Amy Cappiccie, PhD, LCSWWestern Kentucky University

Region IX Representative, NASW

Intro to the DSM 5 for the Trauma Focused Care Worker

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.

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

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

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

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

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

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

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

DSM 5 Sections(APA, 2013)

Section I: DSM 5 BasicsSection II: Diagnostic Criteria and CodesSection III: Emerging Measures and ModelsSection IV: Appendix

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

Neurodevelopmental DO(APA, 2013; Klott, 2013)

Intellectual DisabilityAutism Spectrum DOAttention-Deficit- Hyperactivity DO

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

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?)

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

Schizophrenia Spectrum and Other Psychotic DO (APA, 2013; Klott, 2013)

SchizophreniaSchizoaffective DO

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

Attenuated Psychosis Syndrome(Klott, 2013)

Not billable due to being in section 3Research not completed on section 3

diagnosesUse for early symptoms of schizophrenia

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

Bipolar and Related DO

Bipolar I DOBipolar II DO

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

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

Depressive DisordersDisruptive Mood Dysregulation DOPremenstrual Dysphoric DO

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

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

Obsessive Compulsive and Related DO Obsessive Compulsive DOHoarding DOHair-Pulling DOSkin Picking DO

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

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

Hair Pulling DO and Skin Picking DO(APA, 2013; Klott, 2013)

Now listed as Trichotillomania (Hair Pulling Disorder)

Skin Picking DO: New diagnosis

Anxiety DisordersPanic DOAgoraphobiaSeparation Anxiety DOSelective MutismGeneralized Anxiety DO

Panic DO and Agoraphobia(APA, 2013; Klott, 2013)

Panic DO and Agoraphobia delinked into two separate diagnosis

Diagnoses Shifting to Anxiety DO (APA, 2013; Klott, 2013)

Separation Anxiety DOSelective Mutism

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

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%)

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)

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

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

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

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)

Feeding and Eating DO(APA, 2013; Klott, 2013)

Rumination DO, Pica and Avoidant/Restrictive Food Intake DO (moved from childhood section)

Binge Eating DO

Binge Eating DO(APA, 2013; Klott, 2013)

Binge piece of Bulimia without purgingAt least one binge weekly over the last 3

months

Gender Dysphoria(APA, 2013)New diagnostic classSeparate categories for children and

adolescents/adultsSpecifications for:

With a disorder f sex developmentPost transition

Disruptive, Impulse-Control and Conduct DisordersConduct DOOppositional Defiant DO

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

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)

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

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