History/Timelines of DSM. Before the DSM. Conflict of Interest. Objectives DSM I APNA 27th Annual Conference Session 1035: October 9, 2013

Transcription

1 History/Timelines of DSM Conflict of Interest 0 The speakers have no conflicts of interest to disclose 0 The speakers will not be discussing off label uses Before the DSM US Census: insane and idiots US Census: mania, melancholia, monomania, dementia, dipsomania Kraepelin organized psychopathology including dementia praecox and manic depression International Classification of Disease (ICD) American Medico Psychological Association (former APA), Statistical Manual for the Use of Institutions for the Insane with 22 categories American Psychiatric Association, 1918 Objectives 0 Describe the history/timeline of the Diagnostic and Statistical Manual (DSM) 0 Compare the DSM IV TR organizational structure with the organizational structure of the DSM 5 0 Describe major changes to specific diagnostic categories and specific disorders 0 Identify the role of psychiatric nurses in the development of the DSM 5 DSM I Directed by William C. Menninger, a psychiatrist and brigadier general 0 Focus on treatment of soldiers 0 70 terms used Reaction, e.g., Schizophrenic Reaction 0 Controversy about being psychoanalytic used the term unconscious a few times vs. codified Freudian ideas 106 diagnoses, 130 pages, American Psychiatric Association, 1952 Halter, Limandri 1

2 DSM II Based on psychoanalytic principles 0 Goal of using terms that coincided with ICD 8 0 Removed all reactions 0 A 1974 revision replaced homosexuality with egodystonic homosexuality 0 Gap between neurosis and psychosis 182 diagnoses, 134 pages, American Psychiatric Association, 1968 DSM Arabic numbers to clarify online revisions (DSM 5.1, DSM 5.2, etc.) 0 Goal to decrease number of disorders (297 DSM IV TR) 0 About the same number of ways to say You re not okay 0 Psychobiological dysfunction replaces behavioral, psychological, biological dysfunction 300+ diagnoses, 991 American Psychiatric pages Association, 2013 DSM III axis 0 Terms made consistent with the ICD 0 Listed symptoms rather than causes banished neurosis 0 Vast increase in background information 0 PTSD added egodystonic homosexuality removed 265 diagnoses, 494 pages American Psychiatric Association, 1980 Timeline : Development of DSM 5 Pre Planning white papers, : APA/NIH/WHO global research planning conferences : Chairs, work group chairs, and members are appointed and announced 0 April 2010 February 2012: Field trial testing 0 October 2011 April 2012: Data analysis of field trials 0 Spring 2012: Revisions posted and open to a third public feedback for two months; further edits 0 December 31, 2012: Published 0 May 18 22, 2013: Released during the APA s 2013 Annual Meeting in San Francisco, CA DSM IV 1994 DSM IV TR Symptoms that caused clinically significant distress included 0 Retained Freudian based terms such as fetishism 0 Greater international involvement and consultation with other disciplines 0 Client centered patient with schizophrenia 0 Many NOS and co morbidities 297 diagnoses, 886 pages American Psychiatric Association, diagnoses, 943 pages American Psychiatric Association, 2000 Some of APA s Selling Points 0 Evidence based (20 years) 0 More in line with International Classification of Disease (ICD) 0 Categories ordered based on relatedness 0 Neurodevelopmental approach within categories 0 Recognizes the influence of gender and culture on the presentation of psychiatric illness 0 Dimensional assessments 0 Severity rating for symptoms specific to diagnosis 0 Severity of symptoms that are present across multiple disorders (e.g., suicide risk, anxiety) 0 Biomarkers for some diagnoses (e.g., narcolepsy/hypocretin deficiency) Halter, Limandri 2

