DSM 5 Changes that may affect adolescent care.

DSM 5 Changes that may affect adolescent care.

DSM 5 Changes that may affect adolescent care. 132 pages Mental disorders as reactions Definitions were simple, brief paragraphs with prototypical descriptions DSM-II (1968) DSM-III (1980)

DSM-IV (1994) 134 pages 494 pp 886 pp Reaction terminology dropped Descriptive and neutral (atheoretical) regarding etiology. Inclusion of a clinical

significance criterion Users encouraged to record multiple psychiatric diagnoses (in order of importance) and associated physical conditions Coincided with ICD8 Coincided with ICD-9. Multiaxial classification system. Goal to introduce New disorders

introduced (e.g., Acute Stress Disorder, PTSD, Bipolar II Disorder, Aspergers Disorder), others deleted (e.g., Cluttering, DSM-5 (2013) 947 5 pages instead of V Anticipates change e.g. DSM 5.1 5.2 Work Groups were to consider: Dimensional measures.

e.g. severity scales or cross-cutting across disorders Culture/gender issues. NOS used in DSM IV = 41 Other/Unspecified used in DSM-5 =65 (To match ICD-10) Categories 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 Dissociative Disorders Somatic Symptom Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse Control, and Conduct Disorders Substance Use and Addictive Disorders Neurocognitive Disorders

Personality Disorders Paraphilic Disorders Other Disorders New Disorders Social (Pragmatic) Communication Disorder Disruptive Mood Dysregulation Disorder Premenstrual Dysphoric Disorder Hoarding Disorder Excoriation (SkinPicking) Disorder Disinhibited Social Engagement Disorder (split from Reactive Attachment Disorder) Binge Eating Disorder Central Sleep Apnea Sleep-Related Hypoventilation

Rapid Eye Movement Sleep Behavior Disorder Restless Legs Syndrome Caffeine Withdrawal Cannabis Withdrawal Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other Medical Conditions) Mild Neurocognitive Disorder Eliminated Sexual Aversion Disorder PolysubstanceDependence Combined Language Disorder Expressive Language Disorder & Mixed Receptive Expressive Language Disorder

Autism Spectrum Disorder Autistic Disorder, Aspergers Disorder, Childhood Disintegrative Disorder, Retts disorder Pervasive Developmental Disorder-NOS) Specific Learning Disorder Reading Disorder, Math Disorder, Disorder of Written Expression Delusional Disorder Shared Psychotic Disorder & Delusional Disorder Combined Panic Disorder Panic Disorder Without Agoraphobia Panic Disorder With Agoraphobia

Dissociative Amnesia Dissociative Fugue Dissociative Amnesia Somatic Symptom Disorder Somatization Disorder Undifferentiated Somatoform Disorder Pain Disorder Insomnia Disorder Primary Insomnia Insomnia Related to Another Mental Disorder Hypersomnolence Disorder Primary Hypersomnia Hypersomnia Related to Another Mental Disorder Non-Rapid Eye Movement Sleep Arousal Disorders Sleepwalking Disorder

Sleep Terror Disorder *Substance* Use Disorder *Substance* Abuse *Substance* Dependence Stimulant Use Disorder Cocaine Abuse/Dependence Amphetamine Abuse/Dependence Major Changes Change Comment Elimination of multiaxial system and GAF Clinicians wanted simplified, diagnosis-based system; distinctions between Axis I and Axis II disorders were never clearly justified; clinicians can still specify external stressors; new assessment measures will be introduced

Establishes 20 diagnostic classes or categories of mental disorders Categories based on groupings of disorders sharing similar characteristics; some categories represent spectrums of related disorders Introduction of new diagnostic category of Neurodevelopmental Disorders to include Autism Spectrum Disorder and ADHD and other disorders reflecting abnormal brain development Increasing emphases on neurobiological bases of mental disorders and the developing understanding that abnormal brain development underlies many types of disorders Major Changes Change

