DSM-5: Changes in Anxiety and Depression Dx. Karen Tuoriniemi Nelson, ACSW

Transcription

1 DSM-5: Changes in Anxiety and Depression Dx Karen Tuoriniemi Nelson, ACSW

2 Changes in the DSM-5

3 I don t like change. This way has been working just fine. I m too old to change. I don t want to.

4 Change Definition of change is: To put or take in place of something else. To exchange (i.e. change seats). To make different (alter, vary). To leave one plane/train and board another. To put on other clothes. Money returned. Coins. Coins/bills that together equal a single larger coin or bill.

5 When we think of change, it s usually in the manner of taking place of something else or to make different. Which. Can create anxiety. Anxiety related to change is not abnormal.

6 After a 14-year revision process and a lot of contentiousness, the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is here.

7 Hx old txs

8 DSM-5 Definition of Mental Disorder Each disorder identified in the manual must meet the definition of a mental disorder. Although no definition can capture all aspects of all disorders, the following elements are required: A mental disorder is a syndrome characterized by clinically significant disturbance in an individual s cognition, emotion regulation, or behavior

9 DSM-5 Definition of Mental Disorder that reflects a dysfunction in the psychological, biological, or developmental processes underlying the mental dysfunction. Mental disorders are usually associated with significant distress or disability is social, occupational, or other important activities.

10 DSM-5 Definition of Mental Disorder An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (i.e. political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.

11 General Changes in DSM-5: A developmental focus Re-orders disorders according to the age they are most likely to appear. Begins with neurodevelopmental disorders that occur most often in childhood. Ends with disorders associated with old age, such as neurocognitive disorders. The disorders descriptions also describe how they may present differently throughout the life span.

12 General Changes in DSM-5: New diagnostic criteria A new disorder (autism spectrum disorder) collapses what were 4 separate disorders into 1 with different levels of symptom severity. Eliminates the previous version s 4 subtypes of schizophrenia. Section on bipolar disorder now emphasizes changes in activity/energy as well as mood during manic and hypomanic episodes to facilitate earlier detection and increasing diagnostic accuracy.

13 General Changes in DSM-5: Move toward dimensional measures This shift is based on the realization that the lines between many disorder categories blur over the life span that symptoms attributed to a single disorder may also appear in other disorders, just with different levels of severity.

14 General Changes in DSM-5: Move toward dimensional measures For example, the new autism spectrum disorder allows a clinician to choose among 3 levels of severity in dimensions of social communication and interaction and repetitive behavior and interests. This shift represents a first step toward thinking about psychopathology in a new way. Chris Hopwood, Ph.D. (Asst. Professor of Psychology at MSU)

15 General Changes in DSM-5: Move toward dimensional measures Hopwood also states: There s been a tension between the desire to move toward more evidence-based models on the one hand and the need to not disrupt clinical practice as it stands. People have more than one psychiatric disorder because many disorders reflect problems in the same dimension (or system). The dimensional approach means thinking about what disorders have in common vs what makes them different.

16 General Changes in DSM-5: More emphasis on culture & gender A new section will describe common cultural syndromes, how they are expressed and possible causes. It is hoped that the new information will not only encourage clinicians to take into account such differences, but to help standardize such information across clinicians.

17 More General Changes in DSM-5 DSM-5 includes equivalent ICD-9-Clinical Modification (CM) codes and equivalent ICD-10- CM codes. A new section on areas that need further research. Will include 3 sections: 1) Introduction with instructions on using manual; 2) Section with diagnoses/diagnostic criteria; 3) A new section with information on conditions that require additional research before they can be incorporated into the official diagnoses. Arabic numeral for ease of revisions.

18 DSM-5

19 DSM-5 Changes: ANXIETY OCD and PTSD The chapter on anxiety disorders no longer includes obsessivecompulsive disorder or PTSD. Instead, they now have been relocated to their own respective chapters.

20 DSM-5 Changes: ANXIETY Agoraphobia, Specific Phobia, Social Anxiety Disorder The largest change for these 3 disorders is that the person no longer has to recognize that their anxiety is excessive or unreasonable in order to receive one of these diagnoses. The change is based on evidence that individuals often overestimate the danger in phobic situations and that older individuals often misattribute phobic fears to aging.

