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Some Early Proposals for the DSM-5

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Some Early Proposals for the DSM-5

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  1. DSM-5 Powerpoint Supplement to Mash/WolfeAbnormal Child Psychology(2013, 5th Edition)This material is based on a DSM-5 Powerpoint presentation prepared by Kenneth J. Zucker and on the DSM-5 supplement to Barlow and Durand, Abnormal Psychology, prepared by Jade Qi Wu, Hannah Tavormina, David Barlow and Mark Durand. Adapted with permission.

  2. Some Early Proposals for the DSM-5 • A revised meta-structure and harmonization with ICD-11 (~ 2015) • Reduced usage of NOS (Not Otherwise Specified) • Dimensional diagnosis to complement categorical diagnosis • Deletion of the distress/impairment criterion (X) • Greater emphasis on a life-course developmental perspective, culture-related, and gender-related diagnostic issues • Elimination of the multiaxial system (Axes I-V) • Biomarkers • DSM-5 as a “living document” (5.1, 5.2, etc.)

  3. General Changes in DSM-5 • Revised definition of a mental disorder and distress/impairment criterion • Some dimensional options described in Section III (Assessment Measures) • Not Otherwise Specified Becomes “Other Specified X Disorder” and “Unspecified X Disorder” • Section III contains a chapter on Cultural Formulation and the Appendix contains a Glossary of Cultural Concepts of Distress (9 examples: Ataque of nervios, Dhat syndrome, Susto, etc.)

  4. Definition of a Mental Disorder

  5. The Distress/Impairment Criterion

  6. Chapter Organization for DSM-5 • Neurodevelopmental Disorders • Schizophrenia Spectrum and Other Psychotic Disorders • Bipolar and Related Disorders • Depressive Disorders • Anxiety Disorders • Obsessive-Compulsive and Related Disorders

  7. Chapter Organization for DSM-5 (cont’d) • Trauma- and Stressor-Related Disorders • Dissociative Disorders • Somatic Symptom and Related Disorders • Feeding and Eating Disorders • Elimination Disorders • Sleep-Wake Disorders • Sexual Dysfunctions • Gender Dysphoria

  8. Chapter Organization for DSM-5 (cont’d) O. Disruptive, Impulse Control, and Conduct Disorders P. Substance-Related and Addictive Disorders Q. Neurocognitive Disorders R. Personality Disorders T. Paraphilic Disorders U. Other Mental Disorders

  9. Changes in Chapter Structure

  10. Overview of Key Changes in DSM-5 Relevant to Children and Adolescents • Greater Attention to Developmental Issues in Diagnosis • Changes in Organization Related to Childhood Disorders • Other Changes in Organization • New Categories for Children • Changes to Existing Categories for Children • Addition of Subtypes and Specifiers • Proposed New Disorders and Features (Section III)

  11. 1. Greater Attention to Developmental Issues in Diagnosis • Subsections of the text of DSM-5 on “Development and Course” describe how presentations of the disorder may change across the lifespan. • Age-related factors in diagnosis such as symptom presentation and differences in prevalence are included. • The DSM-5 manual is organized to reflect a lifespan approach, with disorders typically diagnosed in children (e.g., neurodevelopmental disorders) at the beginning and those more applicable to older adults (e.g., neurocognitive disorders) at the end.

  12. Greater Attention to Developmental Issues in Diagnosis (cont’d) • Age-related factors have been added to the diagnostic criteria (e.g., revised criteria for posttraumatic stress disorder in children under age 6; specific criteria to describe how symptoms are expressed in children). • Greater integration of information regarding sex and gender differences and cultural issues into diagnosis as relevant.

  13. 2. Changes in Organization Related to Childhood Disorders • Consistent with a lifespan emphasis, and in an effort to integrate developmental issues throughout, DSM-5 has eliminated the separate section for “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” previously included in DSM-IV. For the most part, these disorders (e.g., ADHD, Autism Spectrum Disorder) now appear in a section on neurodevelopmental disorders, but not entirely. • For example, a number of disorders usually first diagnosed in infancy (e.g., reactive attachment disorder, pica) and childhood (e.g., selective mutism, separation anxiety disorder, oppositional defiant disorder, conduct disorder) are now integrated throughout the manual in sections with other disorders that have a later onset.