Comment Introduces more dimensionality (severity ratings) but does not restructure personality disorders as some had proposed Major changes in personality disorders held over until next revision, the DSM 5.1 (or maybe 5.2) Roman numerals dropped: DSM-5, not DSM-V Allows for easier nomenclature for midcourse revisions, 5.1, 5.2, etc. Removes obsessive-compulsive disorder from category of Anxiety Disorders and places it in new category of Obsessive-Compulsive and Related Disorders Recognizes a spectrum of obsessive-compulsive type

disorders, including body dysmorphic disorder; however, anxiety remains the core feature of OCD, so questions remain about separating it from anxiety disorders Major Changes Change Comment Removes ASD and PTSD from Anxiety Disorders and places them in new category of Trauma and StressorRelated Disorders Groups all stress-related psychological disorders under the same umbrella; Adjustment Disorders may now be coded in context of traumatic stressors Creates new diagnostic category of Substance-Related and Addictive Disorders

Now includes Gambling Disorder (previously Pathological Gambling) but other forms of nonchemical addiction, such as compulsive Internet use and compulsive shopping, dont make it into the manual and remain under study Eliminates distinction between substance abuse and dependence disorders, collapsing them into single category of substance use disorders Recognizes that there is no clear line between substance abuse and dependence disorders; also brings certain compulsive patterns of behavior into a spectrum of addictive disorders Major Changes Change Comment

Provides a means of rating severity of symptoms, such as for ASD Encourages clinicians to recognize the dimensionality of disorders Greater emphasis on comorbidity; e.g., use of anxiety ratings in diagnosing depressive and bipolar disorders Provides more explicit recognition of comorbidity in having clinicians rate level of anxiety in mood disorders Major Changes Change Comment Elimination of term somatoform disorders (now

Somatic Symptom and Related Disorders) Eliminates a term few people understood (somatoform disorders) and now emphasizes the psychological reactions to physical symptoms, not whether they are medically based Reorganization of mood disorders into two separate diagnostic categories of Depressive Disorders and Bipolar and Related Disorders No major changes anticipated, but no clear basis for eliminating umbrella construct of mood disorders Major Changes Change Removal of developmental trajectory in organizing classification of disorders: Eliminates category of Disorders

Usually First Diagnosed in Infancy, Childhood, or Adolescence Comment May make it easier to diagnose traditional childhood disorders like ADHD and even separation anxiety disorder in adults. Conversely, it may also make it easier to diagnose disorders typically seen in adults, like bipolar disorder, in children. The new category of Neurodevelopmental Disorders includes many disorders previously classified as childhood onset disorders, however it excludes disorders involving abnormal emotional development, such as separation anxiety disorder and selective mutism. Where does this new classification leave the study of child psychopathology? Elimination of bereavement exclusion from major depression Recognizes that a major depressive episode may overlay a normal reaction to loss; critics claim it may pathologize bereavement

Major Changes Change Comment Hypochondriasis dropped as distinct disorder Eliminates the pejorative term hypochondriasis; people formerly diagnosed with hypochondriasis may now be diagnosed with Somatic Symptom Disorder if their physical symptoms are significant or with Illness Anxiety Disorder if their symptoms are minor or mild Factitious Disorder moved to Somatic Symptom and Related Disorders Associated with other somatic symptom disorders, but is distinguished by intentional fabrication of symptoms for no apparent gain other than assuming medical

patient role A brief History of Substance Use Diagnostics Over time the definition of the problem has changed In the 1930s the APA called substance abuse a mentally altered state deemed inappropriate, undesirable, harmful, threatening, or, at minimum, culturealien." In the 1960s the terms misuse and abuse emerged as distinctly different, and dependence

was considered a part of abuse. In the 1970s and 1980s the terms dependence and drug-induced were included in official definitions of the problem as separate entities. A few Definitions Clinically Significant Impairment Decreased functioning in one or more life area (school, work)

Legal problems Recurrent social/ interpersonal problems A few Definitions Substance Abuse Excessive Clinically Use in spite risk taking/ Significant of ignoring Impairment problems risk

