Welcome. Rogers treats children, adolescents and adults with: Anxiety disorders Eating disorders Mood disorders Substance use disorders

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1 Welcome Rogers treats children, adolescents and adults with: Anxiety disorders Eating disorders Mood disorders Substance use disorders rogershospital.org

2 Major Changes in DSM-5 As it Relates to Pediatric Psychiatry Keyur H. Parikh, MD Pediatric Psychiatrist Rogers Memorial Hospital Assistant Clinical Faculty Medical College of Wisconsin American Council for School Social Work Mental Health in Schools Institute September 30, 2013

3 Overview Intellectual Disability (Intellectual Developmental Disorder) - IDD Specific Leaning Disorder Communication Disorders Social (Pragmatic) Communication Disorder Autism Spectrum Disorder Disruptive Mood Dysregulation Disorder Premenstrual Dysphoric Disorder Reactive Attachment Disorder Disinhibited Social Engagement Disorder Attention Deficit Hyperactivity Disorder (ADHD) Oppositional Defiant Disorder Conduct Disorder Intermittent Explosive Disorder

4 Basic Changes.in the Thought Process Diagnosis in terms of the life span (e.g. for ADHD) Age relevant examples to help with diagnostic clarity Natural history of the symptoms Less of a list of symptoms and more realignment between emotions & behavior. 5 simpler than V. (Also looks good when jellybean kitkat)

5 Intellectual Disability (Intellectual Developmental Disorder) Need for assessment of both Cognitive Capacity (IQ) and adaptive functioning. Severity determined more by adaptive functioning rather than IQ Mental Retardation (DSM-IV) replaced by Intellectual Disability.

6 Intellectual Disability (Intellectual Developmental Disorder) A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, and academic learning and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing. B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, and across multiple environments, such as home, school, work, and recreation. C. Onset of intellectual and adaptive deficits during the developmental period.

7 Specific Learning Disorder DSM-IV Separate disorders for Reading, Written expression, Mathematics & NOS. Clinical Reality Commonly occur together. DSM-5 Single disorder with coded specifiers for reading, writing and mathematics. Separate specifiers can be used to code the level of deficits in each area (mild, moderate, severe). Text acknowledges international descriptions such as dyslexia and dyscalculia.

8 Specific Learning Disorder A. Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite provision of interventions that target the difficulties (inaccurate or slow and effortful word reading; difficulty understanding the meaning of what is read; difficulties with spelling; difficulties with written expression; difficulties mastering number sense, number facts, or calculation; difficulties with mathematical reasoning) B. The affected academic skills are substantially and quantifiably below those expected for the individual s chronological age, based on appropriate standardized measures, and cause significant interference with academic or occupational performance or with activities of daily living.

9 Specific Learning Disorder C. The learning difficulties begin during school age years but may not become fully manifest until learning demands exceed the individual s limited capacities. D. The learning difficulties are not better accounted for by: intellectual disabilities, global developmental delay, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate educational instruction.

10 Communication Disorder Language Disorder (Combines DSM-IV expressive and mixed expressive-receptive language disorders) Speech Sound Disorder (DSM-IV Phonological Disorder) Childhood Onset Fluency Disorder (DSM-IV Stuttering) Social (Pragmatic) Communication Disorder (NEW condition) Unspecified Communication Disorder

11 Social (Pragmatic) Communication Disorder NEW Condition For Persistent difficulties in the social uses of verbal and nonverbal communication. Social communication deficits are one component of ASD Social pragmatic) communication disorder cannot be diagnosed in the presence of restricted repetitive behaviors, interests and activities (the other component of ASD) Some patients with DSM IV PDD, NOS may meet criteria.

12 Social (Pragmatic) Communication Disorder A) Persistent difficulties in the social use of verbal and nonverbal communication as manifest by deficits in all of the following: 1. Deficits in using communication for social purposes, in a manner that is appropriate for the social context 2. Impairment in the ability to change communication to match context or the needs of the listener 3. Difficulties following rules for conversation and storytelling 4. Difficulties understanding what is not explicitly stated

13 Social (Pragmatic) Communication Disorder B) Deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance. C) Deficits must be present in the early developmental period, but may not become fully manifest until social communication demands exceed limited capacities. D) Deficits are not better explained by autism spectrum disorder, intellectual disability (intellectual development disorder), global developmental delay, or another mental disorder or medical condition.

14 Autistic Spectrum Disorder (ASD) DSM-IV Pervasive Developmental Disorders (PDD) 1. Autistic Disorder 2. Asperger Disorder 3. PDD, NOS 4. Childhood Disintegrative Disorder 5. Rett Disorder DSM-5 Autistic Spectrum Disorder (ASD)

15 Autistic Spectrum Disorder (ASD) Consensus: 4 previously separate disorders are actually a single condition with levels of symptom severity in two core domains social communication and restrictive / repetitive behaviors (RRB). 3 diagnostic domains (social interaction, communication deficits and RRB) became 2 (social communication and RRB) Both components needed to diagnose ASD. If no RRBs present diagnose Social (Pragmatic) Communication Disorder.