21 DSM-5 Changes: ANXIETY Agoraphobia, Specific Phobia, Social Anxiety Disorder The anxiety now must be out of proportion to the actual threat or danger the situation poses, after taking into account all the factors of the environment and situation. The symptoms must also last at least 6 months for all ages now. Change intended to minimize over-diagnosis of occasional fears.

22 DSM-5 Changes: ANXIETY Panic Attack No significant changes to criteria for panic attack. Does remove the descriptions of different kinds of panic attacks and lumps them into 1 of 2 categories expected and unexpected.

23 DSM-5 Changes: ANXIETY Panic Attack, Specifier Symptoms are present for identifying a panic attack. However, panic attack is NOT a mental disorder and CANNOT be coded. PA can occur in the context of any anxiety disorder as well as other mental disorders and some medical conditions.

24 DSM-5 Changes: ANXIETY Panic Attack, Specifier When the presence of a panic attack is identified, it should be noted as a specifier (i.e. PTSD with panic attacks). For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.

25 DSM-5 Changes: ANXIETY Panic Attack, Specifier Palpitations, pounding heart, accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath/smothering Feelings of choking Chest pain/discomfort Nausea/abdominal distress Feeling dizzy, unsteady, light-headed, faint Chills or heat sensations Paresthesia Derealization Fear of losing control Fear of dying

26 DSM-5 Changes: ANXIETY Panic Attack, Specifier 4 or more of symptoms must occur. Note: Culture-specific symptoms (such as tinnitus, neck soreness, headache, uncontrollable screaming/crying) may be seen. Such symptoms should not count as one of the 4 required symptoms of panic attack specifiers.

27 DSM-5 Changes: ANXIETY Panic Disorder and Agoraphobia No longer linked together and recognized as 2 separate disorders. Justified because APA found that a significant number of people with agoraphobia do not experience panic symptoms. Only change to agoraphobia is endorsement of fears from 2 or more agoraphobia situations is now required.

28 DSM-5 Changes: ANXIETY Specific Phobia (Simple Phobia) Only change to Specific/Simple Phobia is: Adults no longer must recognize that their anxiety or fear is excessive or unreasonable. Symptoms must also now have been present for at least 6 months for all ages in order for a diagnosis of Specific Phobia.

29 DSM-5 Changes: ANXIETY Social Anxiety Disorder Adults no longer must recognize that their anxiety or fear is excessive or unreasonable. Symptoms must also now have been present for at least 6 months for all ages. The generalized specifier has been deleted and replaces with a performance only specifier.

30 DSM-5 Changes: ANXIETY Separation Anxiety Disorder Wording of the criteria has been slightly modified and updated. Diagnostic criteria no longer specify that age at onset must be before 18 years. A duration criterion typically lasting for 6 months or more has been added for adults. Was moved from DSM-IV (D/O Usually First Dx d in Infancy) and now considered an anxiety disorder.

31 DSM-5 Changes: ANXIETY Selective Mutism Was previously classified in D/O Usually First Diagnosed in Infancy, Childhood, or Adolescence. Now considered an anxiety disorder. A large majority of children with selective mutism are anxious. Diagnostic criteria largely unchanged from DSM-IV.

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33 DSM-5 Changes: DEPRESSION Many important updates and changes made to major depression and depressive disorders. Introduction of 2 new disorders: 1. Disruptive Mood Dysregulation Disorder 2. Premenstrual Dysphoric Disorder

34 DSM-5 Changes: DEPRESSION Dysthymia is gone, replaced with Persistent Depressive Disorder. New condition includes both chronic major depressive disorder and the previous dysthymic disorder. Why? An inability to find scientifically meaningful differences between these 2 conditions led to their combination with specifiers included to identify different pathways to the dx/provide continuity with DSM-IV. -PsychCentral.com, J. M. Grohol, Psy.D.

35 DSM-5 Changes: DEPRESSION Disruptive Mood Dysregulation D/O New condition introduced in the DSM-5 to address symptoms that had been labeled as childhood bipolar disorder. This disorder can be diagnosed in children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme, out-of-control behavior.

