introduction to dsm-5 - forensic psychology

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Changes in the Diagnostic and Statistical

Manual of Mental Disorders that Impact Forensic Psychology

Kristine M. Jacquin, Ph.D.

Fielding Graduate University

Presented at ACFP Symposium 2014

Overview of Presentation

  Brief introduction to DSM-5

  Primary differences in DSM-5

  Overall impact of DSM-5 on forensic practice

  Specific DSM-5 changes that impact psycholegal issues

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Copyright Disclaimer

  Some of the content of this presentation (e.g., diagnostic criteria) comes directly from DSM-5, published by the American Psychiatric Association.

  Consider this disclaimer to be the proper quotation and citation of included content, when relevant.

  Note: not intended to be used as a substitute for DSM-5 (in some cases, incomplete information is provided in favor of brevity)

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Introduction to DSM-5 Section and Chapter Structure and Content

Overview of DSM-5

  Section I: Basics

  Section II: Diagnostic criteria and codes

  Section III: Emerging measures and models

 Appendix

  Index

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Section I: Basics

  Orients readers to “the purpose, structure, content, and use” of the manual

  Discusses process of creating DSM-5

  Summarizes structure of DSM-5 and movement away from multiaxial system

  Discusses clinical case formulation and using the DSM-5

  Includes caution about forensic use of DSM-5

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Section II: Diagnostic Criteria and Codes

  Chapters categories of disorders

  Mental disorders described in detail within each chapter

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Section II Chapters

  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

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Section II Chapters cont.

  Dissociative disorders

  Somatic symptom and related disorders

  Feeding and eating disorders

  Elimination disorders

  Sleep-wake disorders

  Sexual dysfunctions

  Gender dysphoria

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Section II Chapters cont.   Disruptive, impulse-control, and conduct

disorders

  Substance-related and addictive disorders

  Neurocognitive disorders

  Personality disorders

  Paraphilic disorders

  Other mental disorders

  Medication-induced movement disorders & other adverse effects of medication (not mental disorders)

  Other conditions that may be a focus of clinical attention (not mental disorders)

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Section III: Emerging Measures and Models

  Purpose: provides a place for content that may be clinically useful but requires further research

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Section III Content

  Assessment Measures

  Cultural Formulation

  Alternative DSM-5 Model for Personality Disorders

  Conditions for Further Study

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Appendix

  Highlights of changes from DSM-IV to DSM-5

  Glossary of technical terms

  Glossary of cultural concepts of distress

  Alphabetical listing of DSM-5 diagnoses and codes for ICD-9-CM and ICD-10-CM

  Numerical listings of DSM-5 diagnoses and codes for ICD-9-CM and ICD-10-CM

  DSM-5 advisors and other contributors

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Beyond DSM-IV-TR: Comparing DSM-IV and DSM-5

DSM-IV-TR DSM-5

  172 157 specific mental disorders

  50 disorders combined into 22

  15 new disorders added

  2 disorders removed

  Some disorders re-categorized

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Disorders Combined in DSM-5

  Language Disorder (Expressive Language Disorder & Mixed Receptive Expressive Language Disorder)

  Autism Spectrum Disorder (Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder, & Rett’s Disorder)

  Specific Learning Disorder (Reading Disorder, Math Disorder, & Disorder of Written Expression)

  Delusional Disorder (Shared Psychotic Disorder & Delusional Disorder)

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Combined Disorders cont.

  Panic Disorder (PD without Agoraphobia & PD 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)

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  Non-Rapid Eye Movement Sleep Arousal Disorders (Sleepwalking Disorder & Sleep Terror Disorder)

  Genito-Pelvic Pain/Penetration Disorder (Vaginismus & Dyspareunia)

  Alcohol Use Disorder (Alcohol Abuse & Alcohol Dependence)

  Cannabis Use Disorder (Cannabis Abuse & Cannabis Dependence)

  Phencyclidine Use Disorder (Phencyclidine Abuse & Phencyclidine Dependence)

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  Other Hallucinogen Use Disorder (Hallucinogen Abuse & Hallucinogen Dependence)

  Inhalant Use Disorder (Inhalant Abuse & Inhalant Dependence)

  Opioid Use Disorder (Opioid Abuse & Opioid Dependence)

  Sedative, Hypnotic, or Anxiolytic Use Disorder (SHA Abuse & SHA Dependence)

  Stimulant Use Disorder (Amphetamine Abuse, Amphetamine Dependence, Cocaine Abuse, Cocaine Dependence)

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  Stimulant Intoxication (Amphetamine Intoxication & Cocaine Intoxication)

  Stimulant Withdrawal (Amphetamine Withdrawal & Cocaine Withdrawal)

  Substance/Medication-Induced Disorders (aggregate of Mood, Anxiety, and Neurocognitive Substance/Med Induced)

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New Disorders in DSM-5   Social (Pragmatic) Communication Disorder

  Disruptive Mood Dysregulation Disorder

  Premenstrual Dysphoric Disorder (*DSM-IV-TR appendix)

  Hoarding Disorder

  Excoriation (Skin-Picking) Disorder

  Disinhibited Social Engagement Disorder (split from Reactive Attachment Disorder)

