Transcript Cappicie presentation INTRO to DSM 5

Intro to the DSM 5 for the Trauma
Focused Care Worker
Amy Cappiccie, PhD, LCSW
Western Kentucky University
Region IX Representative, NASW
Learning Outcomes
 Participants will be able to identify at least one
major change to the philosophy behind the DSM 5
 Participants will be able to list and describe at
least three new DSM 5 disorders.
 Participants will be able to compare and contrast
at least three revised DSM 5 disorders with the
equivalent DSM IV TR disorders.
Historical Perspective: DSM I
(Blashfield, 1998; Scotti & Morris, 2000; Klott, 2013)
DSM
Purpose
#
Diagnosis
Changes
Problems
DSM I
(1952)
Compiling
Knowledge
based on
info at the
time;
Original
copyright
with military
3 categories:
1) Organic
brain
syndrome
s,
2) Functiona
l DO,
3) Mental
deficienc
y
Only 1
applied to
children:
Questionnair
es to 10%
members;
Adjustment
Reaction to
Childhood/
Adolescents
Subjective
perspective
** Harry
Stack
Lack of
reliability
and/or
validity,
Reaction Theory
(Klott, 2013)
 “We bring into adulthood early childhood defense
mechanisms” Harry Stack Sullivan, 1951
 Reaction theory:
 Trauma + coping strategies = survival
 Survival can = personality changes into adulthood
Historical Perspective: DSM II
(Blashfield, 1998; Scotti & Morris, 2000; Klott, 2013)
DSM
Purpose
#
Changes Problems
Diagnosi
s
DSM II
(1968)
Further
increase
communic
ation
among
profession
als
11
categories
with
increased
attention
to children
APA
Additional
category =
Behavioral
Disorders
of
Childhood
and
Total: 165 Adolescen
diagnosis ts
Lack of
reliability
and
validity;
Lack of
descriptio
n for
diagnosis
Historical Perspective: DSM III
(Blashfield, 1998; Scotti & Morris, 2000; Klott, 2013)
DSM
Purpose
# Diagnosis
Changes
Problems
DSM III (1980)
Questions of
reliability and
validity
Total = 265
Removal of
homosexuality
Became
guideline for
insurance
Multi-axis
review
Political debates
over
terminology and
diagnostic
criteria
Increase in size
(p. 92 to p. 482
not “user
Friendly”)
Differences in
coding between
ICD and DSM
Reliability
computation
across class
Historical Perspective: DSM III R
(Blashfield, 1998; Scotti & Morris, 2000; Klott, 2013)
DSM
Purpose
#
Diagnosis
Changes
Problems
DSM III R
(1987)
New
research,
field trails
and coding
Total = 297
Six new
categories
deleted
Different
amounts of
attention
provided to
diagnosis
Added:
Trichotillom
ania
Questioned
scientific
Controversial underpinning
diagnosis
s
considered
not used:
Field trails by
Premenstrual experts =
Historical Perspective: DSM IV/ IV TR
(Blashfield, 1998; Scotti & Morris, 2000; Klott, 2013)
DSM
Purpose
#
Changes
Diagnosis
DSM IV
Increased
Total = 365
research
(p. 886)
findings
3 step
process:
1)
Literature
review
2) Data
gathering
and analysis
Problems
Restructuri Bias toward
ng
biological
categories
Problems
Provides
with
information symptoms
on each
overlap
DO
between
diagnosis
Sources =
decision
Continued
DSM 5 Philosophy
(Klott, 2013)
 Started 1999: Delays due to replacing members (50%






