Using DSM-5: A Brief Summary. Handout Packet # 1

Transcription

1 Using DSM-5: A Brief Summary Handout Packet # 1 Carlton Munson, PhD Professor University of Maryland Baltimore School of Social Work 8/16/2013 Copyright 2013 Dr. Carlton Munson 1

2 Disclaimer DSM and DSM 5 are registered trademarks of the American Psychiatric Association (APA). The APA is not affiliated with this training and does not endorses this seminar or its content. Material under APA Copyright in this presentation is used according to U.S. Copyright Office regulations regarding fair use (sections 107 through 118 of the copyright law (title 17, U. S. Code. Permission is NOT granted to participants in this training to copy and distribute the paper copy handouts used in the presentation. For further information about APA and the DSM-5 visit the official APA DSM-5 website at 8/16/2013 Copyright 2013 Dr. Carlton Munson 2

3 Name will officially be DSM-5 Not DSM-V Donald Black & Jon Grant DSM-5 Collection August September 2013 John Barnhill Laura Weiss Roberts & Alan K. Louie Michael First Philip Muskin 8/16/2013 Pages Copyright missing 2013 apparent Dr. Carlton rush Munson to publication without thorough proof reading

4 DSM-5: Online DSM-5 ON-LINE AVAILABLE FALL September 2013 There will be an on-line DSM-5 DSM-IV-TR version was $490 annually DSM-5 version $420 annually There will be price restructuring related to the product options This resource can be helpful for students and others adjusting to the DSM-5 changes 8/16/2013 Copyright 2013 Dr. Carlton Munson 4

5 Licensing Exam Conversion to DSM-5 Social Work LCSW Exam Does not apply to this exam no questions on DSM there are questions on assessment LCSW-C Examination January 2015 NOTE: In Maryland in October 2013 LGSWs can diagnose when under supervision of LCSW-C Psychologists Conversion August 2014 CPC, CPC-MFT, CAC-AD, & CSC-AD No information posted at the ACA or MD BOPC website 8/16/2013 Copyright 2013 Dr. Carlton Munson 5

6 Changes in Social Work Licensing Statute OCTOBER 1, 2013 CHANGES IN THE SOCIAL WORK STATUTE Definitions Section Deleted from the general definition of social work practice: FORMULATING DIAGNOSTIC IMPRESSIONS Added to the definition of graduate and certified social work: FORMULATING A DIAGNOSIS, UNDER THE DIRECT SUPERVISION OF A LICENSED CERTIFIED SOCIAL WORKER-CLINICAL Treatment of BIOPSYCHOSOCIAL CONDITIONS TREATMENT OF mental disorders... Added to the definition of clinical social work: PETITIONING FOR EMERGENCY EVALUATIONS UNDER TITLE 10, SUBTITLE 6 OF THE HEALTH- GENERAL ARTICLE Scope of license A licensed Bachelor social worker may not ENGAGE IN PRIVATE PRACTICE Changed A licensed Graduate social worker may not diagnose a mental disorder WITHOUT THE DIRECT SUPERVISION OF A LICENSED CERTIFIED SOCIAL WORKER- CLINICAL A licensed Graduate social worker may not ENGAGE IN PRIVATE PRACTICE WITHOUT THE DIRECT SUPERVISION OF A LICENSED CERTIFIED SOCIAL WORKER-CLINICAL A licensed Certified social worker may not diagnose a mental disorder WITHOUT THE DIRECT SUPERVISION OF A LICENSED CERTIFIED SOCIAL WORKER- CLINICAL 8/16/2013 Copyright 2013 Dr. Carlton Munson 6

7 SLIDE KEY Some material in this presentation is keyed to color and symbols Text in blue indicates a change for DSM-5 Green indicates my interpretation or a relevant study or information This symbol represents a change with questionable rationale or outcome (i.e., no empirical basis) This symbol indicates disorder or section new to DSM-5 Indicates a reading assignment slide Most slides have DSM-5 page references and participants who have DSMs can follow the presentation of the new material and make notes in the manual Some slides in the presentation are not in the handouts due to copyright restrictions 8/16/2013 Copyright 2013 Dr. Carlton Munson 7

8 ,000+ DSM History Diagnostic Inflation? Coding: Categories-Disorders-Pages

9 Research Domain Criteria RDoC Thomas Insel on March 06, Most genes associated with risk for schizophrenia also contribute to risk for bipolar disorder and autism. -RDoC primary focus is neural circuits. Accumulating findings on neural circuitry that generates behavior is making it possible to use this approach. -Genes cut across current diagnostic labels and neuroimaging often helps sub-divide current groups. -By studying patterns of brain activity either at rest or with activation the brain tell us different forms of mood, anxiety, or psychotic disorders. -This is the diagnostic approach in neurology, where imaging is used routinely for localizing lesions, rather than relying exclusively on motor or sensory changes. -Current systems see disorders as present or absent. RDoC approach is dimensional- RDoC incorporates magnitude or severity measures, analogous to tests of blood pressure or cholesterol. -RDoC will develop administered tests of dimensional information in reliable and valid ways. -RDoC framework is a heuristic to facilitate incorporation of behavioral neuroscience in the study of psychopathology. 8/16/2013 Copyright 2013 Dr. Carlton Munson 9

10 Mental Illness Context -In US 50% will have lifetime incidence of a mental disorder % met criteria for a mental disorder during any 12-month period -78% of cases are mild to moderate severity -22% have significant impairment severity -75% of all lifetime disorders have onset by age 24 -Conclusion: Interventions should be aimed at young people, but mental illness increasing in the elderly 8/16/2013 Copyright 2013 Dr. Carlton Munson 10

