Changes in the Diagnostic and Statistical Manual of Mental s that Impact Forensic Psychology Kristine M. Jacquin, Ph.D. Fielding Graduate University Presented at ACFP Symposium 2014 Overview of Presentation Brief introduction to DSM-5 Primary differences in DSM-5 Overall impact of DSM-5 on forensic practice Specific DSM-5 changes that impact psycholegal issues 2 Copyright Disclaimer Some of the content of this presentation (e.g., diagnostic criteria) comes directly from DSM-5, published by the American Psychiatric Association. Consider this disclaimer to be the proper quotation and citation of included content, when relevant. Introduction to DSM-5 Section and Chapter Structure and Content Note: not intended to be used as a substitute for DSM-5 (in some cases, incomplete information is provided in favor of brevity) 3 Overview of DSM-5 Section I: Basics Section II: Diagnostic criteria and codes Section III: Emerging measures and models Appendix Index Section I: Basics Orients readers to the purpose, structure, content, and use of the manual Discusses process of creating DSM-5 Summarizes structure of DSM-5 and movement away from multiaxial system Discusses clinical case formulation and using the DSM-5 Includes caution about forensic use of DSM-5 5 6 1
Section II: Diagnostic Criteria and Codes Chapters categories of disorders Mental disorders described in detail within each chapter Section II Chapters 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 7 8 Section II Chapters cont. Dissociative disorders Somatic symptom and related disorders Feeding and eating disorders Elimination disorders Sleep-wake disorders Sexual dysfunctions Gender dysphoria 9 Section II Chapters cont. Disruptive, impulse-control, and conduct disorders Substance-related and addictive disorders Neurocognitive disorders Personality disorders Paraphilic disorders Other mental disorders Medication-induced movement disorders & other adverse effects of medication (not mental disorders) Other conditions that may be a focus of clinical attention (not mental disorders) 10 Section III: Emerging Measures and Models Purpose: provides a place for content that may be clinically useful but requires further research Section III Content Assessment Measures Cultural Formulation Alternative DSM-5 Model for Personality s Conditions for Further Study 11 12 2
Appendix Highlights of changes from DSM-IV to DSM-5 Glossary of technical terms Glossary of cultural concepts of distress Alphabetical listing of DSM-5 diagnoses and codes for ICD-9-CM and ICD-10-CM Beyond DSM-IV-TR: Comparing DSM-IV and DSM-5 Numerical listings of DSM-5 diagnoses and codes for ICD-9-CM and ICD-10-CM DSM-5 advisors and other contributors 13 DSM-IV-TR DSM-5 172 157 specific mental disorders 50 disorders combined into 22 15 new disorders added 2 disorders removed Some disorders re-categorized s Combined in DSM-5 Language (Expressive Language & Mixed Receptive Expressive Language ) Autism Spectrum (Autistic, Asperger s, Childhood Disintegrative, & Rett s ) Specific Learning (Reading, Math, & of Written Expression) Delusional (Shared Psychotic & Delusional ) 15 16 Combined s cont. Panic (PD without Agoraphobia & PD with Agoraphobia) Dissociative Amnesia (Dissociative Fugue & Dissociative Amnesia) Somatic Symptom (Somatization, Undifferentiated Somatoform, & Pain ) Insomnia (Primary Insomnia & Insomnia Related to Another Mental ) Hypersomnolence (Primary Hypersomnia & Hypersomnia Related to Another Mental ) Combined s cont. Non-Rapid Eye Movement Sleep Arousal s (Sleepwalking & Sleep Terror ) Genito-Pelvic Pain/Penetration (Vaginismus & Dyspareunia) Alcohol Use (Alcohol Abuse & Alcohol Dependence) Cannabis Use (Cannabis Abuse & Cannabis Dependence) Phencyclidine Use (Phencyclidine Abuse & Phencyclidine Dependence) 17 18 3
Combined s cont. Other Hallucinogen Use (Hallucinogen Abuse & Hallucinogen Dependence) Inhalant Use (Inhalant Abuse & Inhalant Dependence) Opioid Use (Opioid Abuse & Opioid Dependence) Sedative, Hypnotic, or Anxiolytic Use (SHA Abuse & SHA Dependence) Stimulant Use (Amphetamine Abuse, Amphetamine Dependence, Cocaine Abuse, Cocaine Dependence) Combined s cont. Stimulant Intoxication (Amphetamine Intoxication & Cocaine Intoxication) Stimulant Withdrawal (Amphetamine Withdrawal & Cocaine Withdrawal) Substance/Medication-Induced s (aggregate of Mood, Anxiety, and Neurocognitive Substance/Med Induced) 19 20 New s in DSM-5 Social (Pragmatic) Communication Disruptive Mood Dysregulation Premenstrual Dysphoric (*DSM-IV-TR appendix) Hoarding Excoriation (Skin-Picking) Disinhibited Social Engagement (split from Reactive Attachment ) Binge Eating * Central Sleep Apnea (split from Breathing- Related Sleep ) 21 New s cont. Sleep-Related Hypoventilation (split from Breathing-Related Sleep ) Rapid Eye Movement Sleep Behavior (Parasomnia NOS) Restless Legs Syndrome (Dyssomnia NOS) Caffeine Withdrawal* Cannabis Withdrawal Major Neurocognitive with Lewy Body Disease (Dementia Due to Other Medical Conditions) Mild Neurocognitive * 22 s Eliminated from DSM-5 Sexual Aversion Polysubstance-Related New NOS Terminology DSM-IV = Not Otherwise Specified (41 instances) DSM-5 = Other Specified and Unspecified (65 instances) Changed to be more consistent with ICD 23 24 4