outside US)
Reflects ICD 10
Reduce stigma of mental disorders
Reduce use of medications
Focus on relationship in therapy and diagnosis
Redefining goal of manual: Sullivan focus vs. billing
Mandatory compliance of October 2015
DSM 5 Sections
(APA, 2013)
 Section I: DSM 5 Basics
 Section II: Diagnostic Criteria and Codes
 Section III: Emerging Measures and Models
 Section IV: Appendix
DSM5 : Classifications
(APA, 2013)
Neurodevelopmental
DO
Schizophrenia
Spectrum and Other
Psychotic DO
Bipolar and Related
DO
Depressive DO
Anxiety DO
Obsessive Compulsive
and Related DO
Trauma and Stressor
Related DO
Dissociative DO
Somatic Symptom and
Related DO
Feeding and Eating
DO
Elimination DO
Sleep-Wake DO
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse
Control and Conduct
DO
Neurodevelopmental DO
(APA, 2013; Klott, 2013)
 Intellectual Disability
 Autism Spectrum DO
 Attention-Deficit- Hyperactivity DO
Intellectual Disability
(APA, 2013; Klott, 2013)
 IQ based on testing plus perception of the test administrator
 Severity based on functioning NOT number on test
 Requires assistance in functioning
 Onset before age 18 years
 Use of severity index important to show level of impairment
 Later name will be Intellectual Developmental DO
Autism Spectrum DO
(APA, 2013; Klott, 2013)
 Change to single diagnosis with emphasis given to severity
index
 Do still focuses on: 1) Deficits in social communication and
social interaction and 2) Restricted repetitive
behaviors/interests/activities
 What severity index will be covered? (3 or 4 only?)
Attention-Deficit Hyperactivity DO
(APA, 2013; Klott, 2013)
 Criteria similar
 Few change highlights: Information added on adults,
Comorbidity allowed with ASD, Symptoms prior to age 12
(rather than 7)
 Interesting research:
 60% of those diagnosed as children will still have as an adult
 Adult symptoms = irritability, difficult concentrating, increased
use of cannabis and cocaine
Schizophrenia Spectrum and Other
Psychotic DO (APA, 2013; Klott, 2013)
 Schizophrenia
 Schizoaffective DO
Schizophrenia
(APA, 2013; Klott, 2013)
 Subtypes removed
 More information on differential diagnosis (i.e. substance
abused psychosis, schizoaffective DO and MDD with
psychotic features
 Must complete risk assessment within first 6 weeks of
diagnosis due to increased risk for suicide
 Interesting research: Females increased risk ages 17-24 with
high paranoia, males increased risk ages 36-42
Attenuated Psychosis Syndrome
(Klott, 2013)
 Not billable due to being in section 3
 Research not completed on section 3 diagnoses
 Use for early symptoms of schizophrenia
Schizoaffective DO
(APA, 2013)
 Major mood episode present for majority of the duration of
disorder
 Use the 2-4-2 rule
 During 8 weeks of treatment: 2 weeks psychosis, 4 weeks
mood, 2 weeks psychosis
Bipolar and Related DO
 Bipolar I DO
 Bipolar II DO
Bipolar I DO
(APA, 2013; Klott, 2013)
 Interesting research: watch for co-occurring disorders of
alcohol, cocaine and/or amphetamines
 Symptoms in children under 11 years
 Mania = hyperactivity, grandiosity, psychosis, elated mood,
rapid speech, racing thoughts, refuses sleep
 Depression = personality change, drop in grades, morbid
thoughts, pessimistic, suicidal ideation, somatic complaints
Suicide Risk and Bipolar I and II
(Klott, 2013)
 Suicide should be assessed on both
 Bipolar I research:
 Psychotic driven grandiosity
 Depressive episodes = disabling
 Syntonic
 Decrease risk for suicide (except at psych hospital, new meds or
realize what has been done during mania)
 Bipolar II research:
 Increased risk for suicide during hypomania if high levels of
irritability
Depressive Disorders
 Disruptive Mood Dysregulation DO
 Premenstrual Dysphoric DO
Disruptive Mood Dysregulation DO
(APA, 2013; Klott, 2013)
 Suicide should be assessed
 Child (under 10) into adulthood
 Symptoms:
 Temper outbursts (verbal and behavioral)
 Outbursts more than 3 times per week
 Overall sad/low/irritable mood
Premenstrual Dysphoric DO
(Klott, 2013)
 Suicide should be assessed
 Severity index MUST be 3 or 4
 Symptoms:
 Depressed mood one week prior to cycle
 Feelings of depression, hopelessness, self critical
Obsessive Compulsive and Related DO
 Obsessive Compulsive DO
 Hoarding DO
 Hair-Pulling DO
 Skin Picking DO
Obsessive Compulsive DO
(APA, 2013; Klott, 2013)
 Must assess for suicide risk
 No longer viewed as an anxiety disorder
 High risk for alcohol use
 Insight an important factor in treatment (stress inoculation)
 Symptoms:
 Compulsive acts
 No psychosis
 Intrusive thoughts
Hoarding DO
(APA, 2013; Klott, 2013)
 New diagnosis
 Not within OCD now
 Symptoms:
 Difficulty discarding “things”
 Perceived need to save items
 Extreme distress associated with discarding items
Hair Pulling DO and Skin Picking DO
(APA, 2013; Klott, 2013)
 Now listed as Trichotillomania (Hair Pulling Disorder)
 Skin Picking DO: New diagnosis
Anxiety Disorders
 Panic DO
 Agoraphobia
 Separation Anxiety DO
 Selective Mutism
 Generalized Anxiety DO
Panic DO and Agoraphobia
(APA, 2013; Klott, 2013)
 Panic DO and Agoraphobia delinked into two separate
diagnosis
Diagnoses Shifting to Anxiety DO
(APA, 2013; Klott, 2013)
 Separation Anxiety DO
 Selective Mutism
Generalized Anxiety DO
(Klott, 2013)
 Must access for suicide risk
 Symptoms noted as either: in children, in adolescents or in
adults
 In children 0 – 11 years, GAD is noted as: terror, fear around
natural disasters (3 or 4 severity)
 Adolescents: performance issues in athletics or academics (3
or severity)
 *** higher risk for suicide
 Adults: persistent worry about lots of things, high level of
crisis, busy style to deal with worry
 ** * higher risk for suicide
Suicidal Ideation in GAD
(Klott, 2013)
 Use of Cannabis = high suicide risk
 Does not typically seek treatment due to busy management
style
 Cannot relax due to anxiety and cannabis forces this…person
unable to cope
 Hymen and Waggonner (80-100% will attempt with these
factors present)
 Affected by THC level (past = 3-5% and now = 13-15%)
Trauma and Stress Related DO
 Reactive Attachment DO
 Disinhibited Social Engagement DO
 Posttraumatic Stress DO
 Adjustment DO (now housed in this category)
 Non-suicidal self injurious behavior (section III)
Reactive Attachment DO and Inhibited
Social Engagement DO (APA, 2013; Klott, 2013)
 Both must look at Specifier 4 (Pathogenic care realms)
 Reactive Attachment DO