A few Definitions Substance Dependence (Addiction) Physical Clinically Lifestyle symptoms of Significant centers tolerance/ Impairment around use withdrawal Current diagnostics Substance Abuse At least 1 of 4

symptoms Dependence At least 3 of 7 symptoms Either one or the other, maximum number of problems anyone can experience is 7. Future Diagnosis: Substance Use Disorder No disorder: 0-1 Symptom Mild: 2-3 symptoms Moderate: 4-5

symptoms Severe: 6 or more 11 Symptom continuum that ranks Substance Use Disorder from mild to severe. Prevalence Prevalence NIAAA estimates that alcohol and drug abuse are associated with 100,000 deaths per year and cost society $180 billion per year. The overall cost of drug abuse rose 5.3 percent annually between 1992 and 2002, increasing from $107.5 to $180.9 billion. The most rapid growth in drug costs came from increases in criminal justice system activities, including productivity losses associated with growth in the population imprisoned due to drug abuse. Drug use by age

Group 31.5% of young people have used in the past month Source: NSDUH 2011 Alcohol use by age 39.8% Of young people aged 18-25 were bingeing Source: NSDUH All other drugs 20.6% increase in

MJ use since 2007 Source: NSDUH Adolescent use is on the rise 65-87% increase in MJ use since 1990 Source: NSDUH 2009 Most commonly Abused Drugs 1

Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically. Perception of risk by Adolescents Risk perception decreases with age for ETOH and MJ Perceived risk among clinicians Alcohol by far outranks most perceptions of harm CAREERS OF USE LAST DECADES

Percent in Recovery 70% 60% 50% 0-9* Careers are shorter the sooner they get to treatment 10-19* 40% 20+ Years to 1st Tx Groups

100% 90% 80% 30% 20% 10% 0% 0 5 10 15 20 25

Years from first use to 1+ years abstinence 30 * p<.05 (different from 20+) Source: Dennis 30 al 2005 et Careers of use last decades 100% 90% 80% Percent in Recovery 70%

60% 50% Median duration of 9 years and 3 to 4 episodes of care 40% 30% 20% 10% 0% 0 5 10

15 20 Years from first Tx to 1+ years abstinence 25 Source: Dennis 31 al 2005 et Relapse Rates of chronic illnesses 50% to 70% ASTHMA 50% to 70% HYPERTENSION

40% to 60% DRUG ADDIC TION 30% to 50% TYPE I DIABETES 0% 10% 20% 30% 40% 50% 60% Source: McLellan, et al., 2000 70% 80% Lapse vs. relapse Lapse

Impulsive Short duration Accompanied by guilt Small amount/duration of use Relatively low consequence Desire to return to change process Relapse

Planned Longer duration High defensiveness Large amount/duration of use Uncertain about desire to return to change process Median Length of Stay in Days The Majority Stay in Tx Less than 90 days 90

60 52 42 33 20 30 0 Outpatient Intensive Short Term Long Term Outpatient Residential Residential Level of Care Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville,

MD: Substance Abuse and Mental Health Services Administration. Retrieved from 34 DEPRESSIVE DISORDERS DISRUPTIVE MOOD DISREGULATION Severe, age inappropriate temper outbursts 3+x weekly Daily irritable, angry mood 12 months, not asymptomatic 3 months; 2/3 settings Dx between 6-18 years; onset <10 years Not meeting criteria for manic/hypomanic for full day or ODD or IED (Purpose: Prevent Manic dx & subsequent antipsychotic medication) MAJOR DEPRESSIVE DISORDER Bereavement exclusion removed Includes note: significant loss may result in some Criterion A symptoms. MDD may also be considered in context of clinical judgment, history, and cultural norms.

