and DSM -5 Hoarding Disorder New Diagnosis - In the past most were diagnosed OCD, but most do not exhibit OCD or respond to medication Hoarding may be a symptom of OCD, but data indicate that hoarding can be a separate dynamic Persistent difficulty discarding or parting with possessions Distorted need to save items and extreme distress associated with discarding them Quantity of items sets them apart Not particularly distressed by the behavior, others are Indications of a unique neurological correlate different from OCD (PET Scans) Public health and safety issues Level of Insight Specifier 24

29 Highlights of Changes DSM-IV-TR and DSM -5 otrichotillomania (Hair-Pulling Disorder) o Essentially same criteria as DSM-IV, but moved to a new section to emphasize tension-release dynamic oexcoriation (Skin-Picking) Disorder o New Category with substantial evidence base o Must have been repeated attempts to decrease or stop picking o Estimated that 2-4 percent of general population osubstance/medication-induced Obsessive-Compulsive Disorder (formerly Anxiety disorders due to a General Medical Condition, with obsessive-compulsive symptoms) Highlights of Changes DSM-IV-TR and DSM -5 Obsessive-Compulsive Disorder Due to Another Medical Condition (formerly Substance-induced Anxiety Disorder, with obsessive-compulsive symptoms) Other Specified and Unspecified Obsessive-Compulsive and Related Disorders Old Anxiety Disorder NOS Body focused repetitive behavior (other than hair pulling or skin-picking) e.g. nail-biting, lip biting Obsessional jealousy (non-delusional preoccupation with partner s fidelity) 25

30 Highlights of Changes DSM-IV-TR and DSM -5 Chapter 7. Trauma and Stressor Related Disorders NEW Chapter Brings together anxiety disorders that are preceded by a distressing or traumatic event Acute Stress Disorder Criterion A requires being explicit as to whether trauma were experienced directly, witnessed, or indirectly experienced Eliminates the subjective reaction to event (first resp) Must exhibit 9 of 14 symptoms (3/4) Categorizes symptoms as intrusion, negative mood, dissociation, avoidance, and arousal Highlights of Changes DSM-IV-TR and DSM -5 Adjustment Disorder Included in Trauma and Stressor Chapter Re-conceptualized from a clinically significant distress that does not meet criteria for another disorder to a stress response to a distressing event Subtypes have been retained unchanged 26

31 Highlights of Changes DSM-IV-TR and DSM -5 Posttraumatic Stress Disorder Significant changes and re-conceptualization Criterion A requires being explicit as to whether trauma were experienced directly, witnessed, or indirectly experienced Clearer line as to what constitutes traumatic events Criterion A2 subjective reaction has been eliminated (fear, helplessness, horror) Military, First Responders may have no subjective distress Requires that a disturbance continues for one month and eliminates the distinction between acute and chronic stages Highlights of Changes DSM-IV-TR and DSM -5 Posttraumatic Stress Disorder Three major symptom clusters have been expanded to four: re-experiencing, avoidance, persistence negative alterations in cognitions and mood, and alterations in arousal and reactivity Re-experiencing includes spontaneous memories, recurrent dreams, flashbacks, and intense distress Avoidance refers to distressing memories, thoughts, feelings, or external reminders Negative Cognition and Mood reflects a myriad of feelings, including: self-blame, estrangement, diminished interests, and inability to remember Arousal is marked by aggressive, reckless/self-destructive behaviors, sleep disturbances, and hyper vigilance. Fight/Flight, 27

32 Highlights of Changes DSM-IV-TR and DSM -5 Posttraumatic Stress Disorder (continued) PTSD Preschool Differences Eliminates the criteria for repeated or extreme exposure Provides example of ways of re-enactment May or may not display same negative alterations in cognitions and emotions (fear, guilt, sadness, shame or confusion) but are manifested behaviorally (social withdrawal, constriction of play, expression of positive emotions) Marked physiological reactions to reminders of the event Avoidance is to concrete stimuli and not memories PTSD Dissociative Subtype Depersonalization or Derealization Highlights of Changes DSM-IV-TR and DSM -5 Reactive Attachment Disorder DSM-IV had two subtypes: Inhibited and Disinhibited. Now two distinct disorders Reactive Attachment Disorder Both are the result of neglect (pathogenic care), but differ RAD more closely resembles an internalizing disorder, a lack of or incomplete attachment to caregivers. Disinhibited Social Engagement Disorder DSED more closely resembles ADHD, can form superficial attachments but lack control or boundaries Not simply impulsivity (ADHD) but social unawareness Course of disorders and response to intervention are different 28

33 Highlights of Changes DSM-IV-TR and DSM -5 Chapter 8. Dissociative Disorders Depersonalization Disorder Now also includes derealization and name has been changed to Depersonalization/Derealization Disorder Dissociative Fugue Eliminated as a Disorder and now is a specifier for Dissociative Amnesia Dissociative Identity Disorder Cultural pathological possession and neurological symptoms covered Transitions in identity may be observable or self-reported Recall gaps may be for everyday events and not just trauma Highlights of Changes DSM-IV-TR and DSM -5 Chapter 9. Somatic Symptom and Related Disorders (formerly Somatoform Disorders) Overlap and lack of clarity was particularly problematic for primary care settings Emphasis in holistic care and removes mind-body separation Categories are combined and eliminated, including: Somatization Disorder, Hypochondriasis, Pain Disorder, and Undifferentiated Somatoform Disorder Medically Unexplained Symptoms (New) Defines on the basis of positive symptoms rather than absence of medical explanation (distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors 29

34 Highlights of Changes DSM-IV-TR and DSM -5 Somatic Symptom Disorder (new) Hybrid diagnosis combining Somatization Disorder and Undifferentiated Somatoform Disorder Diagnosis for Somatoform Disorder was based on an unrealistically high symptom count (4 pain, 2 GI, 1 sex, and 1 neurological), now the focus is on abnormal thoughts, feelings, and behaviors that may or may not have a medical condition No specific number of symptoms is required, but they must be persistent (six months) No longer requires that medical symptoms are unexplainable Conversion Disorder (Functional Neurological Symptom Disorder) Emphasizes neurological exam and recognizes that psychological factors may not be identified immediately Highlights of Changes DSM-IV-TR and DSM -5 Illness Anxiety Disorder Hypochondriasis was eliminated due to pejorative connotation and interference with therapeutic bond Those previously diagnosed with Hypo and high symptoms will fall into Somatic Symptom Diagnosis This category covers those with high health anxiety, but low symptoms Pain Disorder Eliminates the distinction between psychological factors, disease and injury, or both. Chronic pain is viewed as a combination of somatic, psychological, and environmental influences 30

35 Highlights of Changes DSM-IV-TR and DSM -5 Psychological Factors Affecting Other Medical Conditions and Factitious Disorder A hybrid combination of two disorders with predominant somatic symptoms The specific psychological factors are removed as they are covered in the stem diagnosis No external gain is obvious Highlights of Changes DSM-IV-TR and DSM -5 Chapter 10. Feeding and Eating Disorders Binge-Eating Disorder NEW Diagnosis Graduated from Further Study to a Disorder after extensive research Typically addressed in past by diagnosis of Eating Disorder NOS Recurring episodes of eating more food than normal in a short period of time, with feelings of loss of control, guilt, embarrassment, and disgust Only change from DSM-IV proposal was the reduction in frequency of binge eating from twice weekly for 6 months to weekly for 3 months Distinguishes between binge eating and overeating 31

36 Highlights of Changes DSM-IV-TR and DSM -5 Pica and Rumination Disorder Reworded and extended to all ages Avoidant/Restrictive Food Intake Disorder Feeding Disorder of Infancy and Childhood has been renamed and criteria significantly expanded Adults and adolescents also restrict food intake and experience physiological/psychological issues Broad Category intended to capture a variety and range of presentations Highlights of Changes DSM-IV-TR and DSM -5 Anorexia Nervosa Core concepts are unchanged, but drops amenorrhea Criterion A focuses on behaviors, but still requires the person to be at a significantly low body weight, no longer 85% and wording clarifications Criterion B is expanded to include not only overtly expressed fear of weight gain, but behavior that interferes with normal weight gain Bulimia Nervosa Only change is a reduction from twice to average of once weekly for binge eating 32

37 Highlights of Changes DSM-IV-TR and DSM Chapter 11. Elimination Disorders Free-standing Category with no major changes Chapter 12. Sleep-Wake Disorders Sleep disorders can occur in isolation or with other disorders (multiple diagnosis) Narcolepsy (hypocretin deficiency) separated from other Hypersomnolence Disorders Breathing Related Sleep Disorders obstructive sleep apnea, central sleep apnea, sleeprelated hypoventilation Restless Leg Syndrome included in DSM-5 Highlights of Changes DSM-IV-TR and DSM Chapter 13. Sexual Dysfunction Gender specific sexual dysfunctions Female Sexual Desire and Female Arousal combined into Female Sexual Interest/Arousal Disorder Paraphilias now have their own chapter Chapter 14. Gender Dysphoria Replaces Gender Identity Disorder Emphasizes gender incongruence Developmentally appropriate criteria 33