3 DSM IV TR 0 Axis I: Major mental disorders 0 Axis II: Personality disorders and intellectual disabilities 0 Axis III: Acute medical conditions 0 Axis IV: Environmental factors contributing to the disorder 0 Axis V: Global Assessment of Functioning Scale Axis I, II, III, IV, V No Scientific Basis DSM 5 0 Simpler: Collapse I, II, and III and put together to align with ICD codes 0 More complex: Change IV to match ICD codes 15 p. checklist 0 Functioning: World Health Organization s Disability Assessment Schedule (WHODAS) Neurodevelopmental s Formerly known as s Usually First Evident in Infancy, Childhood, and Adolescence 0 Intellectual Developmental (formerly mental retardation) 0 Communication s 0 Autism Spectrum 0 Attention Deficit/Hyperactivity 0 Learning s 0 Motor s Steinberg, M Changes to Specific Diagnostic Categories within the DSM 5 Autism Spectrum s Brumpbm, 2011 Autistic, Asperger s, Childhood Disintegrative, and Pervasive Developmental NOS Specifiers: Rett Syndrome, Fragile X, Asperger s Levels of Support: I. Requires support II. Requires substantial support III. Requires very substantial support Symptom Onset (previously age 3): Begin in early childhood, but may not be manifest until social demands exceed capacity (e.g. adolescence). Categories of s 1. Neurodevelopmental 11. Elimination 2. Schizophrenia Spectrum 12. Sleep Wake 3. Bipolar and Related 4. Depressive 5. Anxiety 6. Obsessive Compulsive 7. Trauma and Stressor 8. Dissociative 9. Somatic Symptom 10. Feeding and Eating 13. Sexual Dysfunctions 14. Gender Dysphoria 15. Disruptive, Impulse Control, and Conduct 16. Substance Use and Addictive 17. Neurocognitive 18. Personality 19. Paraphilias 20. Other s Attention Deficit/Hyperactivity DSM IV TR Hyperactive impulsive or inattentive symptoms that caused impairment were present before age 7 DSM 5 Raising the age of onset before age 12: trigger a fad of Adult Attention Deficit leading to widespread misuse of stimulant drugs. ~ Allen Frances Professor Emeritus, Duke University Chair of DSM IV Task Force Halter, Limandri 3

4 Schizophrenia Spectrum s 0 Schizotypal Personality 0 Schizophrenia 0 Schizoaffective 0 Schizophreniform 0 Delusional 0 Brief Psychotic 0 Psychotic Due to Another Medical Condition 0 Substance Induced Psychotic 0 Catatonic Features Specifier 0 Catatonia Due to Another Medical Condition Bipolar and Related s Mixed Episodes DSM IV Bipolar I Mixed Episode Simultaneous presence of: 1. fully manic syndrome 2. fully depressive syndrome for at least 4 days DSM 5 Mixed specifier for major depression, hypomania, or mania Simultaneous presence of: 1. 2 to 3 manic or hypomanic symptoms 2. fully depressive syndrome for at least 2 3 days National Park Service, 2013 Schizophrenia Spectrum Attenuated Psychosis Syndrome Controversy Pro: People with early psychotic like symptoms are often diagnosed as depressed or anxious. Early detection of symptoms and treatment can reduce severity and disability VS Con: Ambiguous diagnosis results in unnecessary alarm and stigmatization; early antipsychotic treatment not helpful in the long term and exposes people to unnecessary antipsychotic therapy Depressive s Previously listed in the Mood Chapter along with Bipolar s 0 Disruptive Mood Dysregulation (old childhood bipolar, onset before age 10) 0 Major Depressive (single and recurrent) 0 Dysthymic 0 Premenstrual Dysphoric (new) 0 Substance Induced Depressive Bipolar and Related s Formerly listed under Mood s Increased energy/activity has been added as a core symptom of manic and hypomanic episodes 0 Bipolar I 0 Bipolar II 0 Cyclothymic 0 Substance Induced Bipolar 0 Bipolar Associated with Another Medical Condition Disruptive Mood Dysregulation For 0 Children are being wrongly diagnosed with bipolar disorder 0 Accurate treatment is withheld 0 Powerful and unnecessary medication is being used Against 0 Pathologizing temper tantrums 0 Increases the unnecessary use of medication 0 Oppositional defiant disorder already covers this problem 0 Fighting a fire with kerosene. Severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation. Dvorsky, 2012 Halter, Limandri 4