  14. Changes in Organization Related to Childhood Disorders (cont’d) • The goal of emphasizing a lifespan approach and greater recognition of the fact that many disorders can and do manifest across the lifespan has merit. • While true that boundaries drawn between disorders of childhood and other age groups are arbitrary, and potentially hamper tests of continuity of disorders over time, the long-term implications of this significant change to DSM organization are unclear. • The addition of a specific section dedicated to disorders of childhood in DSM-III was widely regarded as having played a critical role in increasing research interest in childhood disorders; whether removing this distinction will result in a decrease in the level of attention being paid to disorders of children remains to be seen (Hayden and Mash, in press).

  15. 3. Other Changes in Organization • DSM-5 has moved to a nonaxial documentation of diagnosis, eliminating the multiaxial system (Axis I, II, III, IV, and V) included in DSM-IV-TR. • The melding of Axes I, II, and III reflects the view that different mental disorders are fundamentally conceptualized in a similar way, integrating biological, physical, behavioral, and psychosocial factors and processes. • Separate notations are now made for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).

  16. Other Changes in Organization (cont’d) • Obsessive-Compulsive Disorder is no longer included in the section on anxiety disorders, but in a new separate section on Obsessive Compulsive and Related Disorders (e.g., trichotillomania [hair-pulling disorder]. • Posttraumatic Stress Disorder and Acute Stress Disorder are no longer included in the section on anxiety disorder, but in a new separate section on Trauma- and Stressor-Related Disorders.

  17. 4. New Categories for Children • Autism Spectrum Disorder (ASD) is a new DSM-5 disorder that contains the previous DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS).

  18. New Categories for Children(cont’d) • Disruptive Mood DysregulationDisorder (DMDD)is a new disorder for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral control. • This new category, which is included in DSM-5 as a Depressive Disorder, was added to address concerns about potential over-diagnosis and over-treatment of bipolar disorder in children.

  19. New Categories for Children (cont’d) • Social (pragmatic) Communication Disorderis a new condition involving persistent difficulties in the social uses of verbal and nonverbal communication. • Some individuals previously diagnosed with Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) in DSM-IV may meet criteria for Social Communication Disorder, provided that they do not also display restricted behaviors, interests, and activities.

  20. 5. Changes in Existing Categories for Children • The term Intellectual Disability (intellectual developmental disorder) replaces the term Mental Retardation that was used in DSM-IV. • The names of several communication disorders have been changed (e.g., phonological disorder has been changed to speech sound disorder). • A new category of Specific Learning Disorder combines the diagnoses of Reading Disorder, Mathematics Disorder, and Disorder of Written Expression.

  21. Changes in Existing Categories for Children (continued) • Symptoms of autism spectrum disorder are grouped into two categories, rather than three: • Deficits in social communication and social interaction; and • Restricted, repetitive patterns of behavior, interests, or activities. Note: Previously, deficits in communication and social interaction were view separately. However, research now indicates that they are best viewed as single factor (Guthrie et al., 2013).

  22. Changes in Existing Categories for Children (cont’d) • Selective Mutism and Separation Anxiety Disorder are now classified as anxiety disorders rather than as Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.

  23. Changes in Existing Categories for Children (cont’d) • Criteria for Oppositional Defiant Disorder are now grouped into three types:angry/irritable mood,argumentative/defiant behavior, and vindictiveness. • Conduct disorder features a specifier to indicate when it occurs with limited prosocial emotions. This specifier is intended to capture children with CD who display: lack of remorse or guilt, callous-lack of empathy, unconcerned about performance, and shallow or deficient affect.

  24. 6. Addition of Subtypes and Specifiers • DSM-5 provides subtypes and specifiers for increased specificity of diagnoses. • Subtypesdefine mutually exclusive and jointly exhaustive subgroupings within a diagnosis (e.g., predominantly inattentive, predominantly hyperactive/impulsive, or combined presentation in the case of ADHD), and are indicated by the instruction: “Specify whether” in the diagnostic criteria set.

