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H 382 The Challenges Kids Face DSM 5 LECTURE September 11, 2015 Holly Lem, H 382 The Challenges Kids Face DSM 5 LECTURE September 11, 2015 Holly Lem, Ph. D.

Hypotheticals Hypotheticals

When Mind Meets Body: Are psychological problems the same as medical problems? What do 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 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; 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 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” “The lack of objective tests for mental disorders makes diagnostic reliability a difficult problem” (Hyman, 2015)

of The DSM-5 creates a veneer of objectivity that does not accurately reflect the of The DSM-5 creates a veneer of objectivity that does not accurately reflect the heterogeneity of mental illness nor the subjective experience mental illness. (Lem, now)

Does it have to be either/ or? Subjective (psychology, art vs. Objective ) (science, 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 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 DSM 5 Clinical Services Drug Companies DSM 5 Nexus: Insurance Companies School DSM 5 Clinical Services Drug Companies

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-5, 2013) A child with a diagnosis, 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 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: q. A curious skeptic q. A self-serving relationship q. My Approach to the DSM: q. A curious skeptic q. A self-serving relationship q. An imperfect relationship that I can’t get out of q. All of the above

Can the DSM account for complexity? Story of “Belle” 16 y. o girl of 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 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 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 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 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 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 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 IV ? “Belle” (by DSM-IV standards) Axis I V code? Axis II ? Axis IV ? Axis V GAF =

V Codes (Other Conditions that May Be a Focus of Clinical Attention) Parent-Child Relationship 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 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 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 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 with primary support group Problems related to social Axis IV Psychosocial and Environmental Problems with primary support group Problems related to social environment Educational Problems Housing problems Economic Problems related to legal system

Axis V Global Assessment of Functioning Clinical judgment about level of functioning: social, academic/occupational, 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 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 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 Interview

Section II: Table of Contents Neurodevelopmental D/Os (ADHD, Autism) Schizophrenia Spectrum & Other Psychotic Section II: Table of Contents Neurodevelopmental D/Os (ADHD, Autism) Schizophrenia Spectrum & Other Psychotic D/Os Bipolar and Related Disorders Depressive Disorders (DMDD*, PDD) Anxiety Disorders (Phobias, GAD, Social Anxiety) Obsessive-Compulsive/Related Disorders (Body Dysmorphic d/o, Hoarding, Excoriation) 7. Trauma and Stressor Related Disorders 8. Dissociative Disorders 9. Somatic Symptom and Related Disorders 1. 2. 3. 4. 5. 6.

Section II: 10. Feeding and Eating Disorders 11. Elimination Disorders 12. Sleep-Wake Disorders 13. 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 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, 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 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 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 1. Co-morbidity: extremely commonplace 2. Excessive use of “NOS”- not The Limits of Categories 1. 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

DSM-5 dabbles with dimensionality Autism Spectrum Disorder Schizophrenia Intellectual Disability Severity Index 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 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 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 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 “Requiring substantial support” skills; social impairments apparent even with supports in place; restricted/repetitive behaviors appear frequently enough to be Inflexibility of behavior, difficulty coping with change, or other 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 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 Mc. Partland (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 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 Outline for Cultural Formulation DSM- 5 The clinician should provide a systematic assessment of the following categories: 1. 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

Cultural Formulation Interview (CFI) “A set of 16 questions that clinicians can use to 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 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? 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 “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)