5 Medicalizing Grief Removing the Bereavement Exclusion For 0 Losing a loved one is similar to other losses/stressors in life. 0 Treatment delay for severe grief increases the risk of suffering and impairment. 0 Criteria for grief could be tightened to reduce false positives. Against 0 Losing a loved one is essentially different than other stressors. 0 A diagnosis impairs the normal, dignified process of grief and the usual reliance on cultural rituals 0 A variation of normal grief would result in a mental disorder label and unnecessary treatment. Trauma and Stressor Related s (new) 0 Reactive Attachment 0 Disinhibited Social Engagement (new) 0 Acute Stress 0 Post Traumatic Stress 0 Ages six and up 0 Subtype for pre six year olds 0 Adjustment (may be related to bereavement) Wikipedia Commons Anxiety s Dissociative s Changes: 0 Agoraphobia a category separate from Panic 0 Obsessive Compulsive was moved into its own chapter (next) 0 Posttraumatic Stress added to Trauma and Stressor Related s 0 Separation Anxiety 0 Specific Phobia (not just for 0 Generalized Anxiety kids anymore!) (physical sx 0 Panic lowered from 6 2) 0 Agoraphobia 0 Social Anxiety Steinberg, Depersonalization Derealization 0 Dissociative Amnesia 0 Dissociative Identity Obsessive Compulsive s 0 Obsessive Compulsive 0 Formerly listed with anxiety disorders 0 Body Dysmorphic 0 Formerly listed with somatoform disorders 0 Hoarding (new) 0 Hair Pulling (trichotillomania) 0 Skin Picking (excoriation) (new) Dvorsky, 2012 Wikipedia Commons Somatic Symptom s Formerly known as Somatoform s all disorders in this group have physical symptoms and/or concern about medical illness Santa Clara Productions, Somatic Symptom replaces Somatization, Undifferentiated Somatoform, and Pain 0 Illness Anxiety (Hypochondriasis) 0 Functional Neurological Symptom (Conversion ) 0 Psychological Factors Affecting Medical Condition 0 Factitious Halter, Limandri 5

6 0 Pica Feeding and Eating s 0 Bulimia Nervosa 0 Rumination 0 Binge Eating (new 0 Avoidant/Restrictive Food moved from appendix) one Intake (formerly a eating binge per week for childhood disorder) three months 0 Anorexia Nervosa Elimination s 0 Enuresis 0 Encopresis Photobucket Wikimedia Commons Photobucket Formerly listed in s Usually First Diagnosed in Infancy, Childhood, or Adolescence and Impulse Control s Not Elsewhere Classified Disruptive, Impulse Control, and Conduct s 0 Oppositional Defiant 0 Intermittent Explosive (6+ years) 0 Conduct 0 Callous and Unemotional Specifier 0 Limited Prosocial Emotions Specifier 0 Dyssocial Personality (Antisocial Personality ) Hoffman, 2009 Sleep Wake s (formerly Sleep s) 0 Insomnia (Primary insomnia) 0 Hypersomnolence (Primary Hypersomnia) 0 Narcolepsy/Hypocretin Deficiency 0 Obstructive Sleep Apnea Hypopnea Syndrome (new) 0 Central Sleep Apnea (new) 0 Sleep Related Hypoventilation (Sleep Wake Schedule ) 0 Circadian Rhythm Sleep Wake 0 of Arousal (Sleep Terror) 0 Nightmare (Dream Anxiety) 0 Rapid Eye Movement Sleep Behavior (new) 0 Restless Legs Syndrome (new) 0 Substance Induced Sleep White Packert/Getty Images 0 Big change: Substances AND non substances 0 Abuse vs. Dependence: categories arbitrary 0 Mild, Moderate, and Severe 0 Reduced number of symptoms for dx Substance Use and Addictive s 0 Alcohol Related s 0 Caffeine Related s 0 Cannabis Related s 0 Hallucinogen Related s 0 Inhalant Related s 0 Opioid Related s 0 Sedative hypnotic Related s 0 Tobacco Related s 0 Gambling Sexual Dysfunction 0 Erectile 0 Delayed Ejaculation 0 Early Ejaculation 0 Male Hypoactive Sexual Desire 0 Genito Pelvic Pain/Penetration Photobucket 0 Female Orgasmic 0 Female Sexual Interest/Arousal, 0 Female Orgasmic Gender Dysphoria (not ) 0 Gender Dysphoria in Children 0 Gender Dysphoria in Adolescents and Older Adults Binge Drinking = Alcoholism For 0 Earlier interventions could nip problem in the bud 0 Stop physical problems from occurring 0 Save money in the long run by reducing disability Substance Use Severity Scale 0 1 criterion: No diagnosis 2 3 criteria: Mild 4 5 criteria: Moderate 6 + criteria: Severe Against Wikimedia Commons 0 31% of all college students could be labeled alcoholic 0 One study suggests that there will be 60% more alcoholic diagnoses with the new criteria 0 Scarce resources could be taxed further 0 Stigmatizing 0 Obliterates distinction between problem drinkers and alcoholics Wikimedia Commons Halter, Limandri 6