16 I LIKE SAYING RESTRICTIVE REPETITIVE BEHAVIORS AGAIN AND AGAIN!!!

17 Autism Spectrum Disorder (ASD) A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history: 1. Deficits in social emotional reciprocity: back and forth conversation; reduced sharing; failure to initiate or respond 2. Deficits in nonverbal communicative behaviors used for social interaction: eye contact; body language; poorly integrated verbal and nonverbal communication; lack of expressions; poor understanding of gestures 3. Deficits in developing, maintaining, and understanding relationships: adjusting behavior to suit context; no imaginative play or making friends; and absence of interest in peers

18 Autism Spectrum Disorder (ASD) B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history: 1. Stereotyped or repetitive motor movements, use of objects, or speech 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior 3. Highly restricted, fixated interests that are abnormal in intensity or focus 4. Hyper or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment.

19 Autism Spectrum Disorder (ASD) C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies later in life). 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 or global developmental delay. Intellectual disability and autism spectrum disorder frequently co occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

20 Autism Spectrum Disorder (ASD) Specifiers : With/without accompanying intellectual impairment With/without accompanying language impairment Associated with a known medical or genetic condition or environmental factor (e.g. Rett disorder) Associated with another neurodevelopmental, mental, or behavioral disorder (including catatonia) Severity of symptoms Social communication Restricted interests and repetitive behaviors

21 Severity Level Social Communication Restricted, repetitive behaviors Level 3: Requiring very substantial support Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in spheres. Great distress/difficulty changing focus or action. Level 2: Requiring substantial support Level 1: Requiring support Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others Without social supports in place, deficits in social communication cause noticeable impairments. Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.

22 Disruptive Mood Dysregulation Disorder (DMDD) DMDD for children up to 18 years who exhibit persistent (non episodic) irritability and frequent episodes of extreme behavioral dyscontrol. Concerns about potential over diagnosis and over treatment of Pediatric Bipolar Disorder possibly secondary to diagnosing persistent (non- episodic) irritability as mania. May be prescribed less antipsychotics?!? Evidence Alternative to Bipolar, NOS (DSM-IV) Cannot be diagnosed with ODD or IED. (DMDD wins) Can be diagnosed with CD.

23 Disruptive Mood Dysregulation Disorder (DMDD) NEW Condition Verbal or behavioral angry outbursts, out of proportion for developmental level 3 or more times weekly for 12 months With general irritable mood most of the time and observable by others for at least 12 months No three month period in last 12 months free of episodes defined by ALL the above Outbursts and irritability must have started before age 10 Diagnosis not to be made before age 6 or after age 18.

24 Premenstrual Dysphoric Disorder New PDD? NEW Condition A: in the majority of menstrual cycles at least 5 of symptoms must be present in the final week before menses, improve at cessation of menses, and be diminished or absent the week after menses. At least one symptom must come from criterion B, and one from criterion C B: Marked affective liability; Marked irritability or interpersonal conflicts; Marked depressed mood; and Marked anxiety, tension, feeling keyed up or on edge. C: Decreased interest; Lethargy; Decreased concentration; Marked change in appetite; Sleep disturbance; Feeling overwhelmed/ out of control; Physical symptoms including tender or swelling breasts, muscle pain, bloating, weight gain. Symptoms must have occurred most of periods past year, be significantly distressing, not an exacerbation of a present disorder, be measured by ratings of at least 2 prior symptomatic cycles.

25 Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) DSM-IV Reactive Attachment Disorder DSM-5 Reactive Attachment Disorder Disinhibited Social Engagement Disorder (NEW!) INHIBITED (emotionally withdrawn) DISINHIBITED (indiscriminately social)

26 Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) Both result from social neglect or other situations that limit a young child s ability to form selective attachments. Shared etiology but the two differ in course, presentation, response to intervention, etc. and so now considered separate disorders.

27 Reactive Attachment Disorder & Disinhibited Social Engagement Disorder (NEW) RAD dampened positive affect more internalizing symptoms emotionally withdrawn/inhibited resembles Depression/Anxiety absent or incomplete attachments DSED more externalizing indiscriminately social/disinhibited resembles ADHD/DBD may occur even with secure attachments

28 Reactive Attachment Disorder A. Emotionally withdrawn behavior manifested by minimally seeking comfort and responding to comfort when distressed. B. Persistent social/emotional disturbance by 2 of 3: minimal social /emotional responsiveness to others; limited positive affect; and unexplained irritability, sadness or fearfulness evident in nonthreatening interactions with adult caregivers C. Exposure to extremes of insufficient care by 1 of 3: social neglect / deprivation; repeated changes in caregivers; and rearing in unusual settings that limit ability to form selective attachments D. Criterion C responsible for criterion A. E. Not autism F. Before 5 years old G. Older than 9 months developmentally Specify persistent if disorder present for more than 12 months

29 Disinhibited Social Engagement Disorder A. Approach / interact with unfamiliar adults exhibiting 2 of 4: reduced reticence; overly familiar verbal physical behavior; absent checking to primary caregiver; and willingness to leave with unfamiliar adult without hesitation. B. Criteria A not limited to impulsivity alone, but due to social disinhibition C. Exposure to extremes of insufficient care by 1 of 3: social neglect / deprivation; repeated changes in caregivers; and rearing in unusual settings that limit ability to form selective attachments D. Criterion C responsible for criterion A. E. At least 9 months old Specify persistent if disorder present for more than 12 months

30 ADHD Basic Diagnostic Criteria similar to DSM-IV Same 18 symptoms continued to be divided into two symptom domains, (inattention and hyperactivity / impulsivity) of which >= 6 in one domain required. Placed in the Neurodevelopmental chapter to reflect brain development over the lifespan.

