Using the DSM-5 Legally and Ethically: A Clinician s Guide Section C 2017 Anaheim Conference Further Changes to the DSM-5 Ethical Issues C-1 Pica Rumination Disorder Avoidant / Restrictive Food Intake Disorder Anorexia Nervosa Bulimia Nervosa Binge-Eating Disorder C-2 Binge Eating Disorder Elevated to Section II from Appendix B Rationale: BED is highly recognized in the clinical literature as a valid and clinically useful diagnosis. A significant proportion of cases of DSM-IV s eating disorders (NOS) would meet criteria for BED; ; Neimeyer, 2014 New Diagnosis: Avoidant/Restrictive Food Intake Disorder Feeding disorder of infancy or early childhood has been renamed avoidant/restrictive food intake disorder Rationale: Provides accurate diagnosis in children and adults with significantly restricted eating patterns - Versus Eating Disorder NOS. C-3 C-4 Primary Difference between Anorexia and Avoidant/Restrictive: Avoidant/Restrictive Weight loss unnecessary (although possible) Anorexia Requires low body weight Anorexia Nervosa Amenorrhea is eliminated More easily includes males NOT a vanity issue Rationale: Already excluded for males, premenstrual and postmenopausal females, and women using birth control pills. C-5 C-6 Harmell, Copyright, 2017 Section C -1-
Anorexia Nervosa Refusal to maintain body weight at or above minimally normal weight for age and height - Less than 85% of body weight - Only an example Intense fear of gaining weight or becoming fat Or persistent behavior that interferes with weight gain C-7 Anorexia Nervosa Guidance to establish severity of weight criterion using Body Mass Index (BMI) percentile from WHO Use 307.1 along with corresponding BMI C-8 National Heart, Lung and Blood Institute http://www.nhlbi.nih.gov/health/educational/lose_wt/bmi/ bmi_tbl.htm - For formal BMI Calculator Bulimia Nervosa One change Frequency of binges and compensatory behavior from twice to once per week Lower threshold C-9 C-10 'I get FAN MAIL': World's thinnest woman warns against anorexia as she reveals girls idolise her look http://www.mirror.co.uk/news/world The thinnest woman in the world is using her emaciated figure to warn of the horrors of anorexia after revealing she gets FAN MAIL from girls hoping to copy her look. Gender Dysphoria Chapter Gender Dysphoria Before anorexia After anorexia C-11 C-12 Harmell, Copyright, 2017 Section C -2-
Gender Dysphoria Chapter Gender Dysphoria As opposed to Gender Identity Disorder Defining feature is gender incongruence Separate criteria for children and for adults and adolescence C-13, pp. 451-460 Gender Dysphoria Chapter Gender Dysphoria Child criteria: Criterion A: strong desire to be of the other gender or an insistence that he or she is the other gender Must have Criterion A above: necessary but not sufficient for diagnosis Must have B: distress or impairment Now more restrictive and conservative C-14 Gender Dysphoria Chapter Gender Dysphoria Complaints to Task Force ensued DSM-IV we will look at the evidence DSM-5 we will look into your concern about insurance billing C-15 C-16 Substance-Related and Addictive Disorders Chapter 2. Substance Use Disorders - Formerly Abuse and Dependence - Eleven specific criteria C-17 C-18 Harmell, Copyright, 2017 Section C -3-
GENERAL criteria For Substance Use Disorder Note: Must meet 2 of the 11 criteria in a 12-month period Example: Alcohol Use Disorder Note: Must meet 2 of the 11 criteria in a 12-month period C-19 C-20 Substance-Related and Addictive Disorders Chapter Non-Substance-Related Disorders Behavioral addiction C-21 Types of Problematic Internet Use DID NOT MAKE IT IN DSM-5 Online Gaming Online Gambling Cybersex Online Relationships Online Social Networking Online Shopping and Auction Houses Others C-22 Substance-Related and Addictive Disorders Chapter Non-Substance-Related Disorders Behavioral addiction New Diagnosis: Gambling Disorder Substance-Related and Addictive Disorders Chapter Gambling Disorder Rationale: This new term and its location in the new manual reflect research findings that gambling disorder is similar to substance-related disorders in clinical expression, brain origin, comorbidity, physiology, and treatment. C-23 C-24 Harmell, Copyright, 2017 Section C -4-
, pp. 481-589 Substance-Related and Addictive Disorders Chapter DSM-5 gives Substance-Use Disorders criteria for each category of substances alphabetically Example: Cannabis Use Disorder Inhalant Use Disorder Chapter Oppositional-Defiant Disorder Intermittent Explosive Disorder Conduct Disorder Antisocial Personality Disorder (2 listings) Pyromania Kleptomania C-25 C-26 Disruptive, Impulse-Control, and Conduct Disorders Chapter - New Chapter Disorders previously in childhood section Problems in emotional and behavioral self-control Antisocial PD listed two places C-27 Oppositional Defiant Disorder Four symptoms from the following Symptoms are grouped into three types 1. Angry/Irritable Mood (1-3) 1. Often loses temper 2. Touchy, easily annoyed 3. Often angry C-28 Oppositional Defiant Disorder Pattern of angry irritable mood, argumentative/defiant behavior, or vindictiveness At least 6 months At least 4 out of 8 symptoms C-29 Oppositional Defiant Disorder Four symptoms from the following Symptoms are grouped into three types 2. Argumentative/Defiant Behavior 4. Argues with authority 5. Defies others 6. Deliberately annoys others 7. Blames others for own mistakes C-30 Harmell, Copyright, 2017 Section C -5-
