Transcript Section II

DSM 5 LECTURE
September 11, 2015
Holly Lem, Ph.D.
Hypotheticals
When Mind Meets Body:
 Are psychological problems the same
as medical problems?
 What do they have in common?
 What’s different?
 Should the same tools be used to assess
both?
The Well-Meaning Metaphor
“There
is nothing wrong with taking
medication for your depression, if
you had Diabetes, would you think
twice about taking your insulin?”
Major Depressive Disorder
(DSM-5)
Five or more of symptoms, the same 2 week period;
1. Depressed mood most of the day
2. Diminished interest or pleasure
3. Significant weight loss or gain
4. Insomnia or hypersomnia
5. Psychomotor agitation
6. Fatigue or loss of energy
7. Feelings of worthlessness
8. Diminished ability to think/concentrate
9. Recurrent thoughts of suicide
Major Depression
(DSM-5)
Patient #1
Patient #2
1. Depressed Mood
2. Significant weight gain
3. Fatigue and loss of energy
4. Diminished ability to
concentrate
5. Recurrent thoughts of suicide
1.
2.
3.
4.
5.
Diminished interest
Insomnia
Psychomotor agitation
Feelings of worthlessness
Recurrent thoughts of
suicide
“The lack of objective tests for
mental disorders makes diagnostic
reliability a difficult problem” (Hyman,
2015)
The DSM-5 creates a veneer of
objectivity that does not accurately
reflect the heterogeneity of mental
illness nor the subjective experience of
mental illness. (Lem, now)
Does it have to be either/ or?
Subjective (psychology, art)
vs.
Objective
(science, medicine)
DSM- 5
Psychiatry’s New Diagnostic Manual:
“Don’t buy it.
Don’t use it.
Don’t teach it.”
(Allen Frances, MD, Chair
of the DSM-IV task force)
DSM 5 Nexus:
Insurance
Companies
School
DSM5
Clinical
Services
Drug
Companies
DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS (DSM-5, 2013)
A child with a diagnosis, what does this mean
for his/her life?
1. The potential benefits of diagnosing kids?
2. The potential dangers of diagnosing kids?
Our Love/Hate Relationship
With Diagnosis
 “Acceptable”/”unacceptable diagnoses
 Casual use- “I’m so OCD”, “I still haven’t recovered
from my PTSD- he was such a @#$$hole.”
 Intrigued/fascination
 Shocked
 Reconceptualize their life, their identity
around the diagnosis
My Approach to the DSM:
A curious skeptic
A self-serving relationship
An imperfect relationship that I can’t get
out of
All of the above
Can the DSM account for
complexity?
 Story of “Belle”
 16 y.o girl of Haitian descent
 Has a 4 month old baby
 Lives in a residential treatment facility
 The question presented by the Court: Can she
adequately parent this child?
The DSM: A snapshot in time
 DSM-I 1952
 DSM-II 1968
**********
 DSM-III 1980
 DSM-III R 1987
 DSM-IV 1994
 DSM-IV TR 2000
**********
 DSM- 5 May 2013
Significant Changes to DSM-III
(significant problems for the DSM-5)
 Atheoretical
 Categorical system
 Multiaxial system
The DSM-III Revolution
“A Mental Disorder is a Medical
Disorder” (Spitzer, 2005)
On the systemic, evidence based making of the
DSM-III:
“There was very little systematic research
and much of the research that existed
was really a hodgepodge-scattered,
inconsistent, ambiguous”
A Common Sense Approach:
 “The defenders of
the DSM are wrong who
claim that all disorders are medical diseases.
The critics of DSM are wrong who claim that
all disorders are not medical diseases, some
are, some are not. The problem with the
DSM is that it doesn’t care.”

(Ghaemi, 2013)
Multiaxial System
(from the DSM-IV)
 Axis I Clinical Disorders
Other conditions that may be a focus of clinical attention
 Axis II Personality Disorders

Mental Retardation
 Axis III General Medical Conditions
 Axis IV Psychosocial and Environmental Problems
 Axis V Global Assessment of Functioning
“Belle”
(by DSM-IV standards)
Axis I
V code?
Axis II ?
Axis III ?
Axis IV ?
Axis V GAF =
V Codes
(Other Conditions that May Be a Focus of Clinical Attention)
 Parent-Child Relationship problems
 Physical Abuse of Child
 Sexual Abuse of Child
 Neglect of Child
 Acculturation Problem
 Identity Problem
 Academic Problems
Axis II Personality Disorders
Mental Retardation