36 DSM-5 Changes: DEPRESSION Premenstrual Dysphoric Disorder It s official!!!!!!!!!!!!

37 DSM-5 Changes: DEPRESSION PMDD Criteria In most menstrual cycles during the past year, 5 (or more) of the following symptoms occurred during the final week before the onset of menses, started to improve within a few days after the onset of menses, and were minimal or absent in the week postmenses, with at least 1 of the symptoms being either (1), (2), (3), or (4):

38 DSM-5 Changes: DEPRESSION PMDD Criteria 1. marked affective liability (e.g. mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection) 2. marked irritability or anger or increased interpersonal conflicts 3. markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts

39 DSM-5 Changes: DEPRESSION PMDD Criteria 4. marked anxiety, tension, feelings of being keyed up or on edge 5. decreased interest in usual activities (e.g. work, school, friends, hobbies) 6. subjective sense of difficulty in concentration

40 DSM-5 Changes: DEPRESSION PMDD Criteria 7. lethargy, easy fatigability, or marked lack of energy 8. marked change in appetite, overeating, or specific food cravings 9. hypersomnia or insomnia

41 DSM-5 Changes: DEPRESSION PMDD Criteria 10. a subjective sense of being overwhelmed or out of control 11. other physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of bloating, weight gain

42 DSM-5 Changes: DEPRESSION Major Depressive Disorder Limited changes to Major Depressive Disorder. No changes on any of the core criteria, nor the requisite 2-week time period needed before it can be diagnosed. The coexistence within a major depressive episode of at least 3 manic symptoms (insufficient to satisfy criteria for a manic episode is now acknowledged by the specifier with mixed features.

43 DSM-5 Changes: DEPRESSION Major Depressive Disorder The presence of mixed features in an episode of major depressive disorder increases the likelihood that the illness exists in a bipolar spectrum; however, if the individual concerned has never met criteria for a manic or hypomanic episode, the diagnosis of major depressive disorder is retained. APA

44 DSM-5 Changes: DEPRESSION Bereavement Exclusion Little will change for most clinicians. This exclusion was only in effect if a person presented with major depressive symptoms within the first 2 months after the death of a loved one. Exclusion was omitted in the DSM-5 for several reasons:

45 DSM-5 Changes: DEPRESSION Bereavement Exclusion 1. Removes the implication that bereavement typically lasts only 2 months. 2. Bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual.

46 DSM-5 Changes: DEPRESSION Bereavement Exclusion When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, SI, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5, Section III.

47 DSM-5 Changes: DEPRESSION Bereavement Exclusion 3. Bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. 4. The depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non-bereavement-related depression.

48 DSM-5 Changes: DEPRESSION Bereavement Exclusion In the criteria for major depressive disorder, a detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive episode.

49 DSM-5 Changes: DEPRESSION Bereavement Exclusion Although most people experiencing the loss of a loved one experience bereavement without developing a major depressive episode, evidence does not support the separation of loss of a loved one from other stressors in terms of its likelihood of precipitating a major depressive episode or the relative likelihood that the symptoms will remit spontaneously.

50 DSM-5 Changes: DEPRESSION Bereavement Exclusion The DSM-5 change allows the clinician to now exercise their professional judgment as to whether someone with symptoms of major depression and who is in grief should be diagnosed with depression. It is suspected that professionals will continue to refrain from diagnosing depression if the symptoms do not warrant it.

51 Specifiers for Depressive Disorders A new specifier is available that helps shed light on suicidality factors in someone who is depressed. These factors include suicidal thinking, plans, and the presence of other risk factors in order to make a determination of the prominence of suicide prevention in treatment planning for a given individual.

52 Specifiers for Depressive Disorders A new specifier to indicate the presence of mixed symptoms has been added across both the bipolar and the depressive disorders, allowing for the possibility of manic features in individuals with a diagnosis of unipolar depression.

53 Specifiers for Depressive Disorders A substantial body of research conducted over the last 2 decades points to the importance of anxiety as relevant to prognosis and treatment decision making. The with anxious distress specifier gives the clinician an opportunity to rate the severity of anxious distress in all individuals with bipolar or depressive disorders.

54 Changes 10 syndromes

55 Questions?

56 Resources Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association. DSM-5 Changes: Anxiety Disorders & Phobias. Pro.psychcentral.com DSM-5 Changes: Depression & Depressive Disorders. Pro.psychcentral.com The DSM-5 is here: What the controversial new changes mean for mental health care. Clay, Rebecca A. The Next DSM. American Psychological Association, April 2013, Vol. 44, No. 4 Trestman, Robert L., PhD., M.D. DSM-5 and Personality Disorders: Where Did Axis II Go? Journal of American Academy of Psychiatry Law, 42:141-5, 2014.