38 Highlights of Changes DSM-IV-TR and DSM Chapter 15. Disruptive, Impulse Control Disorders Problems associated with emotional and behavioral self-control are grouped in their own chapter Externalizing Disorders as compared to Internalizing Disorders o Oppositional Defiant Disorder o Symptom list remains the same, but is now clustered into three groups: Angry/Irritable Mood, Argumentative/Defiant Behavior, and Vindictiveness o Frequency of symptoms is addressed through coding note: o 6 must be more than once a week for 6 month o 5 occurs on most days for 6 months o Sibling exclusion o Can now be diagnosed with both ODD and CD o Severity rating based on pervasiveness of relationships and settings: Mild one setting; Moderate two settings; and Severe three or more settings Highlights of Changes DSM-IV-TR and DSM o Conduct Disorder Callous and Unemotional Specifier replaced by With Limited Prosocial Emotions *Limited Prosocial Emotions specifier 1)Lack of remorse or guilt,2)callous-lack of Empathy, 3)Unconcerned about Performance, 4)Shallow or Deficient Affect typical patterns in emotional and interpersonal functioning A more severe form of the disorder requiring a different treatment response Specifier attempts to avoid stigmatizing language and focus on a limited display of prosocial emotions such as empathy and guilt Older than 10 o Intermittent Explosive Disorder o Now also includes verbal aggression and nondestructive physical aggression o Must be above the age of 6 o Pyromania and Kleptomania *****DROPPED***** o Insufficient evidence to retain them as distinct disorders and are better accounted for by other disorders ODD, CD, ASPD 34

39 Highlights of Changes DSM-IV-TR and DSM Chapter 16. Substance Use and Addictive Disorders Major Change is the elimination of the distinction between Abuse and Dependence and the formulation of Use Disorder Empirical evidence that Abuse and Dependence exist on a continuum Abuse is different from Dependence by degree, but not by kind Eliminates an arbitrary distinction that is addressed by focusing on Use rather than a false dichotomy Craving is a new concept introduced Highlights of Changes DSM-IV-TR and DSM o Phencyclidene Disorders (PCP, Ketamine, angel Dust) are now covered under Hallucinogen Disorders o Sedative, Hypnotic, or Anxiolytic Disorders are renamed Sedative/Hypnotic-Related Disorders o Amphetamine and Cocaine Disorders are renamed Stimulant Disorders o Gambling Addiction - Major Controversy Justified on basis of tolerance, dependence, and withdrawal Similar genetic markers as substance abusers Brain Imaging shows similar changes in neural circuitry o Severity Specifiers o Remission Specifiers o Prenatal Alcohol Exposure, Caffeine Use Disorder, and Internet Use Disorder are assigned to the Further Research Chapter III 35

40 Highlights of Changes DSM-IV-TR and DSM Chapter 17. Neurocognitive Disorders Head Trauma now called Traumatic Brain Injury Mild Neurocognitive Disorder (New) Recognition and Level of Severity Chapter 18. Personality Disorders Original 11 Personality Disorder Categories were retained after major controversy Group originally recommended reducing to seven categories: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal, and Personality Disorder-Trait Specified pshd Now in Section III For Further Study is a hybrid (categorical and dimensional) approach Criteria A (Impairment of self or interpersonal functioning) and Criteria B five traits (negative affectivity, detachment, antagonism, disinhibition, and psychoticism) Rating scale to assess impairment on a four point scale Chapter 19.Paraphillic Disorders Wording changes and developmental perspective Module IV: Specific Disorders DISORDERS USUALLY FIRST DIAGNOSED IN INFANCY CHILDHOOD OR ADOLESCENCE Or WHAT HAPPENED TO MY OLD DISORDERS? 36

41 DSM-5 Childhood and Adolescent Disorders Work Group Two primary focuses of workgroup 1. Greater emphasis on developmental themes throughout DSM5 than had been present in DSM-IV 2. Review individual disorders and criteria Proposed enhanced text revisions to focus on specific aspects of age related features Extends the designation of age-related subtypes Developmental manifestations of each disorder should be listed The individual disorders are similarly arranged such that those typically diagnosed in childhood are listed first. Major Controversies Autism Spectrum Disorders Autism, Asperser's, Pervasive Developmental Delay, and Childhood Disintegrative Disorder Mental retardation=intellectual disability based on IQ and adaptive function Behavioral addictions (gambling, internet) Temper Dysregulation Disorder new disorder (Child Bipolar) ultimately renamed Disruptive Mood Dysregulation Disorder Binge Eating Disorder and improved Anorexia and Bulimia criteria Suicide and Non-Suicidal Injury (Section III) PTSD in pre-school children 37

42 Disorders Usually First Diagnosed in Infancy, Childhood, and Adolescence Childhood Disorders not Currently Listed in DSM-IV Posttraumatic Stress Disorder in Preschool Children Covered under Posttraumatic Stress Disorder with criteria for children under six Temper Dysregulation Disorder with Dysphoria changed to Disruptive Mood Dysregulation Disorder Callous and Unemotional Specifier for Conduct Disorder changed to Limited Prosocial Emotions Learning Disabilities Three disorders combined to one Non-Suicidal Self Injury Further Study Non-Suicidal Self Injury Not Otherwise Specified Further Study Childhood Disorders Proposed for Possible Reclassification in Another Diagnostic Category Pica Combined and expanded age range Rumination Disorder Combined and expanded age range Feeding Disorder of Infancy or Early Childhood Subsumed by Avoidant/Restrictive Food Intake Disorder Separation Anxiety Disorder Moved to Anxiety Chapter and expanded to include all age ranges Disorders Usually First Diagnosed in Infancy, Childhood, and Adolescence Childhood Disorders Proposed for Possible Removal from DSM Rett s Disorder Dropped Childhood Disorders Proposed to be Divided into New Childhood Disorders Reactive Attachment Disorder of Infancy or Early Childhood Separated into two Diagnoses: Reactive Attachment Disorder and Disinhibited Social Engagement Disorder Childhood Disorders Proposed to be Subsumed Under Other Diagnoses (No DSM-5 Criteria) Disorder of Written Expression Reading Disorder {Learning Disability Mathematics Disorder Learning Disorder Not Otherwise Specified Childhood Disintegrative Disorder Asperger s Disorder {Autism Spectrum Disorder Pervasive Developmental Disorder 38

43 Mental Retardation DSM-IV-TR A. Significantly below average intellectual functioning as measured by IQ below 70 on individually administered tests B. Deficits in adaptive functioning in two areas C. Onset prior to age MILD MENTAL RETARDATION - Formerly categorized as educable. IQ is to MODERATE MENTAL RETARDATION - Formerly categorized as trainable. IQ is to SEVERE MENTAL RETARDATION - Acquire little speech and self care skills. IQ is to PROFOUND MENTAL RETARDATION - Poor motor skills and little capacity for self-care. IQ is below UNSPECIFIED MENTAL RETARDATION - Used when the diagnosis is assumed, but conditions make it impossible to administer standardized tests. Mental Retardation - Changes Proposed DSM-5 Rationale for Mental Retardation The term Mental Retardation to describe cognitive deficits is outdated and pejorative. Proposal to change terminology to Intellectual Disabilities to be consistent with current international thinking. The usefulness of the current categories (Mild, Moderate, Severe, and Profound) may be changed to a single category of Intellectual Disabilities Diagnostic Specifiers to include 1) IQ measure and 2) Adaptive Functioning Added rigor for psychometrics, but no cut-off change Increase number of domains for adaptive functioning including: Conceptual Domain, Social Domain, Practical Domain The DSM-5 proposal is consistent with the proposed ICD-11 criteria which do not list IQ test score requirements 39

44 Intellectual Developmental Disorder DSM5 DSM-IV (paraphrased) A. Significantly subaverage intellectual functioning. IQ of 70 or below DSM5 (paraphrased) 319 Intellectual Disability (Intellectual Developmental Disorder) (F70) Mild, (F71) Moderate, (72) Severe (F73) Profound (IDD) is a disorder that includes both a current intellectual deficit and a deficit in adaptive functioning. The following 3 criteria must be met: A. Characterized by deficits in general mental and confirmed by assessment and individualized, standardized testing. Intellectual Developmental Disorder DSM5 DSM-IV B. Deficits or impairment in adaptive functioning in at least two areas C. Onset prior to 18 DSM5 (paraphrased) B. Deficits in adaptive functioning in one or more aspects of daily life activities, such as communication, social participation, functioning at school or at work, or personal independence C. All symptoms must have an onset during the developmental period. 40

45 Global Developmental Delay DSM5 DSM-IV 319 Mental Retardation, Severity Unspecified A. Strong presumption of Mental Retardation, but intelligence is untestable DSM5 (paraphrased) (F88) Intellectual or Global Developmental Delay (paraphrased) A. Evidence of intellectual or developmental delay, lack of clarifying data, testing is unable to be completed. Learning Disorder/Learning Disability- DSM5 Establishes general criteria for learning disorders Learning disorders interfere with the acquisition and use of one or more of the following academic skills: oral language, reading, written language, mathematics. These disorders affect individuals who otherwise demonstrate at least average abilities essential for thinking or reasoning. As such, Learning Disorders are distinct from Intellectual Developmental Disorder. Diagnostic criteria do not depend upon comparisons with overall IQ and are consistent with abandoning the use of a severe discrepancy between intellectual ability and achievement for determining whether a child has a specific learning disability, as defined in 34 CFR 300.8(c)(10). The Learning Disorder Not Otherwise Specified category may be coded under this super-ordinate category of Learning Disorder. 41