Oppositional Defiant Disorder Four symptoms from the following Symptoms are grouped into three types 3. Vindictiveness 8. Spiteful to others Distinguishing the Difference APA, 2013, p. 465 DMDD vs Oppositional-Defiant DMDD More severe Greater frequency More chronic Oppositional-Defiant When DMDD is Diagnosed do not diagnose OD C-31 A-32 Conduct Disorder Symptoms and behaviors grouped Aggression to People and Animals Destruction to Property Deceitfulness or Theft Serious Violations of Rules Conduct Disorder Mostly unchanged Specifiers Callous and unemotional interpersonal style Lack of remorse or guilt Unconcerned about performance Shallow or deficient affect C-33 C-34 Antisocial Personality Disorder Note Dual Listing for APD: Disruptive, Impulse-Control and Conduct D/O Chapter Personality Disorders Chapter Due to close association with Antisocial PD Conduct Disorder Specify whether: 312.82 (F91.10) Childhood-onset type One symptom prior to age 10 312.82 (F91.2) Adolescent-onset type No symptoms prior to age 10 312.89 (F91.9) Unspecified onset Not enough information C-35 C-36 Harmell, Copyright, 2017 Section C -6-
Intermittent Explosive Disorder Type of aggressive outburst is considered DSM-5 Verbal aggression and nondestructive / non-injurious physical aggression meet criteria requirement Physical aggression not required (DSM-IV) Minimum age 6 to rule out general tantrums C-37 Voyeuristic Disorder Exhibitionistic Disorder Frotteuristic Disorder Sexual Machochism Disorder Sexual Sadism Disorder Pedophilic Disorder Fetishistic Disorder Transvestic Disorder C-38 Primary change: NOT automatically considered mental disorders Difference between paraphlias and the Paraphilic Disorder Ethical Issues ETHICAL ISSUE: Does not pathologize all NON-normative sexual behavior Paraphilias are not a mental disorder If only meets Criterion A and NOT B Paraphilic Disorder IS a mental disorder Meets Criteria A and B A. Specific paraphilia AND B. Stress or impairment C-39 C-40 DSM-5 Comparison Paraphilic Disorder and Paraphilia Paraphilias Need only meet Criterion A A: Recurrent & intense Sexual arousal from. Fill in for the specific paraphilia being diagnosed, such as Exhibitionistic Disorder Paraphilic Disorder Must meet Criterion A and B A. Previous square AND B. Person has acted upon these urges, fantasies or behaviors (potentially) causing harm OR it causes clinically significant distress or impairment C-41 Ethical Issue Denotes any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, psychically mature, consenting human partners there are specific paraphilias that are generally better described as preferential sexual interests than as intense sexual interests. (pp. 685-686) C-42 Harmell, Copyright, 2017 Section C -7-
A paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others and a paraphilia by itself does not necessarily justify or require clinical intervention. (pp. 685-686) Practice Vignette Lisa is a 62 year old woman who has just experienced the death of her husband of 40 years. She is anxious, sad, tearful and stays in bed all day. Lisa does not eat organized meals anymore, fails to get dressed, and is lethargic. What potential diagnoses are available in the new DSM-5? ANSWER: C-43 C-44 What two disorders previously in Appendix B (diagnoses for further study) are now included in Section II (the main mental disorders? What is the primary ETHICAL ISSUE related handling conflicting personal and professional values such as in the Julea Ward situation? C-45 C-46 What is the difference between paraphilias and Paraphilic Disorders? What is the rationale behind adding the new diagnosis Avoidant/Restrictive Food Intake Eating Disorder? C-47 C-48 Harmell, Copyright, 2017 Section C -8-
What is the primary difference between Avoidant/Restrictive Food Intake Disorder and Anorexia Nervosa? What is the non-substance behavioral addiction included in the DSM-5? C-49 C-50 What is the rationale for inclusion of Gambling Disorder in the addictions chapter of DSM-5? Bibliography Axelson, D., Findling, R. L., Fristad, M. A., Kowatch, R. A., Youngstrom, E. A., Horwitz, S. M., et al. (2012). Examining the proposed disruptive mood dysregulation disorder diagnosis in children in the Longitudinal Assessment of Manic Symptoms Study. Journal of Clinical Psychiatry, 73(10), 1342 1350. PubMed CrossRef Brown, J., O Brien, P. M., Marjoribanks, J., & Wyatt, K. (2009). Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database of Systematic Reviews, Apr 15, 2009;(2):CD001396. doi:10.1002/14651858.cd001396.pub2. C-51 C-52 Bibliography Carey, B. (2012). Grief could join list of disorders. New York Times, January 25, 2012, A1 Dobbs, D. (2012). The new temper tantrum disorder. Slate, December 7, 2012. Accessed Dec. 7, 2012 at: http://www.slate.com/articles/double_x/doublex/2012/12 /disruptive_mood_dysregulation_disorder_in_dsm_5_cri ticism_of_a_new_diagnosis.html Frances, A. (2013). The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ, 346(3), f1580. doi:10.1136/bmj.f1580. Bibliography Fusar-Poli, P., & Van Os, J. (2013). Lost in transition: Setting the psychosis threshold in prodromal research. Acta Psychiatrica Scandinavica, 127, 248 252. PubMed CrossRef Jones, K. D., Gill, C., & Ray, S. (2012). Review of the proposed DSM-5 substance use disorder. Journal of Addictions & Offender Counseling, 33(2), 115 123 CrossRef McLaughlin, J. (2002). Reducing diagnostic bias. J of Mental Health Counseling, 24,(3), 256-270. C-53 C-54 Harmell, Copyright, 2017 Section C -9-