11 My General Principles of DSM-5 Diagnostic Criteria Clinical Relevance Is it necessary or appropriate to assign a DSM-5 diagnosis? (E.g., Avoidant PD) Clinical Significance Are symptoms/behaviors/problems at a level that warrants a DSM-5 diagnosis? E.g., (PTSD diagnosis) Clinical Judgment Among competing or cross-cutting symptoms what diagnosis (es) appropriate? (E.g., MDD and/or Anx. Disorder) 8/16/

12 DSM-5: Definition of a Mental Disorder See p. 20 for details DSM-5: A mental disorder is a syndrome characterized by clinically significant disturbance in an individual s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e. g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from the dysfunction in the individual, as described above. 8/16/2013 Copyright 2013 Dr. Carlton Munson 12

13 Where have all the flowers gone? First and foremost, where has the multiaxial format gone? AXIS I Axis II AXIS III Combined and presented in vaguely defined narrative format Continue to list code, diagnosis and medical Conditions Axis IV Primary Support group Social Environment Educational Problem Occupational Problems Housing Economic Problems Access to healthcare Problems with the legal system Other P/S Problems Sent to Other Conditions That May Be a Focus of Clinical Attention section Listed as Notations Axis V Converted to severity Measures in individual disorders 3 Basic Types of Specifiers Specify if: With anxious distress Specify current severity mild, moderate, severe Specify whether: (F90 0.2) Combined presentation: 8/16/ :19:43 AM Copyright 2013 Dr. Carlton Munson 13

14 P. 16 Nonaxial Assessment Diagnosis Good news! It provides latitude 2 Psychosocia l factors now notations 3 Axis 5 now disability Meaning severity 4 Medical Conditions I now report Dx. formulation categories of: 1. Diagnosis 2. Notations 3. Disability Severity 4. Medical conditions

15 DSM-5 Classification -AKA Table of Contents -Codes & page #s for 20 Categories of disorders Preface Section I DSM-5 Basics -Introduction -Use of the Manual -...Forensic Use of DSM-5 Section II -Diagnostic Criteria and Codes -HEART OF THE MANUAL Note: This information In a different format in handout DSM-5:Sections Section III What is in side DSM-5? Emerging Measures and Models -Assessment Measures -Cross-Cutting Symptom Measures -Clinician-Rated...Psychosis...Severity -Cultural Formulation -Alternative...Model...for personality -Conditions for further Study Appendices -Highlights of Changes -Glossary of Technical Term -Glossary of Cultural concepts of Distress -Alphabetic Listings of Diagnoses/Codes -Numeric Listing of Codes (ICD-9-CM) -Numeric Listing of Codes (ICD-10-CM) -DSM-5 Advisors & Contributors -Index 8/16/2013 Copyright 2013 Dr. Carlton Munson 15

16 DSM-5 Organizational Changes: Section II: Essential Elements: Diagnostic Criteria and Codes Neurodevelopmental disorders Schizophrenia spectrum and other psychotic disorders Bipolar and related disorders Depressive disorders Anxiety disorders Obsessive-compulsive and related disorders Trauma- and stressor-related disorders. Dissociative disorders Somatic symptom and related disorders Feeding and eating disorders Elimination disorders Sleep-wake disorders. Breathing-related sleep disorders. Parasomnias Sexual dysfunctions Gender dysphoria Disruptive, impulse-control, and conduct disorders Substance related and addictive disorders Neurocognitive disorders Personality disorders Paraphilic disorders Other mental disorders Notice Grouping Ends with Begins with Medication-Induced Movement Disorders and Other Adverse Effects of Medication Z and V Codes Reordering is sequential to reflect attenuated (weak) effort to suggest dimensional approach to entire manual based on childhood features, adult disorders, and the 5-Factor Model originally proposed in 2 books published by APA 8/16/2013 Copyright 2013 Dr. Carlton Munson 16

17 DSM-5 Organizational Changes: Section III: Emerging Measures and Models Assessment Measures Cross-cutting measures, Level 1 and Level 2 AREA TO WATCH FOR EBP Some used in clinical field trials. I will explain them if you want me to Cultural Formulation Cultural Formulation Interview (CFI) Separate formats for client and informant Replaces Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes Alternative DSM-5 Model for Personality Disorders Conditions for Further Study Attenuated Psychosis Syndrome Depressive Episodes With Short-Duration Hypomania Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Neurobehavioral Disorder Due to Prenatal Alcohol Exposure (ND-PAE) Suicidal Behavior Disorder Nonsuicidal Self-Injury All Section 3 items new to DSM-5 I recommend you ignore and not use this section of DSM-5 8/16/2013 Copyright 2013 Dr. Carlton Munson 17

18 DSM-5 Section: Appendix and Index [pp ] Highlights of changes from DSM-IV to DSM-5 (p. 809) Glossary of technical terms (75 terms in DSM-IV 183 in DSM-5) [p. 817] Glossary of cultural concepts of distress (25 in DSM-IV 9 in DSM-5) [p. 833] Alphabetical listing of DSM-5 diagnoses and codes(icd-9-cm) and ICD-10-CM) Numerical Listing of DSM-5 diagnoses and codes (ICD-9-CM) [p.863] Numerical listing of DSM-5 diagnoses and codes (ICD-10-CM) [p.877] DSM-5 advisors and other contributors [p , See p. 915) Index [p ] Index much improved. You will need to use It to master the changes I worked hard for that small recognition In MH Hx!!! 8/16/2013 Copyright 2013 Dr. Carlton Munson 18