7 Neurocognitive s Other s 0 Delirium 0 Mild Neurocognitive s Modest cognitive decline, functions with effort. 0 Major Neurocognitive s Substantial cognitive decline, independence not possible Mild and Major types: Alzheimer s, Vascular, Frontotemperoral, Traumatic Brain Injury, Lewy Body, Parkinson s, HIV, Substance Induced, Huntington s, Prion Photobuckett 0 Non Suicidal Self Injury 5x in one year intentional self inflicted damage to the surface of the body (new) 0 Suicidal Behavior within the last two years initiated a behavior in the expectation that it would lead to the individual s own death (new) National Institutes of Health Bacweb.org Previously in the Sexual and Gender Identity chapter Adds risk assessing specifiers: In a Controlled Environment In Remission (no distress, impairment, or recurring behavior for five years in an uncontrolled environment) Paraphilias 0 Exhibitionistic 0 Fetishistic 0 Pedophilic (formerly pedophilia 0 Sexual Masochism 0 Sexual Sadism 0 Transvestic 0 Voyeuristic For the diagnosis 0 Creates a way to track suicide risk 0 Distinguishes a disorder from a symptom 0 Distinguishes between self injury and suicidal actions (DSM IV TR did not) Suicidal Behavior Against the diagnosis 0 We don t need it. 0 Gives another stigma to label a patient with 0 Are people suicidal without other symptoms? Personality s DSM IV TR 0 Pervasive pattern of thinking/emotionality/beh aving 0 Ten personality types: antisocial, avoidant, borderline, obsessivecompulsive, schizotypal paranoid, schizoid, narcissistic, histrionic, dependent, and a not otherwise specified category DSM 5 0 Impaired sense of selfidentity or failure to develop effective interpersonal functioning 0 Six personality types: antisocial/psychopathic, avoidant, borderline, narcissistic, obsessivecompulsive, and schizotypal types Transitioning to the DSM 5 0 Clinicians began using the diagnostic codes in May Insurance companies will make the transition by December 31, Insurers can decide to cover or not cover diagnoses Halter, Limandri 7

8 Normal Behavior as a Diagnosis? 0 Grief is now Major Depressive 0 Medical illness is Somatic Symptom 0 Everyday worries are now Generalized Anxiety 0 Forgetting of old age is Mild Neurocognitive 0 Being geeky smart makes you Autistic 0 Gorging is Binge Eating 0 Behavioral addictions open the door for shopping addiction, sun tanning, etc. Removing the Axes: Reduced Stigma? 0 Personality disorders (Axis II) no longer a separate axis 0 Psychiatric disorders (Axis I) and physical disorders (Axis III) blended NCAAD, 2013 Easier to Gain Diagnoses No Funding for DSM Based Research 0 Attention deficit hyperactivity disorder 0 Bipolar mixed 0 Bereavement exclusion 0 Generalized anxiety disorder 0 Somatic symptom disorder 0 First time substance abusers 0 Binge drinking 0 Binge eating Could inflation of diagnoses result in decreased stigma? April 29, While DSM has been described as a Bible it is, at best, a dictionary. 0 DSM is fairly reliable (clinicians use the same terms in the same way), but lacks validity (not based on well founded evidence) 0 Symptoms dictate diagnoses in the absence of evidence of disease 0 Research Domain Criteria (RDoC): A decade long project to develop a new classification system Does Changing the Label Reduce Stigma? 0 Mental Retardation Intellectual Developmental 0 Gender Identity Gender Dysphoria 0 Dementia. Mild and Major Neurocognitive s A rose by any other name. Psychiatric Nurses in the Development of the DSM 5 0 Compiled comments from the American Psychiatric Nurses Association s (APNA) membership 0 APNA sought and gained member inclusion in clinical field trials Recruitment of of a a volunteer sample of of clinicians, consisting of psychiatrists, consisting of psychiatrists, psychologists, licensed clinical psychologists, social workers, licensed licensed clinical social counselors, workers, licensed marriage licensed counselors, and family and therapists, licensed marriage and advanced and practice family therapists. psychiatric mental health nurses. Halter, Limandri 8