46 Learning Disorder/Learning Disability- DSM5 Learning Disorders (DSM-IV) Must contain three elements: substantial discrepancy between achievement and ability, a significant interference in functioning, and in excess of any sensory issues Reading Disorder Mathematics Disorder Disorder of Written Expression Learning Disorder NOS Specific Learning Disorder (paraphrased) Diagnosis is based on synthesis of developmental history, psychoeducation measures, and Response To Intervention based on the following: A. History or current presentation of persistent difficulties in the acquisition of reading, writing, arithmetic, or mathematical reasoning skills during the formal years of schooling. The individual must have at least one of the following: 1. Inaccurate or slow word reading 2. Difficulty comprehending what is read 3. Poor spelling 4. Difficulty with written expression 5. Difficulties remembering number facts 6. Ineffective /inaccurate mathematical reasoning. Learning Disorder/Learning Disability- DSM5 Specific Learning Disorder (paraphrased) B. Current skills in one or more academic skills are well-below the average range for the individual s chronological age, indicated by scores on individually-administered, standardized, appropriate tests of academic achievement in reading, writing, or mathematics. Over 17, a documented history may substitute for testing. C. The learning began during school-age or once demands exceed capability. D. The learning difficulties are not better explained other disorders. 42

47 Learning Disorder/Learning Disability- DSM5 Specific Learning Disorder (paraphrased) Coding Note: Specify all academic domains that are impaired. When more than one domain is impaired, each should be coded individually (F81.0) With Impairment in Reading (F81.81) With Impairment in Written Expression (F81.2) With Impairment in Mathematics Severity Specifiers: Mild, Moderate, and Severe Developmental Coordination Disorder DSM5 DSM-IV (paraphrased) A. Performance in daily activities that require motor coordination is substantially below that expected. This may be manifested by marked delays in achieving motor milestones (e.g., walking, crawling, sitting), dropping things, clumsiness, poor performance in sports, or poor handwriting. B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living. C. The disturbance is not due to a general medical and *does not meet criteria for a Pervasive Developmental Disorder. D. *If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it. DSM (F82) (paraphrased) A. Motor performance that is substantially below expected levels, Difficulties are manifested as coordination problems, poor balance, clumsiness, dropping or bumping into things; B. The disturbance in Criterion A, interferes with activities of daily living or academic achievement. C. Onset is in the early developmental period D. The disturbance is not due to intellectual disability, visual impairment, or a general medical condition 43

48 Stereotypic Movement Disorder DSM-IV A. Repetitive, seemingly driven, and nonfunctional motor behavior (e.g., hand shaking or waving, body rocking, head banging, mouthing of objects, self-biting, hitting own body). B. The behavior markedly interferes with normal activities or results in self-inflicted bodily injury that requires medical treatment (or would result in an injury if preventive measures were not used). C. If Mental Retardation is present, the stereotypic or self-injurious behavior is of sufficient severity to become a focus of treatment. D. The behavior is not better accounted for by a compulsion (as in Obsessive-Compulsive Disorder), a tic (as in Tic Disorder), a stereotypy that is part of a Pervasive Developmental Disorder, or hair pulling (as in Trichotillomania). E. The behavior is not due to the direct physiological effects of a substance or a general medical condition. F. The behavior persists for 4 weeks or longer. Specify if: With Self-Injurious Behavior: if the behavior results in bodily damage that requires specific treatment (or that would result in bodily damage if protective measures were not used) (F98.4) Stereotypic Movement Disorder (paraphrased) A. Repetitive, seemingly driven, and apparently purposeless motor behavior B. The disturbance causes impairment in social, occupational, or other important areas of functioning. C. Onset is in the early developmental period. D. The motor behavior is not due to another disorder. Specify if: With self-injurious behavior or without selfinjurious behavior Severity Specifier: Mild, Moderate, Severe Communication Disorders All former DSM-IV Communication Disorders and all proposed disorders have been subsumed under three superordinate categories Language Disorders, Speech Disorders, and Social Communication Disorders. Mixed Receptive-Expressive Language Disorder, were removed based on research Proposed: earlier classifications Speech Sound Disorder, Childhood Onset Fluency Disorder, Voice Disorder, Language Impairment Disorder, Late Language Emergence Disorder, and Specific Language Impairment Disorder 44

49 Language Disorder DSM5 DSM-IV Expressive Language Disorder - Individuals may have small vocabularies or trouble producing grammatically correct sentences. Acquired type occurs after a major neurological event. Language abilities are substantially below intellectual ability and interfere with functioning Mixed Receptive-Expressive Language Disorder - Individuals have problems producing and understanding language, words, or sentences. This disorder involves difficulty in both understanding words or signs (receptive language) and in using words or signs to communicate (expressive language). Onset is typically prior to age 4 and is seen in approximately three percent of children. Often a predictor of later learning disabilities. DSM (F80.9) Language Disorder (paraphrased) A. Persistent difficulties in the acquisition and use of spoken language or written language and other modalities B. Language abilities that are below age expectations resulting in functional limitations in communication, social participation, or academic achievement. C. Onset of symptoms is in the early developmental period. D. The difficulties are not attributable to sensory impairment, neurological conditions, or intellectual ability Speech Sound Disorder DSM5 DSM-IV Phonological Disorder (formerly Developmental Articulation Disorder) - Speech develops slowly for the individual s age. This was formerly referred to as Developmental Articulation Disorder. Differential with Expressive Language Disorder is that the focus here is on sounds and speech sound production not utilization of language. Often observed in substituting one sound for another and in omitting certain sounds entirely. DSM (F80.0) Speech Sound Disorder (paraphrased) A. Persistent difficulties in speech sound production. B. The disturbance causes limitations in effective communication, social participation, or academic/occupational performance. C. Onset of symptoms is in the early developmental period. D. The difficulties are not attributable to congenital or acquired neurological conditions 45

50 Childhood-Onset Fluency Disorder (Stuttering) DSM Stuttering -There is a frequent disruption in the normal fluency of speech characterized by repetitions or prolongation of sounds. It affects approximately one percent of pre-school children and the onset occurs between ages two to seven with peak onset at about age five. Recovery occurs in approximately 80 percent of individuals by age 18. DSM-5 (paraphrased) (F80.81) Childhood-Onset Fluency Disorder (Stuttering) A. Disturbances in fluency and time patterning of speech marked by frequent occurrences of one or more of the following: 1) sound and syllable repetitions, 2) sound prolongations, 3) broken words, 4) silent blocking, 5) circumlocutions, and 6) monosylabic whole word repetitions B. The disturbance causes anxiety C. Onset of symptoms is in the early developmental period. D. Disturbance is not attributable to sensory deficit, neurological insult, or other medical conditions Social (Pragmatic)Communication Disorder DSM5 (New Diagnosis) New Diagnosis (F80.89) Social (Pragmatic) Communication Disorder (paraphrased) A. Persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication as manifested by 1. Deficits in using communication for social purposes 2. Impairment in ability to change communication to match context 3. Difficulties following rules for conversation. 4. Difficulty in understanding what is not explicitly stated, e.g. idioms, inferences, multiple meanings 46

51 Social (Pragmatic)Communication Disorder DSM5 (New Diagnosis) B. The deficits result in limitations in social participation, communication, academics, or occupational C. Symptoms must be present in early developmental period (but may not become fully manifest until speech, language, or communication demands exceed limited capacities). D. The Symptoms are not attributable to another medical or neurological condition Pervasive Developmental Disorders DSM-IV-TR Autistic Disorder Rett s Disorder Childhood Disintegrative Disorder Asperger s Disorder Pervasive Developmental Disorder DSM Autism Spectrum Disorder Specify if associated with medical, environmental, or genetic factors Specify severity Specify with or without language impairment 47

52 Autism Spectrum Disorder Rationale for Changes in DSM5 Differentiation between ASD and other typical development and nonspectrum disorders is done reliably and consistently; whereas, differentiation among disorders is clouded by severity, language, and intelligence Autism is defined by a common set of behaviors as a single diagnostic category adapted to clinical presentation by specifiers and associated features A single spectrum disorder reflects the state of knowledge and clinical presentation Boundary between high-functioning autism and Asperger s Disorder is artificial --- cleave meatloaf at the joints Gray matter volume can distinguish between Autism and normals, but no distinction between Autism and Asperger s Greater consistency with ICD Ongoing debate about retaining the less stigmatizing diagnoses of Asperger s and PDD NOS Autism Spectrum Disorder Rationale for Changes in DSM5 Three Domains Become Two (Social interaction, Communication, and Restricted Repetitive Behavior) 1) Social/Communication Deficits 2) Fixated Interests and Repetitive Behaviors Communication and Social Behaviors are coterminous Language delays are not universal nor defining and have been removed from criteria Requiring both criteria to be completely met increases accuracy Decision is supported by extensive literature reviews Requiring that all the Social/Communication be met increases accuracy Requiring two symptoms of repetitive behaviors increases accuracy Removes focus on language delay Unusual sensory behaviors are spelled out with greater specificity Onset of symptoms prior to age 3 has been relaxed (late onset due to social demands overwhelming capacity Severity Levels are also specified 48