19 Where have all the flowers gone? Where have all disorders gone? OUT ICA Disorders R/O Rule out By Prior History Asperger's Disorder RELD Schizophrenia Subtypes Substance Abuse IN Global evelopmental Delay DMDD Hoarding Disorder Excoriation DSED PTSD CHILD Criteria Binge Eating Disorder PDD DMDD = Disruptive Mood Dysregulation Disorder DSED = Disinhibited social engagement disorder PDD = Premenstrual Dysphoric Disorder 8/16/ :19:43 AM Copyright 2003 Dr. Carlton Munson 19

20 NOTE: In this slide persistent depressive disorder in depressive disorders classification used as an example. Go to the pages indicated as each icon is explained Brief Introduction Text DSM Fundamental core Diagnostic Criteria Summary See following slide p Diagnostic Criteria Organization for the 20 Categories of Disorders Detailed Descriptive Text See following slide p Other Specified Disorders p Disorder capitalization eliminated -Text section titles right justified -Number of text sections vary for some disorders Unspecified Disorders Essentially Replace NOS p /16/2013 p. 155 Copyright 2013 Dr. Carlton Munson Some redundancy In the sections 20

21 Text Accompanying Each DSM-5 Disorder Diagnostic Criteria Diagnostic Features Associated Features Supporting Diagnosis Prevalence Development And Course Risk And Prognosis Factors Culture-Related Diagnostic Issues Gender-related Diagnostic Issues Diagnostic Markers Functional Consequences Of... Differential Diagnosis Comorbidity Note: Diagnostic Criteria are At the beginning of the text and not at the end as in DSM-I 8/16/2013 Copyright 2013 Dr. Carlton Munson 21

22 Orienting to the DSM-5 Read the Sections Below in the Order Recommended Experienced Users Review Table of Contents Read Use of the Manual (pp ) Review Highlights of Changes From DSM-IV to DSM- 5 (pp ) Review Other Conditions That May be a Focus of Clinical Attention (pp ) Review DSM-5 Classification (pp. xiii-xi) Review the diagnostic criteria and text for disorders you use most Review Cultural Formulation (pp & Glossary of Cultural Concepts of Distress (pp ) Review Glossary of Technical Terms (pp ) Review Assessment Measures (pp ) Beginning Users Review Table of Contents Read Use of the Manual (pp ) Review DSM-5 Classification (pp. xiii-xi) Review diagnostic criteria and text for disorders that you plan to use the most Review closely Glossary of Technical Terms (pp ) Read in detail the text section of the disorders you begin to use Review Other Conditions That May be a Focus of Clinical Attention (pp ) Review Cultural Formulation (pp & Glossary of Cultural Concepts of Distress (pp ) Review Assessment Measures (pp ) 8/16/2013 Copyright 2013 Dr. Carlton Munson 22

23 Persistent Depressive Disorder pp This disorder is consolidation of DSM-IV chronic major depressive disorder and dysthymic disorder. A. Depressed mood for most of the day, for more days than not, as indicated by subjective account or observation by others, for at least 2 years B. Presence, while depressed, of 2 or more of the following: 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness. C. During a 2-year period (1year for children /adolescents), individual has never been without the symptoms in criterion A and B for more than 2 months at a time. D. Criteria for a major depressive disorder may be continuously present for 2 years E. There has never been a manic episode, hypomanic episode, or criteria met for cyclothymic disorder F. Disturbance not better explained by a persistent schizoaffective and disorder, schizophrenia, etc. G. The symptoms are not attributable to physiological effects of a substance H. Symptoms cause clinically significant distress Specify if: With anxious distress With mixed features With melancholic features With atypical features With pericardium onset With mood congruent psychotic features With mood incongruent psychotic features Specify if: In partial remission In full remission Specify if Early Onset Late onset Specify If: With pure dysthymic syndrome With persistent major depressive episode With intermittent major depressive episodes with current episode With intermittent major depressive episodes, without current episode Specify if current severity: Mild (p. 188) Moderate (p. 188) Severe (p. 188) Persistent Depressive Disorder (F34.1) Refers to separate section of depressive disorders, Specifiers for Depressive Disorders, that details specifiers for this class od disorders

24 How to Record DSM-5 Dx. A Holiday Dx. DSM-5 Code Record disorder or condition major depressive disorder, recurrent episode, severe, with seasonal pattern Course Specifier Course Specifier Specifier 8/16/2013 Copyright 2013 Dr. Carlton Munson 24

25 ...strong presumption full criteria will ultimately be met for a disorder, but not enough information available to make a firm diagnosis......clinician can indicate diagnostic uncertainty by recording (provisional) following the diagnosis... Provisional Diagnosis (p. 23) Diagnosis Schizophreniform, With good prognostic features, mild (provisional) Phencyclidine use disorder, severe Notations V62.29 Other problem related to employment V15.59 Personal history of self harm Medical Conditions No reported medical problems see p. 726 Schizophreniform Disorder (F20.81) 2+ present sig. portion of time for 1+m of at least 1 must be 1, 2, or 3: 1. Delusions See. pp Hallucinations, 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms B. Episode 1-m but less than 6m C. Not other psychotic disorder D. Not due to substance or other medical condition see p /16/2013 Copyright 2013 Dr. Carlton Munson 26