DSM-5 and Forensic Practice DSM-5: Overall Impact on Forensic Practice Clinical diagnosis of DSM-5 mental disorder legal criteria for mental disorder Clinical diagnosis of DSM-5 mental disorder meeting legal standard related to mental state Additional info needed to determine legal criteria or legal standard 25 26 DSM-5 and Forensic Practice cont. Evaluators use clinical diagnosis as part of description of mental state Clinical diagnosis is foundation for making certain psycholegal arguments DSM-5: Specific Changes Relevant to Psycholegal Issues 27 28 Intellectual Disability Intellectual Disability Psycholegal questions: Atkins evaluations CST assessment Criminal responsibility evaluation Disability determinations Civil competencies New name Degrees of severity (mild, moderate, etc.) no longer separate diagnostic codes Specify severity with F code Severity based on adaptive functioning rather than IQ Consistent with AAIDD definition Highlights issues that are often raised in legal cases 29 30 5
Intellectual Disability Intellectual Disability 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. Diagnostic features section: complete IQ test, SEM, Flynn effect, practice effects 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. Diagnostic features section: conceptual, social, and practical domains 31 32 Intellectual Disability C. Onset of intellectual and adaptive deficits during the developmental period. Diagnostic features section: deficits are present during childhood and adolescence Autism Spectrum Psycholegal questions: CST assessment Criminal responsibility evaluation Disability determinations Civil competencies 33 34 Replaces: Autism Spectrum Autistic Asperger Childhood Disintegrative Rett Pervasive Developmental NOS Single, behaviorally defined disorder Autism Spectrum Rett disorder & other etiologic subgroups: Associated with known medical or genetic condition or environmental factor 3 symptom domains became 2: social communication and restricted, repetitive behaviors Should allow for more accurate diagnoses 35 36 6
Autism Spectrum A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history: Deficits in social-emotional reciprocity Deficits in nonverbal communicative behaviors used for social interaction Deficits in developing, maintaining, and understanding relationships Autism Spectrum B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history: 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 interests that are abnormal in intensity or focus Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment 37 38 Autism Spectrum 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). Specific Learning Psycholegal questions: Work- and school-related disability determinations and/or accommodations 39 40 Specific Learning Three disorders became one Criterion A describes specific difficulties Specify type Achievement is substantially lower than age based expectations Specific Learning 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 41 42 7
Specific Learning 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. Specific Learning C. The learning difficulties begin during school-age years but may not become fully manifest until learning demands exceed the individual s limited capacities. 43 44 Disruptive Mood Dysregulation Psycholegal questions: Juvenile criminal responsibility Juvenile risk assessment and treatment amenability Disruptive Mood Dysregulation A. Severe recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation. B. Temper outbursts are inconsistent with developmental level. C. Outbursts occur 3+ times/week (avg.) D. Mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others. 45 46 Disruptive Mood Dysregulation G. Dx should not be made for first time before age 6 or after age 18. H. Age of onset before 10 years Premenstrual Dysphoric Psycholegal issues: Disability determinations Diminished capacity 47 48 8
Premenstrual Dysphoric A. In majority of menstrual cycles, at least 5 symptoms present in final week before onset of menses, start to improve within a few days after onset of menses, and become minimal or absent in the week postmenses. Premenstrual Dysphoric B. One or more symptoms: Marked affective lability Marked irritability or anger or increase conflicts. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts Marked anxiety, tension, feeling on edge 49 50 Premenstrual Dysphoric C. One or more symptoms, to reach a total of five symptoms when combined with B: Decreased interest in usual activities Subjective difficulty in concentration Lethargy, easy fatigability, marked lack of energy Marked change in appetite; overeating; cravings Hypersomnia or insomnia Sense of being overwhelmed or out of control Physical symptoms such as breast tenderness or swelling, joint or muscle pain, bloating, weight gain Hoarding Psycholegal questions: Disability determinations Diminished capacity for crimes related to hoarding 51 52 Hoarding A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties. Post Traumatic Stress Psycholegal questions: Diminished capacity Criminal responsibility Psychological injury Disability determinations 53 54 9