53 Autism Spectrum Disorder (F84.0) Autism Spectrum Disorder (paraphrased) Must meet criteria A, B, C, and D: A. Persistent deficits in social communication and social interaction across contexts, as manifested by the following: 1. Deficits in social-emotional reciprocity 2. Deficits in nonverbal communicative behaviors used for social interaction 3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers) Severity is based on social communication impairments and restricted, repetitive patterns of behavior: Level 3: Requiring very substantial support Level 2: Requiring substantial support Level 1: Requiring support Autism Spectrum Disorder 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; 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or non-verbal behavior 3. Highly restricted, fixated interests that are abnormal in intensity or focus 4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment Severity is based on social communication impairments and restricted, repetitive patterns of behavior: Level 3: Requiring very substantial support Level 2: Requiring substantial support Level 1: Requiring support 49

54 Autism Spectrum Disorder C. Symptoms must be present in early developmental period D. Symptoms cause clinically significant impairment in social, occupational and impair current functioning. Specify if: With or without accompanying intellectual impairment With or without accompanying language impairment Associated with a known medical or genetic condition, or environmental factor (use additional codes) Associated with another neurodevelopmental, mental, or behavioral disorder (use additional codes) With Catatonia (use additional code (F06.1) Evolution Of ADHD in DSM5 Proposal to add 4 Impulsivity Criteria Age of onset to age 12 Reduce number of symptoms for adults Inclusion of PDD Add subtype of ADHD Inattentive Restrictive Type In Remission Removal of Restrictive Type 50

55 Attention Deficit Hyperactivity Disorder (paraphrased) A. A persistent pattern of inattention and/or hyperactivity-impulsivity as characterized by (1) or (2) 1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities. Note: symptoms are not a manifestation of oppositional behavior, defiance. For >17 years of age, at least 5 symptoms are required a. Often fails to give close attention to details (e.g., overlooks or misses details, inaccurate). b. Often has difficulty sustaining attention (e.g., has difficulty remaining focused during lectures, conversations, or reading lengthy writings). c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere). d. Often does not follow through on instructions (e.g., starts tasks but quickly loses focus, fails to finish schoolwork, chores, or tasks in the workplace). e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings, poor time management; tends to fail to meet deadlines). f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers). g. Often loses things necessary for tasks or activities (e.g., school materials, wallets, keys, paperwork, eyeglasses, or mobile telephones). h. Is often easily distracted by extraneous stimuli ( include unrelated thoughts). i. Is often forgetful in daily activities (e.g., chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). Attention Deficit Hyperactivity Disorder (paraphrased) 2. Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that impact directly on social and academic/occupational activities. Note: symptoms are not a manifestation of oppositional behavior, defiance, or hostility. For >17 years of age, at least 5 symptoms are required a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, office or other workplace, or in other situations that require remaining seated). c. Often runs about or climbs in situations where it is inappropriate. (In adolescents or adults, may be limited to feeling restless). d. Often unable to play or engage in leisure activities quietly. e. Is often on the go, acting as if driven by a motor (e.g., is unable or uncomfortable being still for an extended time, as in restaurants, meetings, etc; may be experienced by others as being restless and difficult to keep up with). f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., completes people s sentences and jumps the gun cannot take turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people s things without asking or receiving permission, adolescents or adults may intrude into or take over what others are doing). 51

56 Attention Deficit Hyperactivity Disorder (paraphrased) B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12. C. Criteria for the disorder are met in two or more settings (e.g., at home, school or work, with friends or relatives, or in other activities). D. There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). Specify Based on Current Presentation (F90.2) Combined Presentation: A1 and A2 are met for past six months (F90.0) Predominately Inattentive Presentation: A1 is met but A2 is not met for the past six months (F90.1) Predominately Hyperactive/Impulsive Presentation: A2 is met but A1 is not met for the past six months Coding note: If criteria were met previously, but fewer than symptoms than criteria have been met in past six months, but symptoms still impair functioning, Specify: In Partial Remission Severity Specifier: Mild, Moderate, or Severe Oppositional Defiant Disorder Symptom list remains the same, but is now clustered into three groups: Angry/Irritable Mood, Argumentative/Defiant Behavior, and Vindictiveness Some of the 8 symptoms are predictive of other disruptive behavior disorders (ADHD, CD), but the emotional symptoms (Angry/Irritable Mood) are distinctive A severity index is proposed based on pervasiveness, as children who display symptoms in multiple settings are more impaired than those who are symptomatic in only one setting 52

57 Oppositional Defiant Disorder DSM (F91.3) Oppositional Defiant Disorder (paraphrased) A. A persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least six months as evidenced by at least four symptoms from any of the following categories, observed during interaction with at least one individual that is not a sibling. Angry/Irritable Mood 1. loses temper 2. easily annoyed 3. angry and resentful Argumentative/Defiant Behavior 4. argues with authority figures or adults (for children and adolescents) 5. actively defies or refuses to comply with requests from authority figures or rules 6. deliberately annoys others 7. blames others for his or her mistakes or misbehavior Vindictiveness 8. spiteful or vindictive at least twice within the past six months Oppositional Defiant Disorder For children <5, behaviors must occur on most days for 6 months For children >5, behaviors must occur at least once a week for six months While these frequency criteria provide guidance other factors should also be considered such as whether the behaviors are non-normative given the individual s developmental level, gender, and culture. B. The disturbance in behavior is associated with distress in the individual or others in immediate social context (family, peers, work colleagues) causes impairment in social, educational, or vocational activities D. The behaviors do not occur exclusively during the course of a Psychotic, Substance Use, Depressive, or Bipolar Disorder. Also, the individual does not meet criteria for Disruptive Mood Dysregulation Disorder Severity Specifiers: Mild, Moderate, Severe 53

58 Conduct Disorder Conduct Disorder (paraphrased) A. A repetitive and persistent pattern of behavior which violates the rights of others, social norms or rules where three or more of the following were present in the last 12 months, and at least one present in the past six months. Aggression to people and animals 1. Bullies, 2. Physical fights 3. Used a weapon 4. Physically cruel to people 5. Physically cruel to animals 6. Stolen while confronting a victim 7. Forced someone into sexual activity Destruction of Property 8. Deliberately engaged in fire setting 9. Deliberately destroyed other s property Deceitfulness or Theft 10. Broken into houses or cars 11. Lies to obtain goods or favors ( cons ) 12. Stolen items of value without confronting a victim Serious Rules Violations 13. Stays out at night before age Has run away from home overnight at least twice 15. Is often truant from school before age 13 Conduct Disorder B. The disturbance in behavior causes impairment in functioning C. If the individual is over 18, criteria are not met for Antisocial Personality Disorder Specify if: (F91.1) Childhood Onset Type at least one symptom prior to age 10 years (F91.2) Adolescent Onset Type no symptoms prior to age 10 years (F91.9) Unspecified Onset cannot determine if first symptom was prior to age 10. Specify if: With limited prosocial emotions: To qualify for this specifier, a person must have displayed at least two of the following characteristics persistently over at least 12 months and in multiple relationships and settings. Multiple information sources are necessary. Lack of remorse or guilt doesn t feel bad, guilty, or concern Callous-Lack of Empathy disregards and unconcerned about feelings of others Unconcerned about Performance indifferent to poor performance, not put forth effort Shallow or Deficient Affect does not express emotion or emotions used to manipulate Severity Specifiers: Mild, Moderate, Severe 54

59 Non-Suicidal Self Injury (NSSI) Did not make it into DSM- 5 but included in Section III Research has shown that NSSI occurs in a variety of diagnoses Similarity to suicide behaviors promotes the misconception that self-injury with a sharp object is a suicide attempt. Age of onset is 10 to 15, 7% of adolescents report one episode, 4% report four or more times per year. Suicidal Behavior Disorder Did not make it into DSM-5 but included in Section III Despite the fact that suicide behavior is associated with psychiatric disorders, results in high utilization of mental health services, and is the best predictor of nonfatal and fatal suicide attempts, DSM codes are limited to E codes (self-inflicted injury). Suicide behavior and attempts are symptoms of other disorders (BPD, MDD, BPD) but are not disorders Disruptive Mood Dysregulation Disorder The name of the disorder was changed from Temper Dysregulation Disorder to Disruptive Mood Dysregulation Disorder. Most of the children who meet criteria for Disruptive Mood Dysregulation Disorder will also meet criteria for Oppositional Defiant Disorder, since the two disorders have overlapping symptoms. However, only a minority of youth with Oppositional Defiant Disorder will meet criteria for Disruptive Mood Dysregulation Disorder,. Disruptive Mood Dysregulation Disorder requires impairment across two settings, one of which is severe, and the symptom threshold is higher than that set for Oppositional Defiant Disorder. To avoid having artificial comorbidity due to overlapping symptoms, the Work Group has recommended that youth who meet criteria for both Oppositional Defiant Disorder and Disruptive Mood Dysregulation Disorder should only be assigned the diagnosis of Disruptive Mood Dysregulation Disorder. Provides a more appropriate diagnosis for Pediatric Bipolar Disorder 55

