(American Psychiatric Publishing, 2013): Concepts...

Diagnostic and Statistical Manual of Mental Disorders – 5th Edition

(American Psychiatric Publishing, 2013):

Concepts and Issues in Psychological Diagnosis

By Donald J. Frazier, Ph.D. (Region 9)

Educational Diagnostician, School Psychologist and Clinical Therapist 3/19/14

Goals for the Webinar

After completion of this webinar, the participant will:

•  Have a basic conceptual understanding of the DSM approach to psychiatric diagnostics

•  Be able to identify the key changes from the DSM-4 to 5 and two newly developed conditions of interest to educators

•  Understand how to make sense of a psychological report with a DSM diagnosis included

•  Understand the relationship between special education categories and the corresponding DSM-5 diagnoses

•  Have a basic framework for how to distinguish emotional disturbance from social maladjustment

What is the DSM - 4 and 5?

§  The DSM is the standard “best practices” method for making psychological and psychiatric diagnoses.

§  Only DSM-based diagnoses are accepted by insurance companies for therapy payout.

§  The DSM’s 1, 2 and 3 were based upon “old-school” Freudian terms and concepts (e.g., “neurotic anxiety”) that were not observable.

§  Beginning with the DSM-4, the approach was changed to a more behavioral and observable approach to diagnosis.

§  It uses an approach that identifies the key observable behavioral

markers of a given syndrome and then specifies how many of those markers must be present in order for a diagnosis to be made.

Example of DSM Markers ADHD Inattentive Type

a.  At least 6 or more of the following be present in at least 2 distinct settings (e.g., home/school) prior to age 12 b.  Also, must clearly interfere with functioning

• Often fails to give close attention to details or makes careless mistakes in school work or other activities • Often has difficulty sustaining attention in tasks or play activities • Often does not seem to listen when spoken to directly

•  Often does not follow through on instructions and fails to finish school work, chores or duties in the workplace

•  Often has difficulty organizing tasks and activities

•  Often dislikes or is reluctant to engage in tasks that require sustained mental effort

•  Often loses things necessary for tasks or activities

•  Is easily distracted by extraneous stimuli

•  Is forgetful in daily activities

DSM-4 Multi-Axial Diagnosis •  The DSM-4 used a 5 Axis model. Because all existing

diagnoses can be continued, even as the DSM-5 has come out, you may well still see versions of this approach:

•  AXIS I: Attention Deficit Hyperactivity Disorder (primary disorders) Generalized Anxiety Disorder (primary disorders) AXIS II: not applicable (Intellectual disability and personality disorders)

AXIS III: asthma, past history of seizures (Medical issues that can impact

behavior or cognitive functioning) AXIS IV: stressors: family, school, peers, financial (Stress sources) AXIS V: Global Assessment of Functioning = 55 (Global 1-99 rating)

•  No more 5 Axis model

•  Axes 1, 2 and 3 are combined into a single diagnostic factor

•  No more Axis 4 (stress source identifiers)

•  No more Global Assessment of Functioning (Axis 5)

•  Medical, substance abuse and personality issues embedded into Axis I conditions

•  Many more “specifier” and “severity descriptor” options

•  More emphasis on cultural issues in diagnosis-making

•  Two new conditions of interest to educators

–  Disruptive Mood Dysregulation Disorder

–  Social (Pragmatic) Communication Disorder

Key Changes From DSM 4 to 5

Cultural Factors To Consider When Psychiatric Diagnoses

•  Cultural Syndrome = a group of co-occurring, mostly invariant symptoms found in a specific cultural group, community or context (e.g., Puerto Rican syndrome where adult females over 45 tend to have severe panic and dissociative reactions in the face of stress or bad news).

•  Cultural Idiom of Distress = a linguistic term, phrase or way of talking about suffering among individuals of a cultural group (e.g., one African culture refers to depression as kufungisisa, or “thinking too much.”)

•  Cultural Explanation (perceived cause) = a label, attribution

or feature of an explanatory model that provides a culturally conceived etiology or cause for symptoms, illness or distress (e.g., Is seeing a deceased person a hallucination or is the presence of ghostly visits accepted or treasured by the culture?) (Should I see a shrink or a healer?)

What happened to Axes 2, 3, 4 and 5?