9 Psychiatric Nurses and the Implementation of the DSM San Francisco Train the Trainer, May 20, 2013 Selected Assessment Measures 0 Clinician Rated Scales: 0 Severity of Autism & Communication s 0 Dimensions of Psychosis Severity Symptoms 0 Severity of Somatic Symptoms 0 Severity of Conduct & Oppositional Defiant s 0 Severity of Nonsuicidal Self Injury Selected Assessment Measures 0 Cultural Formulation Interviews 0 WHO Disability Assessment Schedule May be used as outcome measure for treatment planning 0 Coordinate with the Recovery Model 0 Periodic reassessment 0 Specific Severity Measures: Adult, Child years Selected Assessment Measures 0 Level of Personality Functioning Scale 0 Personality Trait Rating Form 0 Personality Inventory for DSM 5 Selected Assessment Measures 0 Level 1 Cross Cutting Symptom Measures 0 Self Rated Adult & Child 6 17 years 0 Parent/Guardian Rated Child 6 17 years 0 Level 2 Cross Cutting Symptom Measures Depression Anger Mania Anxiety Irritability (Child) Somatic Symptoms Sleep Disturbance Repetitive Thoughts & Behaviors Substance Use Inattention (Child) Alternative Model for Personality s 0 Criteria A: Level of Personality Functioning Identity Self direction Empathy Intimacy 0 Criteria B: Pathological Traits 0 Criteria C & D: Pervasiveness & Stability 0 Criteria E, F, & G: Alternative Explanations for pathology Halter, Limandri 9

10 References (2 of 5) 0 American Psychiatric Association. (2012a). American Psychiatric Association Board of Trustees Approves DSM 5 (Press Release). Retrieved from /pdfs/2012 apa dsm5 final.pdf 0 American Psychiatric Association. (2012b). DSM 5 development: Frequently asked questions. Retrieved from 0 American Psychiatric Association. (2013). DSM 5. Retrieved from 0 Blumpbm. (2011). DSM V Name a disorder win a prize: The new DSM 5. Retrieved from prescriptiondrug problems.htm 0 Carpenter, W.T., & van Os, J. (2011). Should attenuated psychosis syndrome be a DSM 5 diagnosis? American Journal of Psychiatry, 168, doi: /appi.ajp American Psychiatric Association, 2013 References 0 American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental s, 5 th edition. Washington, D.C.: American Psychiatric Publ, Inc. 0 Nussbaum, A.M. (2013). The Pocket Guide to the DSM 5 Diagnostic Exam. Washington, D.C.: American Psychiatric Publ, Inc. References (3 of 5) 0 Dvorsky, G. (2012). Everything you needed to know about the American Psychiatric Association s updated guidelines. Retrieved from 0 Frances, A. (2012, December 3). DSM is a guide not a Bible: Simply ignore its ten worst changes. Huffington Post. Retrieved from indistress/201212/dsm 5 is guide not bible ignore its ten worstchanges 0 Hoffman, D. (2009). Bedwetting blues. NBC News. Retrieved from wetting blues millions adults suffertoo/#.ugo_0lo9wre 0 Margulies, D.M., Weintraub, S., Basile, J., Grover, P.J., & Carlson, G.A. (2012). Will disruptive mood dysregulation disorder reduce false diagnosis of bipolar disorder in children? Bipolar, 14(5), doi: /j National Council on Alcoholism and Drug Dependence (NCADD). (2013). Five ways you can reduce stigma. Retrieved from help/addictionmedicine/744 five ways you can reduce stigma References 0 American Psychiatric Association. (1918). Statistical manual for the use of the use of institutions for the insane. New York, NY: Author 0 American Psychiatric Association. (1952). Diagnostic and statistical manual of mental disorders (1st ed.). Washington, DC: Author. 0 American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). Washington, DC: Author. 0 American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. 0 American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised). Washington, DC: Author. 0 American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. 0 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. 0 American Psychiatric Association. (2010). DSM 5: Options being considered for ADHD. Retrieved from A%20Options%20for%20ADHD.pdf References (4 of 5) o National Institute o Mental Health. (2013, April 29). Director s blog: Transforming diagnosis. Retrieved from o National Institutes of Health. (2011). Alzheimer s disease: Unraveling the mystery. Retrieved from 2 what happensbrain ad/hallmarks ad o National Park Service. (2013). Beaver marsh in morning mist. Retrieved from AF0AFC 155D E1BB9BBE50A84A9 o Santa Clara Productions. (1960). Little Shop of Horrors. Retrieved from movies/the little shop ofhorrors/ o Steinberg, M. (2008). In depth: Understanding dissociative disorders. PsychCentral. Retrieved from depthunderstanding dissociative disorders/ o Wight, E. (2013). Meet the five to niners starting a business in their spare time. The Guardian. Retrieved from com/global/2013/jul/08/spare time Halter, Limandri 10

11 References (5 of 5) o Willingham, E. (2012). New DSM criteria for autism: Who will be left behind? Forbes. Retrieved from dsm 5 criteria for autism who will be left behind/ o World Health Organization. (2010). Measuring health and disability: WHODAS 2.0. Retrieved from Halter, Limandri 11