(Paranoid PD)
(Schizoid PD)
Schizotypal PD
Antisocial PD
Borderline PD
(Histrionic PD)
Narcissistic PD
Avoidant PD
(Dependent PD)
Obsessive-Compulsive PD
Axis I vs. Axis II
 State vs. Trait
 Dystonic vs. Syntonic
 Character Armor
 Treatment Resistant
Axis III General Medical Conditions
 Should reference source of info
 If medical condition impacts other axes, should note.
(e.g. heart condition and anxiety)
 Mental Disorder Due to General Medical Condition –
Axis I and III
 Belle- chronic headaches, self-reports
Axis IV Psychosocial and Environmental Problems
Problems with primary support group
Problems related to social environment
Educational Problems
Housing problems
Economic Problems
Problems related to legal system
Axis V Global Assessment of Functioning
 Clinical judgment about level of functioning: social,
academic/occupational, psychologically
 Continuous scale- to 100
 Higher the number, better functioning
 70 below most likely carries a diagnosis
 Not designed for children
The DSM-5 (May, 2013)
 Started formulating since 1999
 Composed of 13 work groups
 Designed as a “guidebook for clinicians.”
 Clinical Utility: guiding principle
 pg. 947
 “Transparent process” over 13,000 responses
DSM-5 in a nutshell
 Three Sections: Organized from a developmental
perspective
 Section I: Introductory Information
 Section II: Diagnostic Criteria and Codes
 Section III: Emerging Measures and Models,
Conditions for Further Study,
Cultural Formulation
Cultural Formulation Interview
Section II:
Table of Contents
1.
2.
3.
4.
5.
6.
7.
8.
9.
Neurodevelopmental D/Os (ADHD, Autism)
Schizophrenia Spectrum & Other Psychotic D/Os
Bipolar and Related Disorders
Depressive Disorders (DMDD*, PDD*, PDD)
Anxiety Disorders (Phobias, GAD, Social Anxiety)
Obsessive-Compulsive/Related Disorders (Body
Dysmorphic d/o, Hoarding, Excoriation)
Trauma and Stressor Related Disorders
Dissociative Disorders
Somatic Symptom and Related Disorders
Section II:
10. Feeding and Eating Disorders
11. Elimination Disorders
12. Sleep-Wake Disorders
13. Sexual Dysfunctions
14. Gender Dysphoria
15. Disruptive, Impulse-Control and Conduct Disorder
16. Substance-Related/Addictive Disorders (Gambling)
17. Neurocognitive Disorders
18. Personality Disorders
Section II: Cont.
19. Paraphiliac Disorders
20. Other Mental Disorders
21. Medication-Induced Movement Disorders/adverse
effects of medication
22. Other Conditions that may be a Focus of Clinical
Attention
DSM-5 Controversies
Overpathologizing: looser criteria, new diagnoses
1. Binge Eating Disorder (occurs on average, at least once a
week for 3 mos.)
2. Premenstrual Dysphoric Disorder: Is
this a mental disorder?
3. Behavioral Addictions: Gambling?
Internet gaming disorder? Sexual addiction?
4. Adult ADHD: less symptoms required
DSM-5 Controversies cont.
5. Disruptive Mood Dysregulation Disorder: an attempt
to decrease diagnosis of Bipolar Disorder in children;
(under Depressive Disorders)
*Was initially called “Temper Dysregulation Disorder”
*Little empirical support for new diagnosis
Background: Since 1994, significant increase in dx of
Bipolar Disorder in children:
*** 1994-95: 25 out of 100,000
2002-2003: 1003 out of 100,000
DMDD (DSM-5, 2013)
Severe recurrent temper outbursts manifested
verbally and/or behaviorally that are grossly out of
proportion in intensity or duration to the situation
2. Inconsistent with developmental level
3. On average, 3 or more times per week
4. Mood between outbursts is persistently
irritable/angry most of the day
1.
The Limits of Categories
Co-morbidity: extremely commonplace
2. Excessive use of “NOS”- not otherwise specified
3. Not meeting the threshold, does not mean no
distress- prevents early intervention/prevention
4. Diagnoses evolve into other diagnoses over timeheterotypic continuity
1.
DSM-5 dabbles with dimensionality
 Autism Spectrum Disorder
 Schizophrenia
 Intellectual Disability
 Severity Index
Autistic Spectrum Disorder
 DSM-5 subsumed Asperger’s, Autism, Pervasive
Developmental Disorder NOS under ASD
 Diagnostic criteria is based on:
1. Deficits in social communication/
interaction
2. Restrictive, repetitive patterns of behaviors,
interests of activities
Underdiagnosing?
“Hey, what happened,
I no longer exist.”
(Peter, formerly diagnosed with Asperger’s Syndrome)
Severity Levels for Autism
Spectrum Disorder
Table 2 Severity levels for autism spectrum disorder
Severity level
Social communication
Restricted, repetitive behaviors
Level 3
Severe deficits in verbal and nonverbal social communication
Inflexibility of behavior, extreme difficulty coping with change,
“Requiring very substantial support”