26 ...strong presumption full criteria will ultimately be met for a disorder, but not enough information available to make a firm diagnosis......clinician can indicate diagnostic uncertainty by recording (provisional) following the diagnosis... Provisional Diagnosis (p. 23) Diagnosis Schizophreniform, With good prognostic features, mild (provisional) Phencyclidine use disorder, severe Notations V62.29 Other problem related to employment V15.59 Personal history of self harm Medical Conditions No reported medical problems see p. 726 Schizophreniform Disorder (F20.81) 2+ present sig. portion of time for 1+m of at least 1 must be 1, 2, or 3: 1. Delusions See. pp Hallucinations, 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms B. Episode 1-m but less than 6m C. Not other psychotic disorder D. Not due to substance or other medical condition see p /16/2013 Copyright 2013 Dr. Carlton Munson 27

27 DSM-5 Cultural Formulation and Concepts of Distress Cultural Formulation pp Outline for Cultural Formulation -Cultural identity of the individual -Cultural conceptualization of distress -Psychosocial stressors & cultural features of vulnerability & resilience -Cultural features of relationship of individual & clinician -Overall cultural assessment Cultural Formulation Interview (CFI) -16 questions may use about impact of culture in areas of: -perceptions of cause, context, support -Self-coping & past help seeking -Current help seeking -Supplement modules: -Used with other received information -Used in entirety or selective -Client and informant versions Glossary of Cultural Concepts of Distress pp Blue text indicates new to DSM-5 Ataque de nervios Dhat syndrome Khyal cap Kufugisisa Maladi noun Nervios Shenjing Shuairuo Susto Taijin Kyofusho 8/16/2013 Copyright 2013 Dr. Carlton Munson 28

28 Neurodevelopmental Disorders Intellectual Disabilities Intellectual Disability (Intellectual Developmental Disorder) Global Developmental Delay Unspecified Intellectual Disability (Intellectual Developmental Disorder) Communication Disorders Language Disorder Speech Sound Disorder (previously Phonological Disorder) Childhood Onset Fluency Disorder (Stuttering) Social (Pragmatic) Communication Disorder Unspecified Communication Disorder Autism Spectrum Disorder Autism Spectrum Disorder Attention-Deficit/Hyperactivity Disorder Attention-Deficit/Hyperactivity Disorder Other Specified Attention-Deficit/Hyperactivity Disorder Unspecified Attention-Deficit/Hyperactivity Disorder Specific Learning Disorder Specific Learning Disorder Motor Disorders Developmental Coordination Disorder Stereotypic Movement Disorder Tic Disorders Tourette s Disorder Persistent (Chronic) Motor or Vocal Tic Disorder Provisional Tic Disorder Other Specified Tic Disorder Unspecified Specified Tic Disorder Other Neurodevelopmental Disorders Other Specified Neurodevelopmental Disorder Unspecified Neurodevelopmental Disorder 8/16/2013 Copyright 2013 Dr. Carlton Munson 29

29 Diagnostic Criteria Intellectual Disabilities Intellectual Disability (Intellectual Developmental Disorder) Intellectual disability (intellectual developmental disorder) is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social and practical domains. The following three criteria must be met: A: Deficits in intellectual functioning confirmed by both clinical assessment and intelligence testing. B: Deficits in adaptive functioning with failure to meet developmental & sociocultural standards for personal independence and social responsibility. W/O support adaptive deficits limit functioning in 1 or more areas of: Communication, social participation, & independent living across environments (home, school, work, & Community) * Specify current severity (see Table 1): (F70) Mild (F71) Moderate (F72) Severe (F73) Profound C: Onset of intellectual and adaptive deficits during the developmental period (childhood or adolescence) Coding note: ICD-9-CM code for ID is 319, which is assigned regardless of severity specifier Note the layout difference Specify current severity (see Table 1): Disorder name to far right (F70) Mild Coding is a note and not at the head (F71 )Moderate of the disorder title (F72) Severe This format varies for some disorders (F73) Profound

30 Sample Dx. Necessitated by removal of Prior History specifier (diagnosis) DSM-IV, p. 2 DIAGNOSIS Koma Smith reportedly has had two episodes of mental health treatment and mental health diagnosis in the past. Koma cannot remember the Dx. received and cannot remember the physician s name or the hospital name. Based on the clinical interview, scales administered and collateral information, the following diagnoses were made as part of this assessment: 317, Intellectual developmental disorder, Moderate V61.8 high expressed emotion level within family V15.41 Personal history (past history) of spouse violence, Physical V61.20 Parent-child relational problem V60.1 Inadequate housing V60.2 Low income 8/16/2013 Copyright 2013 Dr. Carlton Munson 31

31 Another Sample DSM-5 Diagnosis Based on my evaluation the following is my DSM-5 diagnostic formulation: Diagnoses -317 Intellectual Disability (Intellectual Developmental disability), Mild Notations -V61.20 Parent-Child Relational Problem -Unspecified Bipolar Disorder by prior diagnosis that may be controlled with medication PTSD by prior diagnosis current symptom level not clear due to client guarded reporting Disability Severity -This woman s diagnoses are of a magnitude that impairs ability to parent children Medical Conditions -Patient reported only medical condition as asthma