60 Disruptive Mood Dysregulation Disorder (F34.8) Disruptive Mood Dysregulation Disorder (paraphrased) A. Severe recurrent temper outbursts manifested verbally and/or behaviorally, that are grossly out of proportion in intensity or duration to the situation or provocation. B. The temper outbursts are inconsistent with developmental level. C. Frequency: The temper outbursts occur, on average, three or more times per week. D. Mood between temper outbursts: persistently irritable or angry most nearly every day, is observable by others (e.g., parents, teachers, peers). E. Criteria A-D have been present for 12 or more months. Throughout that time, the person has not had 3 or more consecutive months without all the symptoms of Criteria A-D. F. Criterion A and D are present in at least two settings (at home, at school, or with peers) and are severe in at least in one setting. Disruptive Mood Dysregulation Disorder G. The diagnosis should not be made for the first time before age 6 or after age 18. H. Age at onset of Criteria A through E is before age 10 years. I. There has never been a distinct period lasting more than one day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. J. The behaviors do not occur exclusively during an episode of Major Depressive Disorder or by another mental disorder (Note: This diagnosis cannot co-exist with Oppositional Defiant Disorder, Intermittent Explosive Disorder or Bipolar Disorder, though it can coexist with Major Depressive Disorder, Attention Deficit/Hyperactivity Disorder, Conduct Disorder, and Substance Use Disorders. Individuals meeting criteria for both Disruptive Mood Dysregulation Disorder and Oppositional Defiant Disorder should only be given the diagnosis of Disruptive Mood Dysregulation Disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of DMDD should not be assigned.) K. The symptoms are not due to the effects of a drug or to a general medical or neurological condition. 56

61 Feeding and Eating Disorders of Infancy or Early Childhood All disorders formerly listed in the Infancy, Childhood, Adolescence Section have been moved to Section called Feeding and Eating Disorders Minor changes in Pica (F98.3) for children must be two years of age (F50.8) for adults Wording clarification in Rumination Disorder (F98.21) Feeding Disorder of Infancy or Early Childhood has been renamed Avoidant/Restrictive Food Intake Disorder (F50.8) in recognition of occurrence across developmental spectrum Anorexia Nervosa (F50.01) Restricting Type or (F50.02) Binge- Eating/Purging Type has undergone minor changes Elimination of the 85% of expected body weight criteria Elimination of the amenorrhea criteria for females Bulimia Nervosa (F50.2) unchanged with exception of lowering criteria from twice a week to once a week A new diagnosis: Binge Eating Disorder is included in DSM5 Binge Eating Disorder (F50.8) Binge-Eating Disorder (paraphrased) A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than normal. 2.A sense of lack of control over eating B. The binge-eating episodes are associated with 3 (or more) of the following: 1. Eating much more rapidly than normal 2. Eating until feeling uncomfortably full 3. Eating large amounts of food when not feeling physically hungry 4. Eating alone because of feeling embarrassed by how much one is eating 5. Feeling disgusted with oneself, depressed, or very guilty after overeating C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for 3 months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior and does not occur exclusively during the course Bulimia Nervosa or Anorexia Nervosa. Specify if : partial remission or full remission Severity Specifier: Mild, Moderate, Severe, Extreme 57

62 Tic Disorders Tourette s Disorder (F95.2)- minor changes in tic free period and elimination of a criteria of distress Chronic Motor or Vocal Tic Disorder (F95.1)- minor wording changes and differential between Tourette s is absence of both motor and vocal Provisional Tic Disorder (F95.0) is a renaming of Transient Tic Disorder and 4 week criteria has been dropped All Tic Disorders now share a common definition of tic as differentiated from Stereotypic Movement Disorder Enuresis and Encopresis With minor language clarification, criteria are essentially unchanged (F98.0) Enuresis (F98.1) Encopresis 58

63 Reactive Attachment Disorder The proposed revision for Reactive Attachment Disorder includes the division of the two DSM-IV types into two disorders: Reactive Attachment Disorder of Infancy and Early Childhood and Disinhibited Social Engagement Disorder. Reactive Attachment Disorder (F94.1) Reactive Attachment Disorder (paraphrased) A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, as manifest by both of the following: 1) Rarely or minimally seeks comfort when distressed. 2) Rarely or minimally responds to comfort offered when distressed. B. A persistent social and emotional disturbance C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least on of the following: 1) Persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. 2) Repeated changes of primary caregiver 3) Rearing in unusual settings D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A E. Does not meet the criteria for Autistic Spectrum Disorder. F. The disturbance is evident before age 5. G. The child has a developmental age of at least 9 months Specify if : Persistent present for at least 12 months Specify Severity: Severe all symptoms of the disorder at a high level. 59

64 Disinhibited Social Engagement Disorder New Diagnosis (F94.2) Disinhibited Social Engagement Disorder (paraphrased) A. A pattern of behavior in which the child actively approaches and interacts with unfamiliar adults by exhibiting at least 2 of the following: 1) Reduced or absent reticence with unfamiliar adults. 2) Overly familiar verbal or physical 3) Diminished or absent checking back 4) Willingness to go off with an unfamiliar adult with minimal or no hesitation. B. A. is not limited to impulsivity as in ADHD but includes socially disinhibited behavior. C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: 1) Social neglect or deprivation in the form of persistent lack of having basic emotional needs 2) Repeated changes of primary caregiver 3) Rearing in unusual settings that limit forming selective attachments D. The care in Criterion C is presumed responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C). E. The child has a developmental age of at least 9 months. Specify if : Persistent present for at least 12 months Specify Severity: Severe all symptoms of the disorder at a high level. Separation Anxiety Disorder Separation Anxiety Disorder (paraphrased) A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following: 1. Recurrent excessive distress 2. Persistent excessive worry about losing attachment figures 3. Excessive worry that an untoward event will lead to separation from a major attachment figure 4. Persistent reluctance or refusal to go to school or elsewhere 5. Excessively fearful to be alone or without major attachment figures 6. Persistent reluctance or refusal to go to sleep without being near major attachment figure/ sleep away from home 7. Repeated nightmares involving the theme of separation 8. Repeated complaints of physical symptoms when separation from major attachment figures occurs or is anticipated (F93.0) Separation Anxiety Disorder (paraphrased) A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: 1. recurrent excessive distress anticipating or experiencing separation 2. persistent and excessive worry about losing major attachment figures 3. persistent and excessive that could lead to separation from a major attachment figure 4. persistent reluctance or refusal to go out, away from home, school, work, for fear of separation 5. excessive fear or reluctance about being alone or without major attachment figures 6. reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure 7. repeated nightmares involving the theme of separation 8. repeated complaints of physical symptoms when anticipating or experiencing separation from major attachment figures 60

65 Separation Anxiety Disorder B. The duration of the disturbance is at least 4 weeks. C. The onset is before age 18 years. D. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder With Agoraphobia. Specify if: Early Onset: if onset occurs before age 6 years B. The fear, anxiety or avoidance is persistent, lasting at least 4 weeks in children and adolescents and six months or more in adults. AGE OF ONSET CRITERIA DROPPED C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. EARLY ONSET MODIFIER IS DROPPED Module V: Case Studies

66 Identify Primary Symptoms/Dysfunctions Possible Differential Diagnoses Diagnoses and Z codes CASE STUDY #1 Stephen Sandstone Stephen was referred to a local Family Services agency by his pediatrician as a result of a history of over activity, behavior problems in school, and poor social relationships. His mother indicated that Steven was particularly active as an infant and a toddler. Stephen s teachers found him difficult to control and they see him as being extremely impulsive and distractible, moving from one activity to the next. His teachers report that he does not seem to listen even when spoken to directly and has difficulty organizing tasks and losing things necessary to complete tasks. He often talks excessively and is reported to be constantly on the go. His teacher reports that he is immature and restless, responds best in a structured one-on-one situation, and is considered the class pest as he is constantly annoying other children. He frequently blurts out answers before the questions are asked and interrupts the work of other students At age 8, he currently knows his alphabet and has a sight vocabulary of approximately 20 words. He cannot read a full sentence and his math skills are also minimal. Because of these learning difficulties Stephen is in a small, self-contained class for learning disabled children and has failed to progress. He often fails to give close attention to details and makes careless mistakes in schoolwork. Since the start of the school year, he has soiled his pants two to three times per week. He does not have any friends and has been reported by the bus driver for fighting with other children. His mother reports that Stephen responds well to discipline, but lately he has started talking back and swearing at her. He frequently throws temper tantrums, especially if she asks him to do something or denies a request. His constant whining is irritating for her, especially since her husband has been in the hospital for the past six months. Because of his illness, his father has been minimally involved with Stephen s discipline for the last two years. 62