skills cause severe impairments in functioning, very limited
or other restricted/repetitive behaviors markedly interfere with
initiation of social interactions, and minimal response to social
functioning in all spheres. Great distress/difficulty changing
overtures from others. For example, a person with few words of
focus or action.
intelligible speech who rarely initiates interaction and, when he
or she does, makes unusual approaches to meet needs only and
responds to only very direct social approaches.
Level 2
Marked deficits in verbal and nonverbal social communication
Inflexibility of behavior, difficulty coping with change, or other
“Requiring substantial support”
skills; social impairments apparent even with supports in place;
restricted/repetitive behaviors appear frequently enough to be
limited initiation of social interactions; and reduced or
obvious to the casual observer and interfere with functioning in
abnormal responses to social overtures from others. For
a variety of contexts. Distress and/or difficulty changing focus or
example, a person who speaks simple sentences, whose
action.
interaction is limited to narrow special interests, and who has
markedly odd nonverbal communication.
Level 1
Without supports in place, deficits in social communication
Inflexibility of behavior causes significant interference with
“Requiring support”
cause noticeable impairments. Difficulty initiating social
functioning in one or more contexts. Difficulty switching
interactions, and clear examples of atypical or unsuccessful
between activities. Problems of organization and planning
responses to social overtures of others. May appear to have
hamper independence.
decreased interest in social interactions. For example, a person
who is able to speak in full sentences and engages in
communication but whose to-and-fro conversation with others
fails, and whose attempts to make friends are odd and typically
unsuccessful.
Will the new ASD reduce
diagnosis?
 Dr. Catherine Lord, head of DSM-5 autism group, will
reduce diagnosis by 10%, not significant?
 Mattila (2011) only 46% who meet DSM-IV criteria, will
meet DSM-5
 Taheri & Perry (2012) 63% of those meeting DSM-IV,
will meet DSM-5
 McPartland (2012) only 60% of those formerly
diagnosed with ASD, will meet DSM-5
 Mandy (2012) 64 out of 66 people with a DSM-IV of
PDD NOS would be excluded from DSM-5
DSM and Culture:
Where is Context in the DSM-5?
 Historically DSM critiqued: lack of cultural sensitivity
 DSM-IV: Outline for Cultural Formulation/Glossary of
Culture-Bound Syndromes pg. 843/886
 DSM-5: Cultural Formulation-Section III, pg. 749/816
 Lack of understanding how to use
 Lack of integration
 Hard to account for culture in the DSM
Outline for Cultural Formulation
DSM- 5
The clinician should provide a systematic
assessment of the following categories:
Cultural identity of the individual
2. Cultural conceptualizations of distress
3. Psychosocial stressors and cultural features of
vulnerability and resilience
4. Cultural features of the relationship between the
individual and the clinician
5. Overall cultural assessment
1.
Cultural Formulation Interview (CFI)
“A set of 16 questions that clinicians can
use to obtain information during a
mental health assessment about the
impact of culture on key aspects of an
individual’s clinical presentation and
care.”
Embracing Culture: (Kress, Eriksen, Rayle & Ford,
2005)
 Have I been able to separate what is important to me and




what is important to this particular client
What do I know about this client’s cultural heritage and
what don’t I know
What is their relationship with his or her culture from their
perspective
To what degree is the client acculturated to the dominant
culture
What are my stereotypes, beliefs and biases about this
culture and how might these influence my understanding
Embracing Culture
Cont.
 What culturally appropriate strategies/techniques should
be incorporated in the assessment process?
 What is my philosophy of how pathology is
operationalized in individuals from this cultural group
 Have I appropriately consulted with other mental health
professionals, members from this culture, and /or family
members or extended family?
 Has this client aided in the construction of my
understanding of this problem?
 “New diagnoses in psychiatry are more dangerous than
new drugs because they influence whether or not
millions of people are placed on drugs-often by
primary care doctors after brief visits. Before their
introduction, new diagnoses deserve the same level of
attention to safety that we devote to new drugs. APA is
not competent to do this.” (Francis, 2013)