32 Neurodevelopmental Disorders Global Developmental Delay (F88)...Reserved for individuals under age 5 years when clinical severity level cannot be assessed during early childhood.dx. when individual fails to meet expected developmental milestones in several areas of intellectual functioning, and child is not able to undergo standardized testing. Requires periodic reassessment Unspecified Intellectual Disability (Intellectual Developmental disorder) 319 (F79)...Reserved for individuals over age 5 when assessment of ID (IDD) by locally available procedures or difficult or impossible due to sensory or physical impairments, as in blindness or pre-lingual deafness; locomotor disability; or presence of severe problem behaviors or co-occurring mental disorder. Used only in exceptional circumstances. Requires periodic reassessment

33 Other Neurodevelopmental Disorders Global Developmental Delay (F88)...Reserved for individuals under age 5 years when clinical severity level cannot be assessed during early childhood.dx. when individual fails to meet expected developmental milestones in several areas of intellectual functioning, and child is not able to undergo standardized testing. Requires periodic reassessment Note change. Coding is under disorder heading Unspecified Intellectual Disability (Intellectual Developmental disorder) 319 (F79)...Reserved for individuals over age 5 when assessment of ID (IDD) by locally available procedures or difficult or impossible due to sensory or physical impairments, as in blindness or pre-lingual deafness; locomotor disability; or presence of severe problem behaviors or co-occurring mental disorder. Used only in exceptional circumstances. Requires periodic reassessment

34 Intellectual Disability (Intellectual Developmental Disorder) was Mental Retardation in DSM-IV ca: Deficits in reasoning, problem-solving, planning, abstract thinking, judgment, academic & experience learning Confirmed by clinical assessment & standardized testing Severity criteria: 319 Mild (IQ 50-70) 319 Moderate (IQ 35-55) 319 Severe (IQ 20-40) 319 Profound (IQ <25) Note: Borderline Intellectual Functioning in OCTMBFCA p. 727 Generally IQ but not specified in DSM-5 cb: Sig. Limitations in adaptive functioning in 2 skill areas of: Communication / Social participation / independent living at home, school, work, & community cc: Onset during developmental period Measured by Clinical assessment and standardized measures like Vineland ABS & AAIDD ABS

35 Intellectual Disability in Maryland DDA 2 levels of eligibility for funded services 1. Developmental Disability Severe, chronic disability that : Attributable to physical/mental impairment, other than Dx of MI or combo of mental/physical impairment Likely to continue indefinitely Inability to live independently Intellectual Developmental Disorder 2. Support Services Only Eligibility for person with severe, chronic, disability that: Attributable to physical/mental impairment other than sole Dx. of MI, or combo of mental/physical impairment, and Is likely to continue indefinitely Intellectual Disability 8/16/2013 Copyright 2013 Dr. Carlton Munson 36

36 Communication Disorders pp (F80.9) Language Disorder (F80.0) Speech Sound Disorder (F80.81) Childhood-Onset Fluency Disorder Used to Dx. RELDs In DSM-IV (F80.89) Social (Pragmatic) Communication Disorder (F80.9) Unspecified Communication Disorder 8/16/2013 Copyright 2013 Dr. Carlton Munson 37

37 Neurodevelopmental Disorders pp A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive see text): 1. Deficits in social emotional reciprocity 2. Deficits in nonverbal communication behaviors used for social interaction Deficits in developing, maintaining, and understanding relationships... Specify current severity: Autism Spectrum Disorder Severity is based on social communication impairments and restricted, repetitive patterns of behavior (see table 2) (F84.0) DSM-5 allows adult Dx. by noting symptoms may not be apparent until adolescence or adulthood. Severity scale may substantiate need for supportive employment and accommodations in the workplace

38 ASD Continued B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least 2 of the following Stereotyped or repetitive motor movements, use of objects, or speech Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior Highly restricted, fixated interest that are abnormal in intensity or focus 4. Hyper-or hyporactivity to sensory input or unusual interest in sensory aspects of the environment... Specify current severity...(see severity specification in ca above) C. Symptoms must be present in the early developmental period D. symptoms cause clinically significant impairment in social occupational or other important areas of current functioning E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay 8/16/2013 Copyright 2013 Dr. Carlton Munson 39

39 ASD Continued Specify if: With or without accompanying intellectual impairment With or without accompanying language impairment Associated with any known medical or genetic condition or environmental factor (Coding note: Use additional code to identify associated medical or genetic condition.) Associated with another neurodevelopmental, mental, or behavioral disorder (Coding note: Use additional codes to identify the associated neurodevelopmental, mental, or behavioral disorder.) With catatonia (refer to criteria for catatonia associated with another mental disorder, pp for definition (Coding note: Use additional code (F06.1) catatonia associated with autism spectrum disorder to indicate presence of comorbid catatonia 8/16/2013 Copyright 2013 Dr. Carlton Munson 40

40 DSM-5: Severity scale Descriptive of ASD ADLs. 3 point severity level: LEVEL 3 Requiring very substantial support Level 2 Requiring substantial support Level 1 Requiring support Note: Need for support defined separately for social communication deficits and restricted interests and repetitive behaviors An individual may be a Level 3 for social communication, and level 2 for repetitive behaviors which need only a moderate level of support 8/16/2013 Copyright 2013 Dr. Carlton Munson 41

41 DSM-5: Autism Spectrum Disorder Severity of impairment in areas of development: pp Level 1 Reciprocal social interaction skills SLIDER BUTTON Level 2 Reciprocal social interaction skills Level 3 Reciprocal social interaction skills Level 1 Level 2 Level 3 Communication Communication skills skills Level 1 Level 2 Communication skills Level 3 Restricted: Behavior RRBs Interests Activities Restricted: Behavior RRBs Interests Activities Restricted: Behavior RRBs Interests Activities