67 Primary Symptoms/Dysfunctions Differential Diagnoses to be Considered Diagnosis: CASE STUDY # 2 James Red James is a five-year-old who shows significant delays in social and self-help skills. He makes a variety of sounds but has yet to form them into intelligible words. At times he uses peculiar finger movements and flaps his hands when he is either very happy or very angry. His parents report that sometimes he is very affectionate, but does not play appropriately with other children very well. A variety of inappropriate behaviors make him a difficult child to manage and he often has temper tantrums and screams without cause. He does not react to spankings and does not cry. His family tolerates his minor daily rituals, but interruptions cause them considerable distress. His father feels that he is babied and catered to, but is mother feels that she must do everything possible, and that sometimes she can t ignore him. His mother does not feel supported by her husband and feels that she is in this by herself. At this point, James does not yet dress himself and wears diapers day and night. He is very attached to a stuffed bear, but easily separates from his mother. Often he will engross himself for long periods of time twisting tissues or blades of grass in front of his face. His parents are concerned that he is oblivious to danger himself unless he is constantly supervised. They report that he rarely complies with commands or expected tasks. When James was 18 months old his parents began to suspect that he was different. He seemed too good and, at the same time, not responsive enough. Intellectual functioning cannot be assessed, but the examiner felt that there are some impairments. On a recent clinic visit James continued to display poor social relations. He easily took the interviewer s hand, but did not discriminate between his mother and other strangers in the waiting room. An occasional grimace momentarily altered his somewhat otherwise bland expression. He appears to tune out and be disinterested in most things about him. The background noise in the clinic agitated him, and he frequently put his fingers in his ears. When he became upset, he butted his head against his mother and resisted her attempts to comfort. 63

68 Primary Symptoms/Dysfunctions Differential Diagnoses to be Considered Diagnosis: CASE STUDY # 3 Dante Purple Dante, an eleven-year-old child, was brought to the clinic by his mother (at the request of his school) because of continued fighting and bullying. His mother claims that Dante has always been a handful, but now feels that he gets out of line too often and that she can no longer control him. She recently found numerous items in his room that she believes to be stolen, and she has received several reports from the neighbors about property damage. He lies constantly, even when caught and confronted. When confronted he shows no remorse or guilt. He was recently suspended from school along with two friends for having set up a blockade to get younger kids on their way home from school. They then made demands for money, but Dante claimed that they intended no harm. There was, however, an incident in which a younger girl was pushed off her bike but Dante saw it as no big deal. Dante has repeated both first and second grades. His teachers report that he is easily frustrated, and is failing most subjects. He is constantly out of his seat creating a disruption. He usually looks unhappy and upset, but is unconcerned about his poor performance. His behavior is viewed as attention seeking. He works much better in a small resource class to which he is assigned two hours a day for help in reading. Most of the rest of the day is spent in the principal s office. Dante is described as showing no empathy, no remorse, and no emotion. Dante is the second oldest of four children in a single parent home. His natural father left over two years ago and his mother works two part-time jobs to make ends meet. This means that the children are left unsupervised a good part of the day with Dante s older sister taking most of the responsibility. Dante does not get along with his sister and will hit and bite her if she tries to manage him. During the interview Dante said little and looked absent. When asked, he denied feeling blue but complained that his sister is mean to him. He stated that his sister once hit him with a bat, but she got a whooping for it. Prior testing showed that Verbal IQ equals 57, Performance IQ equals 78, and Full Scale IQ equals

69 Primary Symptoms/Dysfunctions Differential Diagnoses to be Considered Diagnosis: CASE STUDY # 4 Susan Yellow Six-year-old Susan was brought to the clinic by her parents who stated that their child was ruining their marriage. The father feels that the mother spoils the child with inconsistent discipline. The mother feels that she tries her best without success and that the father is extremely harsh and critical. Mother reports that their marriage was rocky from the very beginning and has just gotten worse with Susan s disruptive behavior. Mother acknowledges that she has been diagnosed with major depression and wonders if she passed this on to Susan. For the past three years Susan has been extremely difficult. She is willful and the terrible twos were never outgrown. Her mother states for the past year she is angry and resistive all the time, and no one wants to have anything to do with her. Susan often spoils family events by her misbehavior. At the private school she attends the teachers often have her play quietly by herself because she irritates and annoys the other children. In turn, the other children who attempt to respond to her are met with aggression such as throwing things or slapping them. She lisps, has difficulty sounding out d s, and stutters when excited, but this has improved somewhat in the past year. Developmental milestones have been reached within normal limits. She is considered quite bright in school but her behavior makes learning difficult. During the clinic interview, Susan seemed to enjoy the individual attention shown her, but was demanding and destructive of the toys in the room. At the end of the interview, she tried to keep the toys even though she was told she couldn t. She refused to help clean up at the end of the session stating she just don t feel like it. Both parents appear to be substantially invested in their child, but are finding her violent temper tantrums more and more difficult to handle. 65

70 Primary Symptoms/Dysfunctions Differential Diagnoses to be Considered Diagnosis: CASE STUDY # 5 Betty Blue Betty is a 15-year-old girl who lives with her parents and is seeking therapy because her parents found her hanging from her closet door with a belt around her neck. Her parents came to her rescue only because they heard her violently kicking the door. Betty states that she changed her mind about wanting to die and the belt hurt my neck. Betty has a history eating when she is upset but no history of purging or other compensatory efforts Her weight has ranged from 160 pounds at age 14 to the current low of 125. She has a tendency to be slightly heavy but is five feet six inches call. She s an excellent athlete, jogs 6 miles a day, and plays competitive basketball on her high school team. There are periods when she feels depressed, because of the way she looks and the friction at home between her parents. and can t take it any more She is more likely to binge during these times, eating in secret, rapidly devouring huge quantities of food usually junk food, even though she is not hungry She has been known to eat an entire chicken at one setting, only to later purge through self-induced vomiting. She then becomes depressed about how fat she looks and refuses dates because of her embarrassment. She has been binging several times a week for months. She reports having a stash of junk hidden in her closet that her father does not know anything about. She is afraid that if he discovers the stash, he ll constantly pull room checks and increase his anger at her daily weigh ins. She feels a great deal of pressure from her father to win an athletic scholarship. She is a good student and is curious about the psychological basis for bingeing. She says she now understands how an alcoholic must feel because she knows that bingeing is bad for her but she simply can t stop when she starts to eat. Something must be terribly wrong with me. Sometimes I am amazed that any human can eat that much She has kept her bingeing a secret from her parents and only one of her friends knows about her habits. 66

71 Primary Symptoms/Dysfunctions Differential Diagnoses to be Considered Diagnosis: CASE STUDY # 6 Helen Black Helen, a five-year old was referred by her caseworker after several disrupted placements in foster care. She was in the 15 th percentile for weight, although height was normal. The caseworker was struck by Helen s sad expression and lack of interest in toys. She moved around the room in almost a frenzy with a constant stream of verbalizing and attempts to get all the adults to focus on her. When the social worker attempted to talk to the foster mother, Helen began going through the social worker s purse. Helen s existence had been chaotic since birth. Having been born to a chronic paranoid schizophrenic mother, who has now been institutionalized, Helen had minimal care from her mother. Her father is unknown. A landlady who took an interest in Helen provided some level of care as her mother s illness deteriorated. Her mother had been hallucinating and delusional since Helen s birth, and it was doubtful whether she would ever be able to provide adequate care. Helen was literally passed from person to person in the neighborhood and the mother would allow her to be on the streets at all hours of the night. She shows no real connection to her biological mother even though she was in the room for the interview. During the interview Helen was constantly interrupted the examiner. Motor development appears to be normal. She moved from lap to lap of any adult who came in the room. She attempted to remove a broach that the case worker was wearing while she sat in her lap. The mother of a little boy in the waiting room accused Helen of acting inappropriately by trying to kiss her son on the mouth. At one point she wandered out of the office and was found in another worker s office playing with a stuffed animal. to play with, she refused and sat in the corner playing with her fingers in a repetitive fashion. 67

72 Primary Symptoms/Dysfunctions Differential Diagnoses to be Considered Diagnosis: Module VI: Other Diagnoses DIAGNOSTIC CATEGORIES NORMALLY USED WITH ADULTS BUT WHICH ARE ALSO APPROPRIATE FOR CHILDREN AND ADOLESCENTS 68

73 Substance Abuse Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure - Included in section III for further study (fetal Alcohol Syndrome) Internet Gaming Disorder - Included in section III for further study Caffeine Used Disorder To be included in section for further study Combining Substance Abuse and Dependence Into One Disorder Substance Use Disorder DSM-IV categories of substance abuse and substance dependence are replaced with the category of substance use disorder. Addiction i.e. Dependence, is not a proposed disorder for DSM-5. The criteria are minimally changed. The symptoms listed in DSM-IV under substance abuse and substance dependence were combined to create the list for substance use disorders. The only change to the list was the removal of legal problems, since these are not included in the World Health Organization s International Classification of Diseases (ICD) because of marked variations in international as well as in local U.S. jurisdiction standards. Section reorganized according to substance (whereas these were previously organized according to the diagnosis Behavioral Addictions Gambling Disorder formerly pathological gambling Substance Use Disorder Each Substance (Alcohol, Caffeine, Cannabis, Phencyclidine, Inhalants, Opoids, Sedative, Stimulants, and Tobacco) has it s own codes and remission, environment, and severity specifiers Alcohol Use Disorder (Coding based on severity) (paraphrased) A. A problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by two (or more) of the following in a 12-month period: 1. Alcohol is often taken in larger amounts or over a longer period than was intended 2. There is a persistent desire or unsuccessful effort to cut down or control use 3. A great deal of time is spent in activities necessary to obtain alcohol, use the substance, or recover from its effects 4. Craving, or a strong desire to use alcohol 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use 8. Recurrent alcohol use in situations in which it is physically hazardous 69