•  Axis 2: formerly Intellectual Disability and Personality Disorders; these have now been moved to Axis 1

•  Axis 3: formerly those medical conditions that could impact behavior; now medically-induced symptoms are embedded into the Axis 1 diagnostic criteria, if applicable

•  Axis 4: formerly stress sources; eliminated and a suggested new optional profile created: DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measurement

•  Axis 5: formerly global functioning estimation; research showed that results were unreliable; now severity ratings are used to indicate the level of functional impairment

What are “specifiers?” •  Specifiers – describes the

particular ways that the disorder presents itself

•  Severity Descriptors - indicates the level of felt distress and impairment

-------------------------------------------- •  Example: Persistent Depressive

Disorder (Dysthymia) Severity Descriptors •  Mild = symptoms are distressing but

manageable, minor functional impairment •  Moderate – between mild and severe •  Severe = intense symptoms that are

seriously distressing and unmanageable, marked interference with functioning

•  Specifier Example: Persistent Depressive Disorder (Dysthymia)

•  Early vs. late (21 or older) onset? •  Currently in partial or full remission? •  With anxious distress? •  With melancholic features? •  With mixed or atypical features? •  With mood congruent psychotic

features? •  With mood-incongruent psychotic

features? •  With peripartem onset?

Differential Diagnosis With The DSM-5

•  A key area of strength for the DSM approach is the provision of “Differential Diagnosis” options to consider.

•  Each disorder has a list of those other mental conditions that can mock or appear similar to it.

EXAMPLE 1: When considering Autism Spectrum, the possible differential diagnoses that must be ruled out include: ADHD, Selective Mutism, Intellectual Disability, Schizophrenia, Communication Disorder or Stereotypic Movement Disorder

EXAMPLE 2: When considering ADHD, the following must be ruled out

include: Oppositional-Defiant, Intermittent Explosive, Learning Disability, Intellectual Disability, Autism, Reactive Attachment, Depressive/Anxiety Disorders, Bipolar, Disruptive Mood Dysregulation, Substance Use, Neurocognitive Disorders, etc.

Additional Information in the DSM-5

•  Each condition contains a wealth of statistical and descriptive information, including:

–  Prevalance rates with a gender breakdown

–  The typical progressive course of the mental disorder

–  Cultural issues to be considered

–  Risk factors or any known causative factors (environmental vs. genetic/physiological)

Broad Categories of Mental Disorders Within the DSM-5

•  Neurodevelopmental •  Schizophrenia/Psychosis •  Bipolar •  Depressive •  Anxiety •  Obsessive-Compulsive •  Trauma and Stress Related •  Dissociative •  Somatic •  Feeding/Eating •  Elimination

•  Sleep/Wake •  Sexual •  Gender Dysphoria •  Disruptive, Impulse Control

and Conduct Disorders •  Substance Use and Addiction •  Neurocognitive •  Paraphilic •  Personality Disorders •  Mental Disorders Due To

Illness or Medications

Who Can Make a DSM Diagnosis? •  Psychiatrists (M.D. in psychiatry) •  Pediatric Physicians (M.D. in pediatric medicine) •  Neurologists (M.D. in neurology) •  Psychologists (Ph.D. in Clinical Psychology) •  School Psychologists (M.A./Ed.S./Ph.D. in School Psychology) •  Counselors/Therapists (M.A. in Counseling)

–  General Clinicians –  Family Therapists –  School Counselors (if curriculum had clinical emphasis) –  Substance Abuse Specialists (minimum of M.A.)

•  Social Workers (M.S.W. in Social Work) NOTE: A Master’s degree is the minimum for making a DSM diagnosis

Should related service (school psychologists, school social workers) make DSM-5 diagnoses when conducted a social-

emotional or sociological evaluation?

•  If qualified, school personnel can make certain DSM-5 diagnoses, such as ADHD or autism spectrum, in the course of making a special education placement.

•  But a DSM-5 specification of the exact mental disorder is not required in order to be considered Emotional Disturbance

•  In doing so, one could conceivably expose the district to potential liabilities

DSM Diagnoses and Emotional Disturbance in Special Education

•  It is not uncommon, though, for the SAT team to be alerted that a student has a psychiatric diagnosis via a clinical report which uses a DSM diagnosis

•  Such an existing diagnosis

can, in some cases, reduce or eliminate the need for additional psychological testing

–  Within the past 2 years (just a guideline!)

–  Made by someone with proper qualifications

•  A DSM diagnosis is not, in and of itself, sufficient for ED eligibility decision making (even if a “quick placement in SPED” is recommended in the clinical report)

•  Educational impact in the

school setting must also first be established.

