amy cappiccie, phd, lcsw western kentucky university region ix representative, nasw intro to the dsm...
TRANSCRIPT
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Amy Cappiccie, PhD, LCSWWestern Kentucky University
Region IX Representative, NASW
Intro to the DSM 5 for the Trauma Focused Care Worker
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Learning OutcomesParticipants will be able to identify at least one
major change to the philosophy behind the DSM 5Participants will be able to list and describe at
least three new DSM 5 disorders.Participants will be able to compare and contrast
at least three revised DSM 5 disorders with the equivalent DSM IV TR disorders.
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Historical Perspective: DSM I (Blashfield, 1998; Scotti & Morris, 2000; Klott, 2013)
DSM Purpose # Diagnosis
Changes Problems
DSM I (1952)
Compiling Knowledge based on info at the time; Original copyright with military
** Harry Stack Sullivan (philosophy)** Meyer (psychiatrist, Nazi affiliation)
3 categories: 1)Organic brain syndromes, 2)Functional DO, 3)Mental deficiency
Total: 106 diagnosis
Only 1 applied to children:
Adjustment Reaction to Childhood/Adolescents
Questionnaires to 10% members;
Subjective perspective
Lack of reliability and/or validity,
Lack of empirical studies
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Reaction Theory (Klott, 2013)
“We bring into adulthood early childhood defense mechanisms” Harry Stack Sullivan, 1951
Reaction theory: Trauma + coping strategies = survival Survival can = personality changes into
adulthood
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Historical Perspective: DSM II(Blashfield, 1998; Scotti & Morris, 2000; Klott, 2013)
DSM Purpose # Diagnosis
Changes Problems
DSM II (1968)
Further increase communication among professionals
APA associated started and more involved
Medical focus = shirt to pharmacology
11 categories with increased attention to children
Total: 165 diagnosis
Additional category = Behavioral Disorders of Childhood and Adolescents
Lack of reliability and validity;
Lack of description for diagnosis = increased error;
Lack of empirical studies
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Historical Perspective: DSM III(Blashfield, 1998; Scotti & Morris, 2000; Klott, 2013)
DSM Purpose # Diagnosis
Changes Problems
DSM III (1980)
Questions of reliability and validity
Multi-axis review
Total = 265 Removal of homosexuality
Political debates over terminology and diagnostic criteria
Became guideline for insurance
Increase in size (p. 92 to p. 482 not “user Friendly”)
Differences in coding between ICD and DSM
Reliability computation across class
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Historical Perspective: DSM III R (Blashfield, 1998; Scotti & Morris, 2000; Klott, 2013)
DSM Purpose # Diagnosis
Changes Problems
DSM III R (1987)
New research, field trails and coding
Total = 297 Six new categories deleted
Added: Trichotillomania
Controversial diagnosis considered not used: Premenstrual Syndrome
Different amounts of attention provided to diagnosis
Questioned scientific underpinnings
Field trails by experts = possible bias
Disagreement about axis
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Historical Perspective: DSM IV/ IV TR(Blashfield, 1998; Scotti & Morris, 2000; Klott, 2013)
DSM Purpose # Diagnosis
Changes Problems
DSM IV Increased research findings3 step process:1) Literature review2) Data gathering and analysis3) Field trials
Total = 365(p. 886)
Restructuring categories
Provides information on each DO
Sources = decision trees and glossaries
Bias toward biological
Problems with symptoms overlap between diagnosis
Continued new axis focus
DSM IV TR Corrected typing errors
Client centered language and Cultural diversity
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DSM 5 Philosophy(Klott, 2013)
Started 1999: Delays due to replacing members (50% outside US)
Reflects ICD 10Reduce stigma of mental disordersReduce use of medicationsFocus on relationship in therapy and
diagnosisRedefining goal of manual: Sullivan focus
vs. billingMandatory compliance of October 2015
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DSM 5 Sections(APA, 2013)
Section I: DSM 5 BasicsSection II: Diagnostic Criteria and CodesSection III: Emerging Measures and ModelsSection IV: Appendix
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DSM5 : Classifications(APA, 2013)
Neurodevelopmental DO
Schizophrenia Spectrum and Other Psychotic DO
Bipolar and Related DO
Depressive DO Anxiety DO Obsessive Compulsive and Related DO
Trauma and Stressor Related DO
Dissociative DO Somatic Symptom and Related DO
Feeding and Eating DO
Elimination DO Sleep-Wake DO
Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse Control and Conduct DO
Substance Related and Addictive DO
Neurocognitive DO Personality DO
Paraphilic DO Other Mental DO
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Neurodevelopmental DO(APA, 2013; Klott, 2013)
Intellectual DisabilityAutism Spectrum DOAttention-Deficit- Hyperactivity DO
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Intellectual Disability(APA, 2013; Klott, 2013)
IQ based on testing plus perception of the test administrator
Severity based on functioning NOT number on test
Requires assistance in functioningOnset before age 18 yearsUse of severity index important to show
level of impairmentLater name will be Intellectual
Developmental DO
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Autism Spectrum DO(APA, 2013; Klott, 2013)
Change to single diagnosis with emphasis given to severity index
Do still focuses on: 1) Deficits in social communication and social interaction and 2) Restricted repetitive behaviors/interests/activities
What severity index will be covered? (3 or 4 only?)