74 Substance Use Disorder 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol 10. Tolerance, as defined by either or both of the following: a. A need for markedly increased amounts of alcohol b. Markedly diminished effect with use of the same amount of alcohol 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for Alcohol Withdrawal) b. Alcohol (or a closely related substance, such as benzodiazepine is taken to relieve or avoid withdrawal symptoms Severity Scale: The Severity of each Substance Use Disorder is based on: symptoms: No diagnosis symptoms: Mild Alcohol Use Disorder (F10.10) symptoms: Moderate Alcohol Use Disorder (F10.20) - 6 or more symptoms: Severe Alcohol Use Disorder (F10.20) Posttraumatic Stress Disorder for Children 6 Years and Younger (F43.10) Posttraumatic Stress Disorder in Preschool Children Differences are in Bold (paraphrased) A. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence, in one or more of the following ways: 1. Directly experiencing 2. Witnessing in person, the event(s) especially primary caregivers. 3. Learning that the event(s) occurred to a parent or caregiver NOTE: Witnessing does not include events that are in electronic media, or pictures B. Presence of one or more of the following intrusion symptoms associated with the traumatic events, beginning after the traumatic event. 1. Recurrent, involuntary, and intrusive distressing memories Note: memories may not necessarily appear distressing and may be expressed as play reenactment. 2. Recurrent distressing dreams (Note: it may not be possible to ascertain that the content is related to the traumatic event). 3. Dissociative reactions(flashbacks) with the most extreme expression being a complete loss of awareness of present surroundings). Such trauma re-enactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to reminders of the traumatic event(s). 70

75 Posttraumatic Stress Disorder for Children 6 Years and Younger C. One or more of the following symptoms representing 1) persistent avoidance of stimuli associated or 2)negative alterations in cognitions and mood after the events: Persistent Avoidance of Stimuli 1. Avoidance or efforts to avoid activities, places, or physical reminders of activities, places or physical reminders, that arouse recollections of the traumatic event. 2. Avoidance of or efforts to stimuli that arouse recollections of the traumatic event Negative Alterations in Cognitions 3. Increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame or confusion. 4. Markedly diminished interest or participation in significant activities, including constriction of play. 5. Socially withdrawn behavior. 6. Persistent reduction in expression of positive emotions. Posttraumatic Stress Disorder for Children 6 Years and Younger D. Alterations in arousal and reactivity associated with the traumatic event (that began or worsened after the traumatic event), as evidenced by 2 or more of the following: 1. Irritable behavior and angry outbursts with no provocation, 2. Hypervigilance 3. Exaggerated startle response 4. Problems with concentration 5. Sleep Disturbance E. Duration of the disturbance is more than one month. F. The disturbance causes clinically significant distress or impairment in relationships G. The disturbance is not attributable to effects of substances. Specify Whether: With Dissociative Symptoms Specify if: With Delayed Expression if full criteria are not met until at least six months after the event (though some symptoms may be immediate) 71

76 Generalized Anxiety Disorder (F41.1)Generalized Anxiety Disorder Essentially unchanged from DSM-IV-TR other than cleaning up some of the language Note: In children only one symptom is required for diagnosis Social Anxiety Disorder (Social Phobia) (F40.10) Social Anxiety Disorder (Social Phobia) (paraphrased) In general, criteria are combined or separated in more meaningful ways with some subtlety of language. A. Marked fear or anxiety about social situations where person is exposed to scrutiny from unfamiliar people. B. Fears that he or she will act in a way that will be negatively evaluated C. The social situations consistently provoke fear or anxiety (In children, may be expressed through crying, tantrums, freezing, clinging, or refusal to speak. D. The social situations are avoided or endured with intense fear or anxiety E. The fear or anxiety is out of proportion to the actual danger F. The duration is at least six months G. The fear, anxiety, and avoidance cause impairment in social, occupational, or other important areas of functioning Specify if: Performance Only fear is restricted to speaking or performing in public 72

77 Obsessive Compulsive Disorder (F42) Obsessive Compulsive Disorder Essentially as in DSM-IV-TR, with wording changes and the removal of the need for recognition that obsessions or compulsions are excessive New Specifiers Specify if: with good or fair insight recognizes that the beliefs are definitely or probably not true, or may or may not be true with poor insight thinks beliefs are probably true with absent insight/delusional beliefs convinced that obsessive-compulsive beliefs are true Specify if: Tic-Related current or past history of a Tic Disorder DSM-5 Diagnostic Criteria for Major Depressive Disorder (Summary) For period of 2 weeks five or more are present 1. depressed mood most of day (children can be irritable) 2. loss of interest in pleasurable activities 3. 5% weight gain or loss, or decrease/increase in appetite 4. insomnia or hypersomnia 5. psychomotor agitation or retardation 6. fatigue or loss of energy 7. feelings of worthlessness or excessive guilt 8. problems thinking or concentrating 9. recurrent thoughts of death, suicide attempts, or suicide plan

78 Major Depressive Disorder No substantial changes to criteria are proposed other than the omission of the Bereavement Exclusion and a specifier of Mixed Features Major Depression Episode must have at least three manic/hypomanic symptoms (two weeks) Manic or Hypomanic Episode must have at least three depressive symptoms in Manic Episode or four depressive symptoms in Hypomanic Episode (one week) Major Depressive Disorder Bereavement Exclusion - Criterion E under DSM-IV is eliminated Exclusion implied that grief protects individuals from Major Depression for 2 months In grief, painful feelings come in waves, and interspersed positive feelings, in depression feelings are constant and negative In grief, self-esteem is preserved, in MDD corrosive feelings of self-loathing and worthlessness MDD should not be diagnosed in the context of bereavement, since it would label a normal process as pathological When grief and MDD co-exist, grief is more severe and prolonged Misconception that grief symptoms are identical to those of MDD Suicidal ideation and wanting to join a deceased loved one are conceptually distinct. 74

79 DSM-5 Diagnostic Criteria for Manic Episode (Summary) The presence of a distinct period of abnormally and persistently elevated, expansive or irritable mood for a period of 1 week. Three or more of following are present 1. inflated self esteem or grandiosity 2. decreased need for sleep 3. excessively talkative or pressured speech 4. flight of ideas, racing thoughts 5. extreme distractibility 6. increased goal directed activity; psychomotor agitation 7. excessive involvement in pleasurable activities that have potential for painful consequences Severe disruption in functioning typically requiring hospitalization 149 DSM5 Manic Episode Minor changes Inclusion of language to reflect increased energy/ activity is a core symptom of a manic episode Added language to reflect lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). Added language in B to reflect and represent a noticeable change from usual behavior. Delete the word pleasurable in #

80 DSM-5 Diagnostic Criteria for Hypomanic Episode (Summary) The presence of a distinct period of abnormally and persistently elevated, expansive or irritable mood for a period of at least four days. Three or more of following are present Atypical mood lasting 4 days 1. inflated self esteem or grandiosity 2. decreased need for sleep 3. excessively talkative or pressured speech 4. flight of ideas; racing thoughts 5. extreme distractibility 6. increased goal directed activity; psychomotor agitation 7. excessive involvement in pleasurable activities Not sufficiently severe to cause marked impairment in functioning or to necessitate hospitalization 151 DSM5 Hypomanic Episode Minor changes are enacted Inclusion of language to reflect increased energy/ activity is a core symptom of a manic episode Added language to reflect lasting at least 4 days and present most of the day, nearly every day (or any duration if hospitalization is necessary). Added language to reflect and represent a noticeable change from usual behavior. Delete the word pleasurable in #7. If psychotic features are present it is a manic episode and not hypomanic

81 Module VII: Case Studies 7-11 and Questions and Answers CASE STUDY # 7 Laura Lemon Laura, age 9 was brought to the clinic for excessive shyness, difficulty going to sleep, and an inability to be alone in the house. In addition, she had begun to brood that the family dog might get sick and die. She looked very sad and her affect was generally very flat. Her mother had just returned home following three months of psychiatric hospitalization for severe depression. The mother s illness had followed her husband separation from the family in order to live with a younger woman whom he intends to marry. Laura had been reluctant to attend school when in kindergarten and first grade, but the school had handled this by setting limits about school attendance. At home, she often attempted to sleep in her parents bed. In the past two years, the problems had worsened considerably. Frequently, Laura would fake illness on school days, and she had begun to do poorly academically. Recent testing had revealed reading difficulties that were thought to be long-standing, and tutoring had been initiated. This academic year she was repeating third grade. Laura has taken this poorly and has no friends in her current class. During the interview, Laura spoke with reluctance and appeared sad. She seemed preoccupied with her dog, named Mandy, and feared that the dog might fall ill. When asked directly, she said she did not sleep well unless she was in the same bed as her mother. Although she admitted that she could not stay in her house alone for even 10 minutes, she claimed this was almost never a problem as long as her older sister, a neighbor, or a baby sitter was with her, which was almost all the time. She admitted she wanted to have more friends but was reluctant to spend much time in their houses except for a girl who lived next door, from whose house she could see her own house. 77