42 DSM-5: Autism Spectrum Disorder (ASD) Alternative Diagnoses Some who no longer meet criteria for ASD in DSM-5 may meet criteria for other DSM-5 diagnoses, including: Intellectual Disability Communication Disorder Anxiety Disorders, and/or Attention Deficit/Hyperactivity Disorder This position of APA and not this presenter 8/16/2013 Copyright 2013 Dr. Carlton Munson 43

43 Combined DSM-5 ADHD ADHD Criteria Fewer symptoms for adult ADHD. Research: Symptoms< w age, but remain- Adult 5 Sx after age 17 Children 6 Sx Addition of ADHD other & Unspecified Before age 12 Subtypes Become Specifiers 24% increase in ADHD Dx. from 2001 To 2010 Increase from 3% to 10% of population In partial remission added

44 Attention-Deficit /Hyperactivity Disorder: Slide 1 pp Sx. = symptom (s) SOA = Social, academic, occupational Diagnostic Criteria Attention-Deficit /Hyperactivity Disorder A. Persistent Sx. of inattention and /or hyperactivity impulsivity interfering with functioning or development characterized by 1 and/or 2: 1. Inattention: 6+ of following Sx. for 6+ months inconsistent with developmental level and negatively impacts directly SAO activities: Note: Sx. not part of oppositional behavior, defiance, hostility or failure to understand tasks or instructions. For older adolescents and adults (age 17+), 5+ symptoms required. a. Often lacks close attention to details or makes careless mistakes. b. Often has difficulty sustaining attention in tasks or play activities. c. Often does not seem to listen when spoken to directly. d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace. e. Often has difficulty organizing tasks and activities. f. Often avoids, dislikes, reluctant to engage in tasks requiring sustained mental effort. g. Often loses things necessary for tasks or activities. h. Is often easily distracted by extraneous stimuli. i. Is often forgetful in daily activities. 8/16/2013 Copyright 2013 Dr. Carlton Munson 45

45 Attention-Deficit /Hyperactivity Disorder: Slide 2 pp Diagnostic Criteria Attention-Deficit /Hyperactivity Disorder 2. Hyperactivity and impulsivity: 6+ of the following Sx. for 6+ months to a degree inconsistent with the developmental level and negatively impacts SOA activities: a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected. c. Often runs about or climbs in situations where it is inappropriate. (Note: Adolescence or adults, may be limited to feeling restless). d. Is often on the go, acting as if driven by a motor. f. Often talks excessively. g. Often blurts out an answer before a question has been completed. h. Often has difficulty waiting his or her turn. i. Often interrupts or intrudes on others. B. Several inattentive or hyperactive impulsive Sx. present prior to age 12. C. Several inattentive or hyperactive impulsive symptoms present 2+ settings. D. Evidence Sx. Interfere with or reduce quality of SAO functioning. E. Sx. do not occur exclusively during schizophrenia or other psychotic disorder and not better explained by another mental disorder. 8/16/2013 Copyright 2013 Dr. Carlton Munson 46

46 Attention-Deficit /Hyperactivity Disorder: Slide 3 pp Diagnostic Criteria Attention-Deficit /Hyperactivity Disorder Specify whether: (F90 0.2) Combined presentation: If both criteria A1 and criteria A2 are met for past 6 months (F90 0.0) Predominantly inattentive presentation: If criteria A1 is met, but criteria A2 is not met for the past 6 months (F90 0.1) Predominantly hyperactive/impulsive presentation: If criteria A2 is met and A1 is not met for the past 6 months. Specify if: In partial remission: Full criteria were previously met, fewer than full criteria have been met for the past 6 months and Sx. still resulting in impairment in SAO functioning. Specify current severity: Mild: Few, if, any symptoms, present and symptoms resulting in no more than minor impairments in SAO functioning. Moderate: Sx. or functional impairment between mild and severe are present. Severe: Many Sx. in excess of those required to make diagnosis, or several Sx. are particularly severe, are present or the Sx. result in marked impairment in SAO functioning. 8/16/2013 Copyright 2013 Dr. Carlton Munson 47

47 Attention-Deficit /Hyperactivity Disorder: Slide 4 pp Sample diagnoses: Attention-Deficit /Hyperactivity Disorder Attention-Deficit /Hyperactivity Disorder, Combined presentation, moderate Attention-Deficit /Hyperactivity Disorder, Predominantly inattentive presentation, mild, in partial remission Predominantly hyperactive/impulsive presentation, severe Attention-Deficit /Hyperactivity Disorder, Combined presentation, Severe, in partial remission. Also note possible use of: Other Specified Attention-Deficit/hyperactivity Disorder, child has symptoms in one setting, home, but no other settings. (See cc) Unspecified Attention-Deficit/hyperactivity Disorder due to lack of information from the school and parent reluctance to have child medicated. 8/16/2013 Copyright 2013 Dr. Carlton Munson

48 Neurodevelopmental Disorders A. Difficulties Learning and using academic skills, indicated by presence of 1+ of the following symptoms that have persisted for 6 months despite intervention: 1. Inaccurate or slow and effortful word reading Difficulty understanding the meaning of what is read Difficulties with spelling Difficulties with written expression... Specific Learning Disorder 5. Difficulties mastering number sense, number facts, or calculation Difficulty with mathematical reasoning B. Affected academic skills are substantially below those expected for the individual s chronological age C. Learning difficulties begin in during school age years... See DSM-5 for specifier categories (p.67) (F90.9) RECEPTIVE EXPRESSIVE LANGUAGE DISORDER (RELD) 76% OF CHILDREN WHO HAVE EXPERIENCED TRAUMA MEET RELD DX. CRITERIA