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Attention-Deficit Hyperactivity DO(APA, 2013; Klott, 2013)
Criteria similarFew change highlights: Information added
on adults, Comorbidity allowed with ASD, Symptoms prior to age 12 (rather than 7)
Interesting research:60% of those diagnosed as children will still
have as an adultAdult symptoms = irritability, difficult
concentrating, increased use of cannabis and cocaine
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Schizophrenia Spectrum and Other Psychotic DO (APA, 2013; Klott, 2013)
SchizophreniaSchizoaffective DO
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Schizophrenia(APA, 2013; Klott, 2013)
Subtypes removedMore information on differential diagnosis
(i.e. substance abused psychosis, schizoaffective DO and MDD with psychotic features
Must complete risk assessment within first 6 weeks of diagnosis due to increased risk for suicide
Interesting research: Females increased risk ages 17-24 with high paranoia, males increased risk ages 36-42
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Attenuated Psychosis Syndrome(Klott, 2013)
Not billable due to being in section 3Research not completed on section 3
diagnosesUse for early symptoms of schizophrenia
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Schizoaffective DO(APA, 2013)
Major mood episode present for majority of the duration of disorder
Use the 2-4-2 ruleDuring 8 weeks of treatment: 2 weeks
psychosis, 4 weeks mood, 2 weeks psychosis
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Bipolar and Related DO
Bipolar I DOBipolar II DO
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Bipolar I DO(APA, 2013; Klott, 2013)
Interesting research: watch for co-occurring disorders of alcohol, cocaine and/or amphetamines
Symptoms in children under 11 yearsMania = hyperactivity, grandiosity,
psychosis, elated mood, rapid speech, racing thoughts, refuses sleep
Depression = personality change, drop in grades, morbid thoughts, pessimistic, suicidal ideation, somatic complaints
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Suicide Risk and Bipolar I and II(Klott, 2013)
Suicide should be assessed on bothBipolar I research:
Psychotic driven grandiosityDepressive episodes = disablingSyntonicDecrease risk for suicide (except at psych
hospital, new meds or realize what has been done during mania)
Bipolar II research:Increased risk for suicide during hypomania if
high levels of irritability
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Depressive DisordersDisruptive Mood Dysregulation DOPremenstrual Dysphoric DO
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Disruptive Mood Dysregulation DO(APA, 2013; Klott, 2013)
Suicide should be assessedChild (under 10) into adulthoodSymptoms:
Temper outbursts (verbal and behavioral)Outbursts more than 3 times per weekOverall sad/low/irritable mood
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Premenstrual Dysphoric DO(Klott, 2013)
Suicide should be assessedSeverity index MUST be 3 or 4Symptoms:
Depressed mood one week prior to cycleFeelings of depression, hopelessness, self
critical
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Obsessive Compulsive and Related DO Obsessive Compulsive DOHoarding DOHair-Pulling DOSkin Picking DO
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Obsessive Compulsive DO(APA, 2013; Klott, 2013)
Must assess for suicide riskNo longer viewed as an anxiety disorderHigh risk for alcohol useInsight an important factor in treatment
(stress inoculation)Symptoms:
Compulsive actsNo psychosisIntrusive thoughts
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Hoarding DO(APA, 2013; Klott, 2013)
New diagnosisNot within OCD now Symptoms:
Difficulty discarding “things”Perceived need to save itemsExtreme distress associated with discarding
items
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Hair Pulling DO and Skin Picking DO(APA, 2013; Klott, 2013)
Now listed as Trichotillomania (Hair Pulling Disorder)
Skin Picking DO: New diagnosis
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Anxiety DisordersPanic DOAgoraphobiaSeparation Anxiety DOSelective MutismGeneralized Anxiety DO
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Panic DO and Agoraphobia(APA, 2013; Klott, 2013)
Panic DO and Agoraphobia delinked into two separate diagnosis
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Diagnoses Shifting to Anxiety DO (APA, 2013; Klott, 2013)
Separation Anxiety DOSelective Mutism
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Generalized Anxiety DO(Klott, 2013)Must access for suicide riskSymptoms noted as either: in children, in
adolescents or in adultsIn children 0 – 11 years, GAD is noted as:
terror, fear around natural disasters (3 or 4 severity)