Inconsistent nurturing/attachment
Responses to relationship = anxiety or no emotional intimacy
Not due to autism
Before age 6 years
 Disinhibited Social Engagement DO





Own distinct DO (instead of specifier in RAD)
Little or inconsistent nurturing/attachment
No boundaries: accepts love/affection from anyone
Before age 6 years
No better accounted for by ADHD
PTSD for Children 6 years and younger
(APA, 2013; Klott, 2013)
 Must check for suicide risk
 Experienced, learned or witnessed trauma about death,
serious injury, sexual violation or violent accident
 Symptoms: nightmares, dissociation, sexual acting out,
emotions of guilt/shame, reenactment in play
 Interesting Research: increased risk for suicide with feelings
of guilt/shame; TV/video will not cause trauma
PTSD (APA, 2013; Klott, 2013)
 Must check for suicide risk
 Symptoms: flashbacks, dissociation, relationship challenges,
emotional constriction, guilt/shame
 Increased risk for suicide with guilt/shame
Non-Suicidal Self-Injurious Behavior
(Klott, 2013)
 Does not correlate with suicidal ideation
 Section III not billable
 Methods of dealing with stress learned in childhood
 This addresses the “why” behind cutting
 Types:





Emotional Regulation Deficits (i.e. anger/rage)
Dissociative Experiences
Body Dysmorphic Issues (i.e. de-sexualize)
Anxiety-Depression Regulation (most common)
Isolation and Social Cohesion Needs (female adolescents,
attention seekers, stops mid to late 30s)
Feeding and Eating DO
(APA, 2013; Klott, 2013)
 Rumination DO, Pica and Avoidant/Restrictive Food Intake
DO (moved from childhood section)
 Binge Eating DO
Binge Eating DO
(APA, 2013; Klott, 2013)
 Binge piece of Bulimia without purging
 At least one binge weekly over the last 3 months
Gender Dysphoria
(APA, 2013)
 New diagnostic class
 Separate categories for children and adolescents/adults
 Specifications for:
 With a disorder f sex development
 Post transition
Disruptive, Impulse-Control and
Conduct Disorders
 Conduct DO
 Oppositional Defiant DO
Conduct DO
(APA, 2013; Klott, 2013)
 Mostly the same except a specifier:
 Callous and unemotional : sociopathy not adult onset, lack of
remorse or guilt, unconcerned about performance, shallow,
lack of affect
 Behavior MUST be observed for 12 continuous months by a
mental health professional and the treating clinician
Oppositional Defiant DO
(APA, 2013; Klott, 2013)
 Moved from childhood disorders
 Three types: 1) angry/irritable mood; 2)
argumentative/defiant and 3) vindictive
 Severity index 3 or 4 (different than typical teen)
Substance Related and Addictive
Disorders (APA, 2013; Klott, 2013)
 Removed poly-substance dependent due to rare via research
field studies
 Gambling DO
 Preoccupation with gambling
 Interesting research: Activates brain in a similar fashion to
drugs/alcohol
 Negative financial and/or legal consequences
Personality Disorders
(APA, 2013; Klott, 2013)
 Many of these diagnoses are put under the appropriate
categories in Section II
 Examples = Schizotypal Personality DO (under Schizophrenia
Spectrum), Antisocial Personality DO (under disruptive,
impulse-control and conduct DO)
 Section III hold interesting new research that has been
gathered thus far
 Can continue to use as in DSM IV TR