DEPRESSIVE DISORDERS PREMENSTRUAL DYSPHORIC DISORDER 5 of4+7 symptoms appear in final week before onset of most menses, then improve (lability, irritability, anxiety, depressive, etc. ) SUBSTANCE/MEDICATION-INDUCED DEPRESSIVE DISORDER Removed Criterion A2:elevated, expansive or irritable mood OTHER SPECIFIED DEPRESSIVE DISORDER Lists a few examples UNSPECIFIED DEPRESSIVE DISORDER e.g. insufficient information ANXIETY DISORDERS The anxiety must be out of proportion to the actual danger or threat in the situation This chapter no longer includes OCD and PTSD DSM 5 creates new chapters for OCD and PTSD Chapter is arranged developmentally. Sequenced by age of onset Now includes Separation Anxiety and

Selective Mutism ANXIETY DISORDERS Panic Attacks and Agoraphobia are unlinked in DSM- 5 DSM- IV terminology describing different types of Panic Attacks replaced in DSM-5 with the terms expected or unexpected panic attack Social Anxiety Disorder : Generalized specifier in DSM-IV has been deleted Replaced with performance only specifier OBSESSIVE COMPULSIVE AND RELATED DISORDERS New chapter created for DSM 5 Rationale for this chapter grouping: Increasing evidence that these disorders are related to each other

New disorders in chapter : Hoarding disorder Excoriation (skin picking) disorder Substance /Medicationinduced OCD OCD due to another medical condition OBSESSIVE COMPULSIVE AND RELATED DISORDERS Trichotillomania, now termed trichotillomania disorder (hair pulling), moved to OCD chapter No longer classified as an impulse control disorder. Specifiers listed for each OCD disorder Specifier with poor insight in DSM- IV has been expanded in DSM- 5

New Specifiers are 1. with good or fair insight 2. with poor insight 3. with absent insight/delusional beliefs Intent of these specifiers is to improve differential diagnoses OBSESSIVE COMPULSIVE AND RELATED DISORDERS Body Dysmorphic Disorder A criterion added: Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others Hoarding Disorder added to DSM-5 Due to evidence that it is not a variant of OCD; Evidence that it is a separate diagnosis Excoriation Disorder added to DSM-5

Based on strong evidence of diagnostic validity and clinical utility OTHER SPECIFIED AND UNSPECIFIED OBSESSIVECOMPULSIVE AND RELATED DISORDERS DSM-5 includes conditions in this chapter such as: Body-focused repetitive behavior disorder - other than excoriation and trichotillomania i.e. nail biting, lip chewing Obsessional jealousy TRAUMA- AND STRESSOR-RELATED DISORDERS New chapter in DSM-5 brings together anxiety disorders that are preceded by a distressing or traumatic event: Reactive Attachment Disorder Disinhibited Social Engagement Disorder (new) PTSD (includes PTSD for children 6 years and younger) Acute Stress Disorder Adjustment Disorders

Disinhibited Social Engagement Disorder: The essential feature of disorder is a pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers. This behavior violates the social boundaries of the culture. DSM-5, p. 269 TRAUMA- AND STRESSOR-RELATED DISORDERS Acute Stress Disorder Stressor criterion in DSM -5 is changed: Criterion requires being explicit whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. DSM-IV Criterion A2 regarding reaction to the event- the persons response involved intense fear, helplessness, or horror has been eliminated TRAUMA- AND STRESSOR-RELATED

DISORDERS Changes in PTSD Criteria Four symptom clusters, rather than three: Re-experiencing Avoidance Persistent negative alterations in mood and cognition Arousal: describes behavioral symptoms DSM-5 more clearly defines what constitutes a traumatic event: Sexual assault is specifically included Recurring exposure, that could apply to first responders DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS Oppositional Defiant Disorder

Criteria exhibited with at least one individual who is not a sibling Spiteful or vindictive twice in 6 months Severity: Mild, moderate, severe <5years most days for 6 months; >5 years, weekly Conduct Disorder Adds specifier With limited prosocial emotions Persistently in 12 months (2 of 4) Lack of Remorse/ guilt Callouslack of empathy Unconcerned about performance Shallow or deficient affect DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS Intermittent Explosive Disorder

Verbal aggression 2x weekly for 3 months Destruction or assault: 3x in 12 months 6 years + Not premeditated AntiSocial Personality Disorder (criteria in PD chapter) Dual coded Pyromania Kleptomania Other DICCD Unspecified DICCD

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