Navigating the Kraepelinian Vortex: Changes in the Diagnoses for Children from DSM-IV to DSM-V

1. Navigating the Kraepelinian Vortex: Changes in the Diagnoses for Children from DSM-IV to DSM-V James A. Burns PhD

2. Sources • American Psychiatric Association • DSM IV and IV-TR • DSM 5 • The Selling of DSM, The Rhetoric of Science in Psychiatry • Various other websites and publications

3. What is Abnormal? • Deviations from statistical norm? • Deviations from social norm? • Maladaptive behavior? • Personal Distress?

4. What is abnormal? • May be statistically uncommon and socially deviant but these are not necessary characteristics. • DSM and psychopathologists seems to weigh more heavily on maladaption and personal distress.

5. Example:

6. What then is a disorder? • Grouping of symptoms? • Illness in and of itself? • Psychological construct versus physical existence. • Misuse of diagnoses (K and K p93) • These problems persist (94 and 95)

7. History of DSM • DSM I (1952) • 132 pages • Disorders as “reactions” • Disorders were nonspecific • Definitions were nonspecific • Descriptions were paragraphs of prototypical cases • Psychodynamic in orientation

8. History of DSM • DSM II (1968) • 134 pages • Reaction terminology dropped • Multiple diagnoses encouraged • Coincided with ICD 8 • Psychodynamic in orientation

9. A revolution? • From DSM II to III something changed • Who was pushing the change? • “scientific psychiatry,” payors, public • What was changing? • Movement away from psychoanalysis • Organized psychiatry and the medicalization of mental health • The “medical model” • Power and Authority

10. History of DSM • DSM III • 494 pages • Multi-axial classification system introduced • Neutral, atheoretical, and descriptive in terms of etiology • More specific criteria • The problem of Reliability • Reliability versus validity

11. DSM III-Reliability-Validity • Reliability • Validity • Interplay between the two • Research versus clinical practice • SCID (Structured Clinical Interview) • DIS (Diagnostic Interview Schedule)

12. History of DSM • DSM IV (1994) • 886 pages • “clinical significance” criterion • New disorders introduced • PTSD, Acute Stress Disorder, Bipolar II, and Asperger’s • Others deleted (some personality disorders)

13. History of DSM • DSM 5 (2013) • 947 pages • Dimensional or severity scales adopted • Cultural and gender issues considered more • Multi-axial system dropped • Diagnoses and associated illness listed together in order of importance

14. DSM 5 Changes • Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence replaced by: • Neurodevelopmental Disorders

15. Neurodevelopmental Disorders • Intellectual Disorder (DSM pps 34-41) • Used to be mental retardation • More emphasis placed on adaptive functioning • IQ still used but balanced against functioning • High quality descriptions.

16. Neurodevelopmental Disorders • Communication Disorders (used to be’s) • Language Disorder (mixed expressive-receptive language disorders) • Speech Sound Disorder (phonological disorder) • Childhood Onset Fluency Disorder (stuttering) • Social Communication Disorder (new)

17. Neurodevelopmental Disorders • Autism Spectrum Disorder • Four previous diagnoses were believed to encompass one illness with differing severities in TWO core domains. • Autism, Asperger’s, Childhood Disintegrative Disorder, and PDD NOS

18. Autism Spectrum Disorder • Core Domains: • Deficits in social communication and social interaction. • Restricted repetitive behaviors, interests, and activities BOTH DOMAINS ARE REQUIRED FOR A DIAGNOSIS

19. Autism Spectrum Disorder • Severity and associated features are indicated through the use of specifiers • Social communication disorder is diagnosed if no restricted repetitive behaviors, interests, and activities are present.

20. Attention-Deficit/Hyperactivity Disorder • Criteria very similar • Inattention and Hyperactivity/Impulsivity domains • Better examples added in criteria • Cross-situational requirement strengthened • Onset changed to before 12 years old • Subtypes replaced with specifiers • Comorbidity with ASD now allowed • Symptom threshold lowered for adults

21. Specific Learning Disorder • Reading Disorder, Math Disorder, and Disorder of Written Expression all combined • Different learning disorders will be differentiated with specifiers

22. Motor Disorders • Developmental Coordination Disorder • Stereotypic Movement Disorder • Tourette’s Disorder • Tic disorders (criteria for a “tic” have been standardized across all disorders)

23. Disruptive, Impulse-Control, and Conduct Disorders • Brings together two chapters of Impulse Disorders and Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. • All are disorders involving emotional and behavioral self-control.

24. Oppositional Defiant Disorder • Symptoms grouped into angry/irritable mood, argumentative/defiant behavior, and vindictiveness. • More guidance on frequency of behavior to justify diagnosis. • Severity rating has been added.

25. Conduct Disorder • Criteria largely unchanged from DSM-IV • Specifier added to distinguish callous and cold interpersonal style.

26. Intermittent-Explosive Disorder • In DSM-IV physical aggression was required now verbal aggression and non-injurious lesser physical aggression also meets criteria. • Frequency of outbursts clearly specified. • Negative impairment, functioning, and consequences added as criteria. • Minimum of 6 years old • Differential diagnoses clarified between this and other disorders such as ADHD DMDD.

27. Trauma and Stressor-Related Disorders • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder • PTSD – criteria added for assessing children under 6 years old (DSM5 pps 272-273) • Acute Stress Disorder • Adjustment Disorders

28. Diagnoses that have moved! • Separation anxiety disorder is now an anxiety disorder. • Selective mutism is now an anxiety disorder. • Obsessive and Compulsive Disorders now has a chapter.

29. New Disorders of interest • Excoriation (skin picking) Disorder • Substance or medication induced OCD • OCD related to a medical condition • Disruptive Mood Dysregulation Disorder • Added in response to over-diagnosis of Bipolar Disorder in children (DSM5 pp156)

30. What I am happy about… • Attempts to cut down on over-diagnosing of Bipolar Disorder in children. • Obsessive and Compulsive Disorders have their own chapter. • Criteria for PTSD in children under 6 • Disruptive Mood Dysregulation Disorder

31. What I am disappointed by… • Dropping 5 Axis diagnosis • Dropping Global Assessment of Functioning • No clear diagnostic category for children who have endured chronic long term trauma.