31 ADHD: Main Differences 1. Examples added to facilitate application across the lifespan. (especially for adults and older adolescents) 2. Cross-situational requirement strengthened; several symptoms in each setting from some in DSM-IV. 3. Onset criterion changed from age 7 to age Subtypes replaced with presentation specifiers 5. Co-morbid diagnosis of ASD now allowed.

32 ADHD: Main Differences 6. Adults (>= 17) require 5 (not 6) symptoms in one of the domains. {reflects clinically significant impairment from ADHD in adults} 7. Being with friends or relatives added as a setting. (DSM-IV home, school, work) 8. From impairment to interfere with or reduce the quality of...functioning.

33 ADHD: DSM-5 A. Similar list of 18 symptoms (9 Inattention ; 9 Hyperactivity-Impulsivity) between categories (5 instead of 6 needed per category for individuals 17 and older) B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). D. There is 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 explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

34 ADHD: DSM-5 Specify whether: (F90.2) Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity impulsivity) is not met for the past 6 months (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months. Specify if: In Partial remission : When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic or occupational functioning. Specify current severity: (NEW) Mild, Moderate, Severe

35 Oppositional Defiant Disorder (ODD) Symptoms now grouped into 3 types: (Both emotional and behavioral) Angry/Irritable Mood Argumentative/Defiant behavior Vindictiveness Frequency more clearly mentioned to clarify diagnostic criteria. (Many behaviors present in normal C&A at various times) ( often more in DSM-IV how often is often?) Placed under Disruptive, Impulse Control and Conduct Disorder Chapter (Not Neurodevelopmental) Criteria more open to interpretation for adults..authority figures, or for Children.with adults

36 Oppositional Defiant Disorder (ODD) At least one individual required to NOT be a sibling (Symptoms exclusively between siblings not diagnostic) CD exclusion eliminated Severity Specifier (NEW) based on number of settings (Mild = 1, Moderate = 2, Severe = 3 or more)

37 ODD: DSM-5 A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling. Angry/irritable mood: often loses temper; easily annoyed; resentful Argumentative/defiant behavior: argues with authority figures, or for children and adolescents, with adults ; refuses to comply with requests or rules; deliberately annoys others; blames others for own misbehavior. Vindictiveness: spiteful or vindictive at least twice in the past 6 mos. Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise noted. For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless otherwise noted (A8). Cause distress to self or others in social context; not accounted for by other diagnosis.(psychotic, Substance, Depression, Bipolar or DMDD) Note : No CD exclusion

38 Conduct Disorder (CD) Basic diagnostic criteria unchanged Descriptive Specifier added: With Limited Prosocial emotions Must display at least 2 of following persistently over at least 12 months and in multiple relationships, settings being a typical pattern, not just occasional. Necessary to consider reports from others who have known individual for extended time periods (eg. Parents, family, teachers, peers, co-workers) 1. Lack of remorse/guilt 2. Callous- lack of empathy 3. Unconcerned about performance (school /other) 4. Shallow or deficient affect

39 Conduct Disorder (CD) Rationale for the specifier: Patients who meet criteria for the specifier have 1. Relatively more severe form 2. Different Treatment Response BETTER response to STIMULANTS POOR response to PARENT TRAINING

40 Intermittent Explosive Disorder (IED) It s not what you re thinking!! Or is it? Primary Changes : 1. Verbal aggression and Non-injurious/non-destructive physical aggression meet criteria Note: Physical Aggression required in DSM-IV 2. Better specified criteria for duration, frequency 3. More emphasis on impulsivity/anger versus to achieve some tangible objective (e.g. money)

41 Intermittent Explosive Disorder (IED) 4. Cause distress/impairment or negative legal/financial consequences 5. Age at least 6 (or equivalent developmentally) Note: paucity of research under this age to be able to distinguish from temper tantrums 6. Exclusions for other Mental disorders, substance, medical clarified. 7. Age 6-18 Adjustment d/o exclusion.

42 References Master Course on DSM-5 at the American Psychiatric Association (APA) 166 th Annual Meeting in San Francisco, May 2013 DSM-5: What you need to know Rogers Memorial Hospital CE Seminar, August 2013 Highlights of Changes from DSM-IV-TR to DSM-5, American Psychiatric Publishing DSM-IV-TR, APA DSM-5, APA

43 Thank you Rogers Five Wisconsin Locations: Oconomowoc Valley Road West Allis West Lincoln Avenue Brown Deer 4600 Schroeder Drive Kenosha th Street Madison 406 Science Drive, Suite rogershospital.org