  25. Addition of Subtypes and Specifiers (cont’d) • Specifiersare used to indicate such things as course (e.g., in partial remission, in full remission), associated conditions (e.g., with or without accompanying intellectual impairment), severity level of a disorder (e.g., mild, moderate, or severe), age of onset (e.g., onset before age 10 years), and/or others. In contrast to subtypes, specifiers are not intended to be mutually exclusive or jointly exhaustive, which means that more than one specifier may be given.

  26. 7. Proposed New Disorders and Features (Section III) • DSM-5 includes a new Section III titled “Emerging Measures and Models.” It presents new disorders referred to as “Conditions for Further Study.” • This section was designed to stimulate further research on less well-studied disorders not yet sufficiently established to be part of the official DSM-5 classification system for routine clinical use. • Three proposed conditions relevant to children & adolescents are: “Suicidal Behavior Disorder,”“Nonsuicidal Self-Injury,”“Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure.”

  27. Proposed New Disorders and Features (Section III) cont’d • An alternative DSM-5 model for personality disorders is included in Section III. This proposal is a hybrid model that has both a categorical and dimensional focus.

  28. Proposed New Disorders and Features (Section III) cont’d • Section III in DSM-5 includes a number of emerging measures for further research and evaluation that, used over time, are intended to provide more accurate and flexible clinical descriptions of individual symptom presentations and associated disability during diagnostic assessments.

  29. Proposed New Disorders and Features (Section III) cont’d • Among these measures are: a. A measure of symptom severityacross multiple domains that can be used across all diagnostic groups. b. A standard measure of global disability level (WHO Disability Assessment Scale [WHODAS]; World Health Organization, 2001) that replaces the more limited Global Assessment of Functioning Scale presented in DSM-IV.

  30. Proposed New Disorders and Features (Section III) cont’d • A variety of tools, techniques, and measures are presented that are designed to enhance clinical decision making with children, adolescents, and adults and to better understand the cultural context in which mental disorders occur. • These “emerging measures” appear in Section III of the DSM-5 manual and, along with others, at the following website: http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures.

  31. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: Changes from DSM-IV to DSM-5 • Attention-deficit/Hyperactivity disorder (ADHD) is now included in the DSM-5’s Neurodevelopmental Disorders chapter instead of the Attention-Deficit and Disruptive Behavior Disorders Section in the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapter (which was eliminated entirely in DSM-5). • Why was this done?

  32. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: Changes from DSM-IV to DSM-5 (cont’d) Two main reasons: • ADHD shares with these other disorders an early onset and persistent course. • ADHD is often associated with disruptions in neurodevelopment and other developmental problems in language, motor, and social development that overlap with the other neurodevelopmental disorders (Nigg & Barkley, in press).

  33. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: Changes from DSM-IV to DSM-5 (cont’d) • The DSM-5 diagnostic criteria for Attention Deficit/Hyperactivity Disorder (ADHD) have been revised to better allow the diagnosis of adults with ADHD. Research has shown that although ADHD begins in childhood, it can continue into adulthood for some individuals. • To assist in its application across the life span, DSM-5 includes examples to illustrate the types of behavior children, older adolescents, and adults with ADHD might exhibit.

  34. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: Changes from DSM-IV to DSM-5 (cont’d) • A symptom threshold change for adults has been made with the cutoff for ADHD of five symptoms, instead of six required for younger individuals, for both inattention and for hyperactivity/impulsivity. • Onset of impairing symptoms before age 7 has been changed to onset of symptoms before age 12. Support for this change comes from research showing no clinical differences between children identified prior to 7 years versus later with respect to severity, course, outcome, or response to treatment (Barkley, 2010).

  35. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: Changes from DSM-IV to DSM-5 (cont’d) • A comorbid diagnosis with Autism Spectrum Disorders is now allowed in the DSM-5, since research has found that symptoms of both disorders can and do co-occur.* *Kotte et al., in press, Pediatrics.