49 DSM-5: Motor Disorders & Tic Disorder pp The following motor disorders are included in DSM-5 neurodevelopmental disorders chapter: Motor Disorders Developmental Coordination Disorder Stereotypic Movement Disorder Tic Disorders Tourette s Disorder Persistent (Chronic) Motor Or Vocal Tic Disorder Provisional Tic Disorder Other Specified Tic Disorder Unspecified Tic Disorder. 8/16/2013 Copyright 2013 Dr. Carlton Munson 50

50 DSM-5: Schizophrenia Spectrum and Other Psychotic Disorders Schizotypal Personality Disorder (New Strategy of dual listing) Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizophrenia Schizoaffective Disorder Substance/Medication-Induced Psychotic Disorder Psychotic Disorder Due to Another Medical Condition DSM-4 subtypes eliminated Catatonia Associated With Another Mental Disorder (Catatonia Specifier) Shared Psychotic Disorder deleted? Catatonic Disorder Due to Another Medical Condition Unspecified Catatonia Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Unspecified Schizophrenia Spectrum and Other Psychotic Disorder 8/16/2013 Copyright 2013 Dr. Carlton Munson 51

51 DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders pp Delusional Disorder (F22) A. Delusions for 1+ months B. ca for Schizophrenia never met Brief Psychotic Disorder (F23) ca. 1+ of 1 must 1, 2, or 3: 1. Delusions, 2. Hallucinations 3. Disorganized speech & behavior B. For 1 day but less than 1 month 4. Grossly disorganized or catatonic behavior Schizophrenia A. Same as Schizophreniform Disorder B. Failure to achieve expected levels of functioning C. 6m+ duration... Schizophreniform Disorder (F20.81) 2+ present sig. portion of time for 1+m of at least 1 must be 1, 2, or 3: 1. Delusions 2. Hallucinations, 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms B. Episode 1 m but less than 6 m C. Not other psychotic disorder D. Not due to substance or other medical condition Eliminated b/o low reliability poor validity Suicide risk in all Schizophrenia phases Prodromal refers to early Psychotic Ds rare in children. Onset in early 20 s for males late 20a for females. Prev

52 DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders pp Delusional Disorder (F22) A. Delusions for 1+ months B. ca for Schizophrenia never met Brief Psychotic Disorder (F23) A. 1+ of 1 must 1, 2, or 3: 1. Delusions, 2. Hallucinations 3. Disorganized speech & behavior B. For 1 day but less than 1 month 4. Grossly disorganized or catatonic behavior Schizophrenia A. Same as Schizophreniform Disorder B. Failure to achieve expected levels of functioning C. 6m+ duration... Attenuated Psychosis Syndrome Proposed criteria A. 1+ present in attenuated form with relatively intact reality testing and is of severity to warrant clinical attention: 1. Delusions 2. Hallucinations, 3. Disorganized speech B. Symptoms present 1+ week for past month C. Symptoms begum or worsened in past year D. Symptoms distressing at level requiring clinical attention E. Not due to another mental disorder See pp F. Criteria for psychotic never met

53 Schizophrenia & Other Psychotic Disorders Schizoaffective Disorder Change to a longitudinal diagnosis Delusional Disorder Delusions for 1 month Removed nonbizarre distinction Shared Psychotic Disorder (Folie a Deux) 293.xx Psychotic Disorder Due to GMC With Delusions With Hallucinations Deleted as separate diagnosis and and making it as specifier for delusional dsrd Substance-Induced Psychotic Disorder (Use specific substance coding, see p. 343) Clarifies distinction of substance-induced psychotic Dsrd and other psychotic w Dsrd comorbid substance use Psychotic Disorder NOS NEC

54 Nutshell Criteria ca. Schizophrenia ca 2+ 1m delusions, hallucinations Disorganized speech Gross disorganized or catatonic Behavior Negative Sx. With mood episode ca1 (Major depressive or manic) Present cb. Delusion or hallucinations 2+ Weeks absent mood episode cc. Mood Sx. present in active & residual phase cd. Not due to substances Clinician-Rated Dimensions of Psychosis Symptoms Survey Necessitated by removal of Axis 5 GAF <20 Diagnostic Recording Example Schizoaffective Disorder (pp ) See pp Schizoaffective disorder, depressive type, multiple episodes, currently in acute episode, delusions present & severe (4), negative symptoms present & moderate (3), depression, present & severe (4). IP has at least three prior episodes of illness with OP Tx and 3 hospitalizations. IP is not currently threat to others, but is threat to self with suicidal thoughts including consideration of suicide methods V62.4 Social exclusion & rejection. Rx. = Hospitalization p. 106, Dx. can be made w/o using this specifier so the alternative Dx recording is: Schizoaffective disorder, depressive type, multiple episodes, currently in acute episode IP has at least three prior episodes of illness with OP Tx and 3 hospitalizations. IP is not currently threat to others, but is threat to self with suicidal thoughts including consideration of suicide methods. V62.4 Social exclusion & rejection. Rx. = Hospitalization See pp /16/2013 Copyright 2013 Dr. Carlton Munson 55