  Binge Eating Disorder*

  Central Sleep Apnea (split from Breathing-Related Sleep Disorder)

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New Disorders cont.   Sleep-Related Hypoventilation (split from

Breathing-Related Sleep Disorder)

  Rapid Eye Movement Sleep Behavior Disorder (Parasomnia NOS)

  Restless Legs Syndrome (Dyssomnia NOS)

  Caffeine Withdrawal*

  Cannabis Withdrawal

  Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other Medical Conditions)

  Mild Neurocognitive Disorder* 22

Disorders Eliminated from DSM-5

  Sexual Aversion Disorder

  Polysubstance-Related Disorder

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New NOS Terminology

  DSM-IV = Not Otherwise Specified (41 instances)

  DSM-5 = Other Specified and Unspecified (65 instances)

  Changed to be more consistent with ICD

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DSM-5: Overall Impact on Forensic Practice

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DSM-5 and Forensic Practice

  Clinical diagnosis of DSM-5 mental disorder ≠ legal criteria for mental disorder

  Clinical diagnosis of DSM-5 mental disorder ≠ meeting legal standard related to mental state

  Additional info needed to determine legal criteria or legal standard

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DSM-5 and Forensic Practice cont.

  Evaluators use clinical diagnosis as part of description of mental state

  Clinical diagnosis is foundation for making certain psycholegal arguments

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DSM-5: Specific Changes Relevant to

Psycholegal Issues

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Intellectual Disability

  Psycholegal questions:

  Atkins evaluations

  CST assessment

  Criminal responsibility evaluation

  Disability determinations

  Civil competencies

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  New name

  Degrees of severity (mild, moderate, etc.) no longer separate diagnostic codes   Specify severity with F code

  Severity based on adaptive functioning rather than IQ

  Consistent with AAIDD definition

  Highlights issues that are often raised in legal cases

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  A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, and academic learning and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing.

  Diagnostic features section: complete IQ test, SEM, Flynn effect, practice effects

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  B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, and across multiple environments, such as home, school, work, and recreation.

  Diagnostic features section: conceptual, social, and practical domains

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  C. Onset of intellectual and adaptive deficits during the developmental period.

  Diagnostic features section: deficits are present during childhood and adolescence

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Autism Spectrum Disorder


  CST assessment

  Criminal responsibility evaluation



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  Replaces:

  Autistic Disorder

  Asperger Disorder

  Childhood Disintegrative Disorder

  Rett Disorder

  Pervasive Developmental Disorder NOS

  Single, behaviorally defined disorder

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  Rett disorder & other etiologic subgroups: Associated with known medical or genetic condition or environmental factor

  3 symptom domains became 2: social communication and restricted, repetitive behaviors

  Should allow for more accurate diagnoses

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  A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history:

  Deficits in social-emotional reciprocity

  Deficits in nonverbal communicative behaviors used for social interaction

  Deficits in developing, maintaining, and understanding relationships

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  B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history:   Stereotyped or repetitive motor movements, use

of objects, or speech

  Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior

  Highly restricted, fixated interests that are abnormal in intensity or focus

  Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment

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  C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies later in life).

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Specific Learning Disorder


  Work- and school-related disability determinations and/or accommodations

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  Three disorders became one

  Criterion A describes specific difficulties

  Specify type

  Achievement is substantially lower than age based expectations

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  A. Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite provision of interventions that target the difficulties:   Inaccurate or slow and effortful word reading   Difficulty understanding the meaning of what is

read   Difficulties with spelling   Difficulties with written expression   Difficulties mastering number sense, number facts,

or calculation

  Difficulties with mathematical reasoning

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  B. The affected academic skills are substantially and quantifiably below those expected for the individual’s chronological age, based on appropriate standardized measures, and cause significant interference with academic or occupational performance or with activities of daily living.

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  C. The learning difficulties begin during school-age years but may not become fully manifest until learning demands exceed the individual’s limited capacities.

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Disruptive Mood Dysregulation Disorder


  Juvenile criminal responsibility

  Juvenile risk assessment and treatment amenability

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

  B. Temper outbursts are inconsistent with developmental level.

  C. Outbursts occur 3+ times/week (avg.)

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

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  G. Dx should not be made for first time before age 6 or after age 18.

  H. Age of onset before 10 years

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Premenstrual Dysphoric Disorder

  Psycholegal issues:


  Diminished capacity

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  A. In majority of menstrual cycles, at least 5 symptoms present in final week before onset of menses, start to improve within a few days after onset of menses, and become minimal or absent in the week postmenses.

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  B. One or more symptoms:

  Marked affective lability

  Marked irritability or anger or increase conflicts.

  Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts

  Marked anxiety, tension, feeling on edge

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  C. One or more symptoms, to reach a total of five symptoms when combined with B:   Decreased interest in usual activities

  Subjective difficulty in concentration

  Lethargy, easy fatigability, marked lack of energy

  Marked change in appetite; overeating; cravings

  Hypersomnia or insomnia

  Sense of being overwhelmed or out of control

  Physical symptoms such as breast tenderness or swelling, joint or muscle pain, bloating, weight gain

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Hoarding Disorder



  Diminished capacity for crimes related to hoarding

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Hoarding Disorder

  A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.