82 Primary Symptoms/Dysfunctions Differential Diagnoses to be Considered Diagnosis: CASE STUDY # 8 Paula Pear Paula is a four-year-old female who currently lives in a foster home. She had been in foster care on several prior occasions as a result of physical and emotional abuse. Recently she had been reunited with her biological mother and her father, who had been diagnosed as a paranoid schizophrenic. Four months ago, she witnessed her father shoot her mother and then threaten to kill Paula before finally turning the gun on himself and making her watch as he pulled the trigger. Since that time she has had repeated nightmares where she re-experiences the evening again. She repeatedly talks about the experience and seems unable to talk about other subjects. Her father s brother has made inquiries about adopting her, however, whenever he visits she cries continually. When her uncle visits she claims that her name is Angel and that God is watching over her. Her uncle is threatening to make her live with them and has hired an attorney to fight the State for custody. She refuses to go back to her hometown even for short visit with her former classmates and neighbors. Paula has become increasingly irritable, has difficulty falling asleep, and has difficulty concentrating in school. She has become excessively afraid of blood and has been known to pass out at school if one of her classmates is injured in a minor fashion. At school she does not participate in class and tends to isolate herself on the playground. She refuses to be left alone in a room, and follows her foster mother from room to room. 78

83 Primary Symptoms/Dysfunctions Differential Diagnoses to be Considered Diagnosis: CASE STUDY # 9 Adam Apple Adam is a well-groomed 16-year-old male whose hands are badly chapped and the color of dusty bricks. He states that, whenever I go to the bathroom I get this feeling that there could be some semen on my hands and it might get some girl pregnant even if I only shook hands with her. I get this urge to wash my hands, but then after I have washed them I m afraid to turn off the water because I touched the handle with my dirty hands. At times I am afraid to come out of the bathroom because I may have touched the door, on my way in and it may have semen on it. Adam was extremely bright and a good student, however, recently his grades had been slipping. Adam attributed this to his hand washing rituals. Whenever he thought he might have accidentally contaminated his hands with semen, by masturbating, he felt compelled to scrub them thoroughly. A year earlier, this had only meant three or four minutes with a bar of soap and water as hot as hot as he could stand it. Now he carries surgical soap with him and may wash for 15 minutes at a time. I know it seems crazy, but if I don t wash, the pressure just won t let up and builds until I have to wash them. Washing is the only thing that relieves the pressure. Adam denied being depressed, although he was visibly saddened and upset about his behavior. He reported that when he thinks about girls and sex he starts tapping his fingers and makes a clucking sound in the back of his throat. His friends have been ridiculing him for it. The one girl who was interested in him now wants nothing to do with him. He can t explain why he has to cluck and I just can t help myself. His sleep and appetite had been normal; he denies hallucinations or delusions; and he did not felt guilty or suicidal. He did acknowledge that his father was a minister, and it would absolutely kill him if he got a girl pregnant, even by accident. 79

84 Primary Symptoms/Dysfunctions Differential Diagnoses to be Considered Diagnosis: CASE STUDY # 10 Rick Rhubarb For the past three months, nine-year-old Rick has expressed fearfulness about attending an after school program. In spite of being an excellent student, he becomes upset at the prospect of spending time in after school care. He reports a mixture of worries about failure and complains of stomachaches and headaches. Primarily, he feels sad, and for the past few weeks he has been unable to enjoy his usual school activities. Going to sleep is problematic also, because he is worried about doing poorly in school and he is frequently awakened several times during the night. At the same time, his school performance has begun to decline, because of missing school and difficulty in concentrating. He has become very blue and on several occasions he has burst into tears for no apparent reason. He has lost 10 pounds in the last month. His mother has had three Major Depressive Episodes. During their 20 years of marriage, his parents have had continuing marital problems. Rick and his two brothers have often been at the center of their disputes. Although shy, he is a likable child and has always been a good student. In the past, he has attended summer camp, and, though he was somewhat home sick, he seemed to enjoy the activities. He has stayed overnight several times with friends who live nearby, but does appear to be somewhat tied to his mother. During the interview, Rick suddenly began to sob and said that he felt terrible all the time. He said that at times he felt he would be better off if he were dead. Although he denied any specific suicidal plan, he indicated that he just didn t want to wake-up in the morning. He feels guilty that he is a problem to his parents and feels responsible for many of their marital difficulties. 80

85 Primary Symptoms/Dysfunctions Differential Diagnoses to be Considered Diagnosis: Case Study #11 Charles Cabbage Charles, a 14 year old whose parents had been divorced since he was 8, was evaluated because in the past two months he had been breaking a variety of school rules. He had consistently been getting into fights with other children, which was quite unlike his previous behavior. He was recently arrested for shoplifting. His mother says that he has gone totally crazy. This appeared to start after his return from summer vacation. Charles had been in California with his father for the summer. All the previous summers had been very enjoyable for Charles who was eager to spend time with his father. This year he was introduced to his father s live-in girlfriend, who the father plans to marry. Charles felt that she monopolized his father s time. She arranged Charles schedule in California to be a series of day camps, so that she had more time with his father alone. Charles was angry with his father and I hate the witch. Charles mother was also upset because his father was trying to reduce child support in connection with his upcoming marriage. When interviewed, Charles was friendly towards the examiner, but brash in criticizing the school and pointing out what dopes his friends were. His boast of being a bad ass is out of proportion to any of his offenses. Since being back home he is openly defiant with his mother, has left the house without permission, and brought drug paraphernalia into the house that he was keeping for a friend. His mother states that he has become a person she doesn t recognize any more and is investigating boarding schools. Psychological testing indicates normal intelligence, but reading is approximately three years below grade level. Charles had always had difficulty with reading and is in a special reading program for junior high school. 81

86 Primary Symptoms/Dysfunctions Differential Diagnoses to be Considered Diagnosis: Evaluation Complete evaluation form at end of manual Seminar # Place Evaluations in box on front desk Certificates available in hallway 82

87 Bibliography A American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition. Washington, D.C. American Psychiatric Association (2013). Apa corrects New York Times article. American Psychiatric Association (2013). DSM5 recent changes. American Psychiatric Association (2013). Update: dsm5 major changes. Psychcentral.com/bolg/archives. American Psychiatric Association (2013). Highlights of changes from the DSM-IV to DSM5. American Psychiatric Association (2013). Insurance implications of DSM5. American Psychiatric Association (2013). Attention deficit/htperactivity disorder. American Psychiatric Association (2013). Social (pragmatic) communication disorder. American Psychiatric Association (2013). Intellectual disability. American Psychiatric Association (2013). Specific learning disorder American Psychiatric Association (2013). Autism spectrum disorder. American Psychiatric Association (2013). Making a case for new disorders. American Psychiatric Association (2013). Mixed features specifier. Bibliography American Psychiatric Association (2013). Schizophrenia. American Psychiatric Association (2013). Obsessive compulsive and related disorders. American Psychiatric Association (2013). Major depressive disorder and the bereavement exclusion. American Psychiatric Association (2013). Feeding and eating disorder. American Psychiatric Association (2013). Posttraumatic stress disorder. American Psychiatric Association (2013). Somatic symptoms disorder American Psychiatric Association (2013). Conduct disorder Kendler, K.S. (2010) Misconceptions about a proposal to eliminate the grief exclusion. Moran, M. (2013). DSM-5 provides new take on neurodevelopmental disorders. Psychiatric News, 48,2,6-23. Moran, M. (2013). DSM-5 fine-tunes diagnostic criteria for psychosis, bipolar disorders. Psychiatric News, 48 (3), Moran, M. (2013). DSM-5 updates depressive, anxiety, and ocd criteria. Psychiatric News, 48 (4), Moran, M. (2013). Eating, sleep disorder criteria revised in DSM-5. Psychiatric News, 48 (6),

88 Bibliography Moran, M. (2013). New gender dysphoria criteria replace GID. Psychiatric News, 48 (7), Moran, M. (2013). New DSM chapter to focus on disorders of self-control. Psychiatric News, 48 (7),

89 Cross Country Education complies with all rules and regulations set forth by the boards/associations to offer continuing education. It is imperative that you complete your evaluation so that proper reporting can be done. Instructions for Completing your Scan Evaluation Form 1. Use a No. 2 pencil or a blue or black ink pen only. 2. DO NOT bend or fold your Scan Evaluation Form. 3. Please make solid marks that fill the response completely without any stray marks. 4. Complete your first and last name in ALL CAPS (if you do not have enough space for you full name, simply use all boxes that are available.) 5. Write in your registration number in the appropriate box. 6. Mark your profession. 7. Fill in license number. 8. Clearly mark all boxes appropriately. 9. Complete the back page of the evaluation; your Seminar Evaluation Objectives are on the following page for you. 10. Return your completed Scan Evaluation form back to the instructor.

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