  36. Neurodevelopmental Disorder: ADHD

  37. DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS, and ANTISOCIAL PERSONALITY DISORDER: Changes from DSM-IV to DSM-5 • Oppositional defiant disorder • Conduct Disorder • Antisocial Personality Disorder

  38. Oppositional Defiant Disorder: Changes from DSM-IV to DSM-5 • DSM-5 groups symptoms of Oppositional Defiant Disorder into three types, in order to reflect that the disorder includes emotional and behavioral components: 1. angry/irritable mood 2. argumentative/defiant behavior 3. vindictiveness (spiteful)

  39. Oppositional Defiant Disorder (ODD): Changes from DSM-IV to DSM-5 (cont’d) • DSM-5 has removed the exclusionary criterion of conduct disorder and antisocial personality disorder (in individuals age 18 years or older) from the oppositional defiant disorder diagnosis, since these disorders can and do co-occur.

  40. Oppositional Defiant Disorder (ODD): Changes from DSM-IV to DSM-5 (cont’d) • DSM-5 provides additional guidance regarding the frequency typically needed for a behavior to be considered symptomatic of the disorder. • Since many symptoms of ODD occur commonly in normally developing children and adolescents, this information is intended to help differentiate ODD from normal oppositional behavior.

  41. Oppositional Defiant Disorder (ODD): Changes from DSM-IV to DSM-5 (cont’d) • DSM-5 adds a severity rating to the criteria for oppositional defiant disorder to reflect research showing that the extent of pervasiveness of symptoms across settings is a significant indicator of severity.

  42. Conduct Disorder (CD): Changes from DSM-IV to DSM-5 • The diagnostic criteria for conduct disorder in DSM-5 are mostly unchanged from DSM-IV. • DSM-5 adds a descriptive features specifier for individuals meeting full criteria for conduct disorder and also presenting “with limited prosocial emotions.”

  43. Conduct Disorder (CD): Changes from DSM-IV to DSM-5 (cont’d) • To qualify for the “limited prosocial emotions”(LPE) specifier the individual must persistently display at least two of the following four characteristics: 1. lack of remorse or guilt 2. callous-lack of empathy 3. unconcerned about performance 4. shallow or deficient affect • Limited prosocial emotions applies to individuals with CD who show a callous and unemotional interpersonal style persistently and across multiple settings and relationships. • This specifier is based on research showing that individuals with CD who meet criteria for LPE tend to have a relatively more severe form of the disorder and a different treatment response (Frick, Ray, Thornton, & Kahn, 2013).

  44. Disruptive, Impulse Control, and Conduct Disorders

  45. Antisocial Personality Disorder (APD): Changes from DSM-IV to DSM-5 • DSM-5 diagnostic criteria for all personality disorders, including Antisocial Personality Disorder are identical to those found in DSM-IV. • During the development of the DSM-5, some professionals working on the DSM-5 personality disorders criteria proposed an alternative model for conceptualizing personality disorders. • Following this model, all personality disorders, including Antisocial Personality Disorder, would be described using standardized criteria that described impaired personality functioning related to self and others, and pathological personality traits.

  46. Antisocial Personality Disorder (APD): Changes from DSM-IV to DSM-5 (cont’d) • In the case of Antisocial Personality Disorder, the proposed pathological personality traits include Antagonism (manipulativeness, callousness, deceitfulness, hostility), andDisinhibition(risk taking, impulsivity, and irresponsibility). • Although the alternative model was not officially adopted, it is included in the DSM-5 (Section III), separate from diagnostic criteria. The table immediately after the Diagnostic Criteria for Antisocial Personality Disorder presented below, outlines the proposed diagnostic structure of personality disorders. This structure provides a useful way of thinking about personality functioning, because it highlights areas that are problematic across all personality disorders.

  47. Personality Disorders

  48. Personality Disorders

  49. Personality Disorders

  50. Anxiety Disorders: Changes from DSM-IV to DSM-5 • Note: In DSM-5, the DSM-IV category Anxiety Disorders has been subdivided into three categories: anxiety disorders, trauma- and stressor-related disorders, and obsessive-compulsive and related disorders. • General changes to DSM-5 anxiety disorders: • Selective Mutism and Separation Anxiety Disorder are newly classified as anxiety disorders. They were previously classified as Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence. • In DSM-5, Separation Anxiety Disorder may be diagnosed in adults.

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