–  Low or missing grades –  Issues with conduct –  Low energy level/attention span –  Poor district/state test results

Making an Emotional Disturbance Diagnosis in Special Education

•  Is a DSM diagnosis required in order to meet eligibility criteria for ED?

NO •  So long as one of the 5

conditions in the Federal definition are met, the student can be eligible under Emotional Disturbance

A condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child's educational performance. • a) An inability to learn that cannot be explained by intellectual, sensory, or health factors. • b) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers. • c) Inappropriate types of behavior or feelings under normal circumstances. • d) A general pervasive mood of unhappiness or depression. • e) A tendency to develop physical symptoms or fears associated with personal or school problems. • Emotional disturbance includes schizophrenia.

• NOTE: The term does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance.

Fragile vs. Acting Out Variations of ED Have Very Different Programming Needs

Fragile ED (e.g., Anxiety) •  Cooperative •  Non-aggressive •  Shy/Introverted •  Nervous •  Depressed •  Non-aggressive •  Bullied •  Meek/inhibited

Acting Out ED (e.g., Bipolar) •  Defiant •  Aggressive/bullying •  Extraverted •  Substance abuse •  Truancy •  Limit testing •  Impulsive/Explosive

The Relationship Between Educational and DSM Clinical Diagnoses

Special Educational Category

Emotional Disturbance (Emotional Disability)

Possible DSM Diagnoses •  Schizophrenic/Psychotic

–  Delusional Disorder –  Schizophreniform Disorder –  Schizoaffective Disorder

•  Bipolar Disorders –  Bipolar I –  Bipolar II –  Cyclothymic Disorder

•  Depressive Disorders –  Major Depressive Disorder –  Persistent Depressive Disorder

(Dysthymia) –  Disruptive Mood Dysregulation –  Premenstrual Dysphoric Disorder –  Substance/Medication Induced




continued

•  Anxiety Disorders –  Separation Anxiety –  Selective Mutism –  Phobic Disorder –  Social Anxiety –  Panic Disorder –  Generalized Anxiety Disorder

•  Obsessive-Compulsive –  Obsessive-Compulsive –  Body Dysmorphic Disorder –  Hoarding –  Hair Pulling –  Skin Picking

•  Dissociative Disorder –  Dissociative Identity –  Dissociative Amnesia –  Depersonalization/Derealization




continued

•  Trauma or Stress Related –  Reactive Attachment Disorder –  Disinhibited Social Engagement –  Post-Traumatic Stress Disorder –  Acute Stress Disorder –  Adjustment Disorder

•  Somatic Symptoms –  Somatic Symptom Disorder –  Illness Anxiety Disorder

•  Care seeking •  Care avoiding

–  Conversion Disorder –  Factitious Disorder

•  Imposed on Self •  Imposed on another

•  Elimination Disorders –  Enuresis –  Encopresis




•  Feeding and Eating –  Pica –  Rumination Disorder –  Avoidant/Restrictive Food Intake –  Anorexia Nervosa –  Bulimia Nervosa –  Binge-Eating

Social Maladjustment vs. Emotional Disturbance

Students with a “social maladjustment” cannot be considered to have an Emotional Disturbance.

• Internalizing vs. Externalizing Tendencies

• Affective-Emotional versus Behavioral-Conduct Issues

• NOTE: People can have both emotional and social maladjustment issues simultaneously

•  Students with ED can show both Internalizing and Externalizing Behaviors

•  But, in general, Internalizing issues are more reflective of “fragile” ED types (anxiety, depression, schizophrenia)

•  Conversely, Externalizing tendencies can emanate from either “acting out” type ED ((bipolar, disruptive mood dysregulation) OR social maladjustment (oppositional-defiant, conduct disorder).

Can We Even Distinguish ED from Social Maladjustment?

•  Gacono and Hughes (2004) thinks we can and took the position that it is important that we not treat disruptive or antisocial students as children with disabilities.

•  According to Tansy (2004), “Treating disruptive behaviors of the socially maladjusted student as a manifestation of a disability creates difficulties with regard to student accountability, school safety, administrative discipline and burnout among teachers and administrators.”

•  Several psychologists (including one in Albuquerque) have developed instruments that purport to distinguish ED from SM.

•  Prior to 1998, the category was titled, “Seriously Emotionally and Behaviorally Disturbed.” But the “behaviorally” descriptor was removed and the notion of excluding social maladjustment was included in IDEA 2004.