Post Traumatic Stress Special criteria for pre-schoolers Dissociative subtype Clearer definitions Tightening of criterion A1 55 Post Traumatic Stress A. The person was exposed to the following event(s): death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways: Directly experiencing the traumatic event Witnessing, in person, the event(s) as they occurred to other(s) Learning that the event(s) occurred to a close relative or close friend; in such cases, the actual or threatened death must have been violent or accidental Experiencing repeated or extreme exposure to aversive details of the events(s) (e.g., first responders collecting body parts, police officers repeatedly exposed to details of child abuse); does not apply to exposure through electronic media, TV, movies or pictures unless exposure is work-related 56 Post Traumatic Stress Eliminated criterion A2 4 symptom clusters instead of 3 DSM-IV-TR Re-experiencing Avoidance & numbing Increased arousal DSM-5 Intrusion symptoms Avoidance Alterations in cognition & mood Alterations in arousal and reactivity Neurocognitive s Psycholegal questions: CST, criminal responsibility Civil competencies 57 58 Neurocognitive s Neurocognitive s Major or Mild Neurocognitive Due to Alzheimer s Disease Major or Mild Frontotemporal Neurocognitive Major or Mild Neurocognitive with Lewy Bodies Major or Mild Vascular Neurocognitive Major or Mild Neurocognitive Due to TBI Substance/Medication-Induced Major or Mild Neurocognitive Major or Mild Neurocognitive Due to HIV Infection Major or Mild Neurocognitive Due to Prion Disease Major or Mild Neurocognitive Due to Parkinson s Disease Major or Mild Neurocognitive Due to Huntington s Disease Major or Mild Neurocognitive Due to Another Medical Condition; Due to Multiple Etiologies; Unspecified 59 60 10
Neurocognitive s Neurocognitive s A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on: 1. Concern of individual, informant, clinician, and 2. A substantial impairment in cognitive performance, documented by testing B. The cognitive deficits interfere with independence in everyday activities. A. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on: 1. Concern of individual, informant, clinician, and 2. A modest impairment in cognitive performance, documented by testing B. The cognitive deficits do not interfere with capacity for independence in everyday activities. 61 62 Conclusions Questions? Significant changes in diagnostic criteria in DSM-5 Contact me at: kjacquin@fielding.edu or drkristinejacquin@gmail.com When diagnosis is relevant to psycholegal question, must be well-versed in DSM-5 criteria and features 63 64 11
Changes in the Diagnostic and Statistical Manual of Mental s that Impact Forensic Psychology Although few psycholegal questions are answered solely on the basis of psychological diagnosis, DSM diagnoses are quite relevant to many psycholegal issues. For example, a diagnosis of intellectual disability is central to the question of whether a convicted offender can be sentenced to death. Similarly, a mental disorder diagnosis is required to legally label someone a sexually violent predator in most states with such designations. Given the relationship between DSM diagnosis and many psycholegal questions, the introduction of a substantially revised DSM (i.e., DSM-5) has a large impact on forensic psychology. The purpose of this presentation is to provide an overview of the changes in DSM-5 and to describe the ways in which these changes impact forensic evaluations. Learning objectives: At the conclusion of this presentation, attendees will be able to: 1. At the conclusion of this presentation, attendees will be able to describe the broad changes in DSM-5 relative to DSM-IV-TR. 2. At the conclusion of this presentation, attendees will be able to summarize the impact of DSM-5 on forensic practice. 3. At the conclusion of this presentation, attendees will be able to explain specific ways in which DSM-5 changes impact psycholegal issues. Presenter biography: Kristine Jacquin earned a B.A. at Northwestern University, and her M.A. and Ph.D. in clinical psychology at the University of Texas at Austin. Dr. Jacquin is a Professor of Psychology and Dean at Fielding Graduate University. She is also a licensed clinical psychologist with a consulting practice focusing on forensic and neuropsychological evaluations. Selected references: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5 th ed.). Washington, D.C.: Author. Bernet, W., & Baker, A. J. L. (2013). Parental alienation, DSM-5, and ICD-11: Response to critics. Journal of the American Academy of Psychiatry and the Law, 41, 98-104. Duschinsky, R., & Chachamu, N. (2013). Sexual dysfunction and paraphilias in the DSM-5: Pathology, heterogeneity, and gender. Feminism & Psychology, 23, 49-55. Tyrer, P. (2013). The classification of personality disorders in ICD-11: Implications for forensic psychiatry. Criminal Behaviour and Mental Health, 23, 1-5. Wakefield, J. C. (2012). The DSM-5 s proposed new categories of sexual disorder: The problem of false positives in sexual diagnosis. Clinical Social Work Journal, 40, 213-223.