Adolescents: performance issues in athletics or academics (3 or severity)*** higher risk for suicide
Adults: persistent worry about lots of things, high level of crisis, busy style to deal with worry** * higher risk for suicide
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Suicidal Ideation in GAD(Klott, 2013)
Use of Cannabis = high suicide riskDoes not typically seek treatment due to
busy management styleCannot relax due to anxiety and cannabis
forces this…person unable to copeHymen and Waggonner (80-100% will
attempt with these factors present)Affected by THC level (past = 3-5% and
now = 13-15%)
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Trauma and Stress Related DOReactive Attachment DODisinhibited Social Engagement DOPosttraumatic Stress DOAdjustment DO (now housed in this
category)Non-suicidal self injurious behavior (section
III)
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Reactive Attachment DO and Inhibited Social Engagement DO (APA, 2013; Klott, 2013)
Both must look at Specifier 4 (Pathogenic care realms)
Reactive Attachment DOInconsistent nurturing/attachmentResponses to relationship = anxiety or no emotional
intimacyNot due to autismBefore age 6 years
Disinhibited Social Engagement DO Own distinct DO (instead of specifier in RAD)Little or inconsistent nurturing/attachmentNo boundaries: accepts love/affection from anyoneBefore age 6 yearsNo better accounted for by ADHD
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PTSD for Children 6 years and younger (APA, 2013; Klott, 2013) Must check for suicide riskExperienced, learned or witnessed trauma
about death, serious injury, sexual violation or violent accident
Symptoms: nightmares, dissociation, sexual acting out, emotions of guilt/shame, reenactment in play
Interesting Research: increased risk for suicide with feelings of guilt/shame; TV/video will not cause trauma
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PTSD (APA, 2013; Klott, 2013) Must check for suicide riskSymptoms: flashbacks, dissociation,
relationship challenges, emotional constriction, guilt/shame
Increased risk for suicide with guilt/shame
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Non-Suicidal Self-Injurious Behavior(Klott, 2013)
Does not correlate with suicidal ideationSection III not billableMethods of dealing with stress learned in
childhoodThis addresses the “why” behind cuttingTypes:
Emotional Regulation Deficits (i.e. anger/rage)Dissociative ExperiencesBody Dysmorphic Issues (i.e. de-sexualize)Anxiety-Depression Regulation (most common)Isolation and Social Cohesion Needs (female
adolescents, attention seekers, stops mid to late 30s)
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Feeding and Eating DO(APA, 2013; Klott, 2013)
Rumination DO, Pica and Avoidant/Restrictive Food Intake DO (moved from childhood section)
Binge Eating DO
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Binge Eating DO(APA, 2013; Klott, 2013)
Binge piece of Bulimia without purgingAt least one binge weekly over the last 3
months
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Gender Dysphoria(APA, 2013)New diagnostic classSeparate categories for children and
adolescents/adultsSpecifications for:
With a disorder f sex developmentPost transition
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Disruptive, Impulse-Control and Conduct DisordersConduct DOOppositional Defiant DO
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Conduct DO(APA, 2013; Klott, 2013)
Mostly the same except a specifier:Callous and unemotional : sociopathy not
adult onset, lack of remorse or guilt, unconcerned about performance, shallow, lack of affect
Behavior MUST be observed for 12 continuous months by a mental health professional and the treating clinician
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Oppositional Defiant DO(APA, 2013; Klott, 2013)
Moved from childhood disordersThree types: 1) angry/irritable mood; 2)
argumentative/defiant and 3) vindictiveSeverity index 3 or 4 (different than typical
teen)
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Substance Related and Addictive Disorders (APA, 2013; Klott, 2013)
Removed poly-substance dependent due to rare via research field studies
Gambling DOPreoccupation with gamblingInteresting research: Activates brain in a
similar fashion to drugs/alcoholNegative financial and/or legal consequences
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Personality Disorders(APA, 2013; Klott, 2013)
Many of these diagnoses are put under the appropriate categories in Section IIExamples = Schizotypal Personality DO
(under Schizophrenia Spectrum), Antisocial Personality DO (under disruptive, impulse-control and conduct DO)
Section III hold interesting new research that has been gathered thus far
Can continue to use as in DSM IV TR