Two Other Models of Social Maladjustment

Hare (1990) •  Superficial charm •  Grandiose sense of self-worth •  Impulsivity •  Irresponsibility •  Lack of long term goals •  Conning and manipulative •  Parasitic lifestyle •  Lack of empathy •  Lack of guilt or remorse •  Callous •  Lies easily

Cleckley (1976) •  Unreliable •  Insincere •  Fails to learn from experience •  Limited emotional experience

(except anger) •  Poor insight •  Low capacity for love •  Lack of anxiety •  No life plan •  One-sided relationships

ED vs. Social Maladjustment •  Michael Tansy, Ph.D. identified

characteristics of Social Maladjustment (2004)

•  Knows and understands the rules and

norms

•  Intentionally breaks rules and norms

•  Perceives self to be “normal”

•  Able to behave “normal” when needed or beneficial to self

•  Views rule breaking as normal or acceptable

•  Misbehavior is motivated by self-gain •  No anxiety or remorse

•  Disruptive, Impulse-Control and Conduct Disorders

•  Oppositional Defiant Disorder •  Conduct Disorder •  Intermittent Explosive Disorder •  Pyromania •  Kleptomania •  Antisocial Personality

•  Paraphilias •  Voyeurism •  Exhibitionism •  Frotteurism •  Sexual Masochism/Sadism •  Pedophilia •  Fetish

•  Substance Abuse •  Personality Disorders

A New Optional DSM-5 Approach to Diagnosis: Personality Disorders

DSM-4 •  Paranoid •  Schizoid •  Schizotypal •  Antisocial •  Borderline •  Histrionic •  Narcissistic •  Avoidant •  Dependent •  Obsessive-Compulsive

DSM-5 •  1. Negative Affectivity (emotional

lability, anxiousness, separation insecurity, submissiveness, hostility, perseveration, depressivity, suspicousness, lack of affect

•  2. Detachment (withdrawal, intimacy avoidance, anhedonia, depressivity, lack of affect, suspiciousness)

•  3. Antagonism (manipulativeness, deceitulfness, grandiosity, attention seeking, callousness, hosility)

•  4. Disinhibition (irresponsibility, impulsivity, distractibility, risk taking, rigid perfectionism)

•  4. Psychoticism (unusual beliefs or experiences, eccentricity, distortions)

A New DSM-5 Depressive Disorder: Disruptive Mood Dysregulation Disorder

•  Developed due to the pattern of over-diagnosis of childhood Bipolar Disorder over the past 10 years

•  Can only be diagnosed between ages 6-18

•  Cannot be co-diagnosed with: –  Oppositional-Defiant Disorder –  Intermittent Explosive Disorder –  Bipolar Disorder

•  A pattern of chronic, severe irritability and temper outbursts

•  Severe recurrent temper outbursts manifested verbally and behaviorally that are grossly out of proportion in intensity to the situation or provocation.

•  The temper outbursts are inconsistent with developmental level.

•  The temper outbursts occur, on average, 3 or more times weekly.

•  The mood between temper outbursts is persistently angry or irritable most of the day, nearly every day, and is observable by others.

•  The above-cited behaviors have occurred for at least 12 months and started before age 10.

•  The above-cited behaviors are presented in at least 2 of 3 possible settings (home, school, with friends) and are “severe” in at least one of these.



Other Health Impaired

•  Neurodevelopmental Disorders –  Attention Deficit Hyperactivity

Disorder •  Inattentive Type •  Hyperactive/Impulsive Type •  Combined Type

–  Motor Disorders •  Tourette’s •  Vocal Tics •  Motor Tics

•  Neurocognitive Disorders –  Associated With:

•  Parkinson’s •  Huntington’s •  HIV •  Drug Abuse



Intellectually Disabled

•  Intellectual Disability (Formerly named Mental Retardation)

•  Must have an IQ score that is more than 2 standard deviations below the test mean of 100 (i.e., 70 or below, 75 when SEM is considered)

•  Must also have serious deficits in at least one aspect of Adaptive Functioning

–  Conceptual (cognitive/communication) –  Social (relationships, coping) –  Practical (self-care)

•  Mild, Moderate, Severe and Profound severity level specifiers for each aspect of adaptive functioning are provided



Specific Learning Disability

•  Specific Learning Disorder –  With Impairment in:

•  Reading –  Word Reading –  Fluency –  Comprehension

•  Writing –  Spelling –  Grammar/Punctuation –  Clarity/Organization of

Writing •  Math

–  Number Sense –  Memorization of Math Facts –  Fluent Calculation –  Accurate Math Reasoning

•  Use caution if no direct testing



Speech-Language Impairment

•  Communication Disorders –  Language Disorder

•  Reduced Vocabulary •  Limited Sentence Structure •  Impairments in discourse

(connected speech)

–  Speech Sound Disorder •  Intelligibility

–  Childhood Onset Fluency Disorder (Stuttering)

•  Use caution if no direct testing cited in diagnosis



Traumatic Brain Injury

•  Mild or Major Neurocognitive Disorder Due to Traumatic Brain Injury

•  NOTE: The remainder of the Neurocognitive Disorders are a result of internal injuries and thus would not meet the eligibility criteria



Autism

• Autistic Disorder (classical) • Pervasive Developmental Disorder NOS • Asperger’s Disorder (high functioning)

•  Autism Spectrum Disorder

–  Asperger’s and PDD-NOS were eliminated

–  It is expected that the rate of autism diagnosis will be reduced by up to 30%

–  The spectrum is now reflected by a severity scale: •  1 - requiring support •  2 - requiring substantial

support •  3 - requiring very

substantial support

Autism Spectrum Disorder Criteria

Deficits Social Communication and Social Interactions (all 3): • Deficits in social-emotional reciprocity, ranging from abnormal social approach and failure of normal back and forth conversation; to reduced sharing of interests, emotions or affect; to failure to initiate or respond to social interactions. • Deficits in nonverbal communicative behaviors used for social interactions, ranging from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact body language or deficits in understanding and use of gestures; to ta total lack of facial expressions and nonverbal communication. • Deficits in developing, maintaining and understanding relationships, ranging from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence or interest in peers

•  Restricted, repetitive patterns of behavior, interests or activities (at least 2 of the following):

•  Stereotyped or repetitive motor movements, use of objects or speech (e.g., simple motor stereotypies, lining up toys or flipping objects; echolalia, idiosyncratic phrases).

•  Insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal and nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, eats same food, takes same routes every day).

•  Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., preoccupation with unusual objects, excessively circumscribed or perseverative interests)

•  Hyper- or hypo-reactivity to sensory input or unusual interest in in sensory aspects of the environment (pain, smells, touch, visual).

Autism and DSM Diagnosis

•  Despite the fact that the DSM-5 has eliminated Asperger’s and PDD-NOS, until the federal law is revised to come into line, the DSM-4 criteria can still be used in eligibility decision making

•  Also, all existing DSM-4 diagnoses made prior to June 2013 will continue to honored henceforth, without needing to meet the new DSM-5 criteria (including Asperger’s and PDD-NOS)

A New DSM-5 Communication Disorder:

Social (Pragmatic) Communication Disorder

•  Developed partly due to the perceived pattern of over-diagnosis of Autism over the past 10 years

•  Persistent difficulty with understanding social-language pragmatics and non-verbal (body language or context) cues

•  Differentiated from autism due to the lack of ongoing “restricted and repetitive patterns of interest.” In other words, motor mannerisms and obsessive or ritualistic tendencies are not noted for this condition

•  Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:

•  Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context.

•  Impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently to a child than an adult and avoiding the use of overly formal language.

•  Difficulties following rules for conversation and story telling, such as taking turns in conversation, rephrasing when misunderstood and knowing how to use verbal and nonverbal signals to regulate interaction.

•  Difficulties understanding what is not explicitly stated (non-literal or ambiguous).

In Sum:

•  You now can now make sense of a DSM diagnosis

•  Get a copy of the DSM-5 for your district if you do not already have one

•  Consult with your school psychologist or social worker if unsure about DSM diagnosis or related issues

References •  Diagnostic and Statistical Manual of Mental Disorders (5th

Edition), June 2013; American Psychiatric Publishing, Washington, D.C.; London, England.

•  Cleckly, H. (1976) The mask of sanity (5th Ed.) St. Louis, MO; Mosby

•  Gacono, C.B. & Hughes, T.L. (2004) Differentiating emotional disturbance from social maladjustment; Assessing psychopathology in aggressive youth. Psychology in the Schools 41 (8).

•  Hare, R. (1990) A research scale for the assessment of psychopathy in criminal populations. Personality and Individual Differences, 1 (111-119)

•  Tansy, M. (2004) Emotional disability or social maladjustment? CEU presentation in Albuquerque, NM.

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