Navigating the Kraepelinian Vortex: Changes in the Diagnoses for Children from DSM-IV to DSM-V

James A. Burns PhD

6th Annual Summit

Supporting Children & Youth Who Struggle

January 24, 2014

Sources

American Psychiatric Association DSM IV and IV-TR DSM 5 The Selling of DSM, The Rhetoric of

Science in Psychiatry Various other websites and

publications

What is Abnormal?

Deviations from statistical norm? Deviations from social norm? Maladaptive behavior? Personal Distress?

What is abnormal?

May be statistically uncommon and socially deviant but these are not necessary characteristics.

DSM and psychopathologists seems to weigh more heavily on maladaption and personal distress.

Example:

What then is a disorder?

Grouping of symptoms? Illness in and of itself? Psychological construct versus

physical existence. Misuse of diagnoses (K and K p93)

These problems persist (94 and 95)

History of DSM

DSM I (1952) 132 pages Disorders as “reactions” Disorders were nonspecific Definitions were nonspecific Descriptions were paragraphs of

prototypical cases Psychodynamic in orientation

History of DSM

DSM II (1968) 134 pages Reaction terminology dropped Multiple diagnoses encouraged Coincided with ICD 8 Psychodynamic in orientation

A revolution? From DSM II to III something changed

Who was pushing the change? “scientific psychiatry,” payors, public

What was changing? Movement away from psychoanalysis

Organized psychiatry and the medicalization of mental health

The “medical model” Power and Authority

History of DSM

DSM III 494 pages Multi-axial classification system

introduced Neutral, atheoretical, and descriptive in

terms of etiology More specific criteria The problem of Reliability

Reliability versus validity

DSM III-Reliability-Validity

Reliability Validity Interplay between the two Research versus clinical practice

SCID (Structured Clinical Interview) DIS (Diagnostic Interview Schedule)

History of DSM

DSM IV (1994) 886 pages “clinical significance” criterion New disorders introduced PTSD, Acute Stress Disorder, Bipolar

II, and Asperger’s Others deleted (some personality

disorders)

History of DSM

DSM 5 (2013) 947 pages Dimensional or severity scales adopted Cultural and gender issues considered

more Multi-axial system dropped

Diagnoses and associated illness listed together in order of importance

DSM 5 Changes

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence replaced by:

Neurodevelopmental Disorders

Neurodevelopmental Disorders

Intellectual Disorder (DSM pps 34-41) Used to be mental retardation More emphasis placed on adaptive

functioning IQ still used but balanced against

functioning High quality descriptions.

Neurodevelopmental Disorders

Communication Disorders (used to be’s) Language Disorder (mixed expressive-

receptive language disorders) Speech Sound Disorder (phonological

disorder) Childhood Onset Fluency Disorder

(stuttering) Social Communication Disorder (new)

Neurodevelopmental Disorders

Autism Spectrum Disorder Four previous diagnoses were

believed to encompass one illness with differing severities in TWO core domains.

Autism, Asperger’s, Childhood Disintegrative Disorder, and PDD NOS

Autism Spectrum Disorder

Core Domains: Deficits in social communication and

social interaction. Restricted repetitive behaviors,

interests, and activities

BOTH DOMAINS ARE REQUIRED FOR A DIAGNOSIS

Autism Spectrum Disorder

Severity and associated features are indicated through the use of specifiers

Social communication disorder is diagnosed if no restricted repetitive behaviors, interests, and activities are present.

Attention-Deficit/Hyperactivity Disorder Criteria very similar

Inattention and Hyperactivity/Impulsivity domains

Better examples added in criteria Cross-situational requirement strengthened Onset changed to before 12 years old Subtypes replaced with specifiers Comorbidity with ASD now allowed Symptom threshold lowered for adults

Specific Learning Disorder

Reading Disorder, Math Disorder, and Disorder of Written Expression all combined

Different learning disorders will be differentiated with specifiers

Motor Disorders

Developmental Coordination Disorder

Stereotypic Movement Disorder Tourette’s Disorder Tic disorders (criteria for a “tic”

have been standardized across all disorders)

Disruptive, Impulse-Control, and Conduct Disorders

Brings together two chapters of Impulse Disorders and Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.

All are disorders involving emotional and behavioral self-control.

Oppositional Defiant Disorder

Symptoms grouped into angry/irritable mood, argumentative/defiant behavior, and vindictiveness.

More guidance on frequency of behavior to justify diagnosis.

Severity rating has been added.

Conduct Disorder

Criteria largely unchanged from DSM-IV

Specifier added to distinguish callous and cold interpersonal style.

Intermittent-Explosive Disorder In DSM-IV physical aggression was required

now verbal aggression and non-injurious lesser physical aggression also meets criteria.

Frequency of outbursts clearly specified. Negative impairment, functioning, and

consequences added as criteria. Minimum of 6 years old Differential diagnoses clarified between this

and other disorders such as ADHD DMDD.

Trauma and Stressor-Related Disorders Reactive Attachment Disorder Disinhibited Social Engagement

Disorder PTSD – criteria added for assessing

children under 6 years old (DSM5 pps 272-273)

Acute Stress Disorder Adjustment Disorders

Diagnoses that have moved!

Separation anxiety disorder is now an anxiety disorder.

Selective mutism is now an anxiety disorder.

Obsessive and Compulsive Disorders now has a chapter.

New Disorders of interest

Excoriation (skin picking) Disorder Substance or medication induced OCD OCD related to a medical condition Disruptive Mood Dysregulation

Disorder Added in response to over-diagnosis of

Bipolar Disorder in children (DSM5 pp156)

What I am happy about…

Attempts to cut down on over-diagnosing of Bipolar Disorder in children.

Obsessive and Compulsive Disorders have their own chapter.

Criteria for PTSD in children under 6 Disruptive Mood Dysregulation

Disorder

What I am disappointed by…

Dropping 5 Axis diagnosis Dropping Global Assessment of

Functioning No clear diagnostic category for

children who have endured chronic long term trauma.