55 DSM-5: Bipolar and Related Disorders Bipolar I Disorder ca for manic and hypomanic episodes now includes emphasis on changes in activity and energy as well as mood. NEW SECTION Bipolar II Disorder Cyclothymic Disorder A specifier added for anxious distress identifies anxiety symptoms not part of bipolar diagnostic criteria Substance/Medication-Induced Bipolar and Related Disorder Bipolar and Related Disorder Due to Another Medical Condition Other Specified Bipolar and Related Disorder Unspecified Bipolar and Related Disorder Bipolar I Dsrd, mixed episode requiring individual meeting full criteria for both mania & depressive episode removed & specifier, with mixed features, added & can be applied to episodes of mania or hypomania when depressive features present 8/16/2013 Copyright 2013 Dr. Carlton Munson 56

56 Bipolar I Disorder pp For diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes. Manic Episode A. A distinct period of abnormality and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal directed activity or energy lasting at least 1 week and present most of the day (or any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy activity 3 or more of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent and noticeable change from usual behavior: See list of 7 symptoms in DSM 5 C. Mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are or psychotic features. D. the episode is not attributable to the physiological effects of a substance Major Depressive Episode A. 5 (or more) of the following symptoms have been present during the same 2-week period and represent a change from previously functioning; at least 1of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure: See list of 9 symptoms in DSM-5 Specify; With anxious distress With Mixed Features With rapid cycling With melancholic features With atypical features With mood congruent psychotic features With peripartum onset With catatonia With mood incongruent psychotic features With catatonia With seasonal pattern Bipolar I Disorder Coding in text section 4 mood episodes in 12 months

57 Bipolar II Disorder pp For diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the following criteria for a current or past major depressive episode: Hypomanic Episode A. A distinct period of abnormality and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal directed activity or energy lasting at least 4 consecutive days and present most of the day, nearly every day. B. During the period of mood disturbance and increased energy activity 3 or more of the following symptoms (4 if the mood is only irritable), represent and noticeable change from usual behavior and have been present to a noticeable degree: See list of 7 symptoms in DSM 5 C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is by definition manic. F. The episode is not attributable to the physiological effects of a substance Major Depressive Episode A. 5 (or more) of the following symptoms have been present during the same 2-week period and represent a change from previously functioning; at least 1of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure: See list of 9 symptoms in DSM-5 See specifiers on pp they are slightly different than specifiers for BPI Bipolar I Disorder (F31.81)

58 DSM-5: Depressive Disorders In DSM-4 Mood Disorders section Disruptive Mood Dysregulation Disorder Major Depressive Disorder, Single and Recurrent Episodes Most likely extensive specifiers survived Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder A specifier added for anxious distress identifies anxiety symptoms not part of depressive Dsrd diagnostic criteria Substance/Medication-Induced Depressive Disorder Depressive Disorder Due to Another Medical Condition Other Specified Depressive Disorder Unspecified Depressive Disorder Depression & Affective Disorders Association DRADA 8/16/2013 Copyright 2013 Dr. Carlton Munson 59

59 Disruptive Mood Dysregulation Disorder pp A. Severe recurrent temper outbursts manifested verbally and or behaviorally toward people or property that are grossly out of proportion in intensity or duration to the situation or provocation. B. The temper outburst are inconsistent with developmental level. C. The temper outbursts occur, on average, 3 or more times per week D. Mood between temper outburst is persistently irritable or angry most of the day nearly every day, and is observable by others. E. Criteria A-D present for 12+ months with no more than 3 consecutive months without the symptoms F. Criteria A. and D. are present in at least 2 of 3 settings G. The diagnosis should not be made for the first time before age 6 or after age 18 H. By history or observation, the age at onset of criterion A-E is before age 10 Disruptive Mood Dysregulation Disorder (F34.8) I. Never been a distinct period lasting more than 1day during which the full symptom criteria, except duration, for a manic or hypomanic episodes have been met. See not in DSM-5 p J. Behaviors do not occur exclusively during an episode of major depressive disorder and not explained by another disorder. K. Symptoms not attributable to physiological effects of substance or other medical/neurological condition

60 1 2 Review Descriptive Text pp Doing a Major Depressive Disorder Diagnosis 3 Review Diagnostic Criteria pp Select Coding Recording Procedures p. 162 In recording the name of a Dx., terms should be listed in following order: major depressive disorder, single or recurrent episode, severity /psychotic/remission specifiers, followed by as many of specifiers w/o codes that apply. Select Code From Coding Table Diagnostic Criteria p. 162 Select Specifier From Specifier List p. 162 Captured from text coding table major depressive disorder, recurrent episode, Mild, with anxious distress, mild 8/16/2013 Copyright 2013 Dr. Carlton Munson Consult Specifiers for Depressive Disorders pp

61 Major Depressive Disorder pp A. 5+ of following symptoms present during the same 2-week period and represent change from previous functioning. At least 1 of the symptoms is either (1) depressed mood or (2) loss of interest in pleasure. 1. Depressed mood most of the day, nearly everyday, as he indicated by subjective report or observation made by others (Note: In children and adolescents can be irritable mood). 2. Markedly diminished interest or pleasure in all or almost all, activities most of the day, nearly every day. 3. Significant weight loss when not dieting or weight gain (note: In children, failure expected weight gain) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day. 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt. 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day. 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. Symptoms cause clinically significant distress or impairment in social occupational or other important areas of functioning. C. Episode is not attributable to the physiological effects of the substance or to another medical condition. D. not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder. E. There is never been a manic episode or hypomanic episode Major Depressive Disorder Coding in text section