  B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them.

  C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties.

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Post Traumatic Stress Disorder


  Diminished capacity

  Criminal responsibility

  Psychological injury


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  Special criteria for pre-schoolers

  Dissociative subtype

  Clearer definitions

  Tightening of criterion A1

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  A. The person was exposed to the following event(s): death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways:

  Directly experiencing the traumatic event

  Witnessing, in person, the event(s) as they occurred to other(s)

  Learning that the event(s) occurred to a close relative or close friend; in such cases, the actual or threatened death must have been violent or accidental

  Experiencing repeated or extreme exposure to aversive details of the events(s) (e.g., first responders collecting body parts, police officers repeatedly exposed to details of child abuse); does not apply to exposure through electronic media, TV, movies or pictures unless exposure is work-related

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  Eliminated criterion A2

  4 symptom clusters instead of 3

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DSM-IV-TR DSM-5

Re-experiencing Intrusion symptoms

Avoidance & numbing Avoidance

Alterations in cognition & mood

Increased arousal Alterations in arousal and reactivity

Neurocognitive Disorders


  CST, criminal responsibility


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  Major or Mild Neurocognitive Disorder Due to Alzheimer’s Disease

  Major or Mild Frontotemporal Neurocognitive Disorder

  Major or Mild Neurocognitive Disorder with Lewy Bodies

  Major or Mild Vascular Neurocognitive Disorder

  Major or Mild Neurocognitive Disorder Due to TBI

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  Substance/Medication-Induced Major or Mild Neurocognitive Disorder

  Major or Mild Neurocognitive Disorder Due to HIV Infection

  Major or Mild Neurocognitive Disorder Due to Prion Disease

  Major or Mild Neurocognitive Disorder Due to Parkinson’s Disease

  Major or Mild Neurocognitive Disorder Due to Huntington’s Disease

  Major or Mild Neurocognitive Disorder Due to Another Medical Condition; Due to Multiple Etiologies; Unspecified

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  A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:

  1. Concern of individual, informant, clinician, and

  2. A substantial impairment in cognitive performance, documented by testing

  B. The cognitive deficits interfere with independence in everyday activities.

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  A. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:   1. Concern of individual, informant, clinician, and

  2. A modest impairment in cognitive performance, documented by testing

  B. The cognitive deficits do not interfere with capacity for independence in everyday activities.

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Conclusions

  Significant changes in diagnostic criteria in DSM-5

  When diagnosis is relevant to psycholegal question, must be well-versed in DSM-5 criteria and features

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Questions?

  Contact me at: [email protected] or [email protected]

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Changes in the Diagnostic and Statistical Manual of Mental Disorders that Impact Forensic Psychology Although few psycholegal questions are answered solely on the basis of psychological diagnosis, DSM diagnoses are quite relevant to many psycholegal issues. For example, a diagnosis of intellectual disability is central to the question of whether a convicted offender can be sentenced to death. Similarly, a mental disorder diagnosis is required to legally label someone a “sexually violent predator” in most states with such designations. Given the relationship between DSM diagnosis and many psycholegal questions, the introduction of a substantially revised DSM (i.e., DSM-5) has a large impact on forensic psychology. The purpose of this presentation is to provide an overview of the changes in DSM-5 and to describe the ways in which these changes impact forensic evaluations. Learning objectives: At the conclusion of this presentation, attendees will be able to: 1. At the conclusion of this presentation, attendees will be able to describe the broad changes in DSM-5 relative to DSM-IV-TR. 2. At the conclusion of this presentation, attendees will be able to summarize the impact of DSM-5 on forensic practice. 3. At the conclusion of this presentation, attendees will be able to explain specific ways in which DSM-5 changes impact psycholegal issues. Presenter biography: Kristine Jacquin earned a B.A. at Northwestern University, and her M.A. and Ph.D. in clinical psychology at the University of Texas at Austin. Dr. Jacquin is a Professor of Psychology and Dean at Fielding Graduate University. She is also a licensed clinical psychologist with a consulting practice focusing on forensic and neuropsychological evaluations. Selected references: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Washington, D.C.: Author. Bernet, W., & Baker, A. J. L. (2013). Parental alienation, DSM-5, and ICD-11: Response to

critics. Journal of the American Academy of Psychiatry and the Law, 41, 98-104. Duschinsky, R., & Chachamu, N. (2013). Sexual dysfunction and paraphilias in the DSM-5:

Pathology, heterogeneity, and gender. Feminism & Psychology, 23, 49-55. Tyrer, P. (2013). The classification of personality disorders in ICD-11: Implications for forensic

psychiatry. Criminal Behaviour and Mental Health, 23, 1-5. Wakefield, J. C. (2012). The DSM-5’s proposed new categories of sexual disorder: The problem

of false positives in sexual diagnosis. Clinical Social Work Journal, 40, 213-223.

introduction to dsm-5 - forensic psychology

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