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Psychiatry UPDATE (an idiosyncratic sample of recent issues)

Psychiatry UPDATE (an idiosyncratic sample of recent issues). Dr Caroline Bradley. Order of Play. Diagnosis ICD-11 DSM-5 Diagnostic tests Risk Assessment – HCR v3 Clustering/PbR. Diagnostic Classification. ICD-10 published 1992 (DCR-10: 1993) DSM-IV published 1994

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Psychiatry UPDATE (an idiosyncratic sample of recent issues)

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  1. Psychiatry UPDATE(an idiosyncratic sample of recent issues) Dr Caroline Bradley

  2. Order of Play • Diagnosis • ICD-11 • DSM-5 • Diagnostic tests • Risk Assessment – HCR v3 • Clustering/PbR

  3. Diagnostic Classification • ICD-10 published 1992 (DCR-10: 1993) • DSM-IV published 1994 • DSM-IV-TR published 2000 • DSM-5 published 2013 • ICD-11 to be released in 2015 • free to download (paper version for a fee) • Compatible with electronic health records • 100 word definition of each entity • Content Model (13 parameters)

  4. ICD-11 Content Model Parameters • ICD Entity Title • Classification Properties • Textual Definitions • Terms • Body System/Structure Description • Temporal Properties • Severity of Subtype Properties • Manifestation Properties • Causal Properties

  5. ICD-11 Content Model Parameters (2) • Functioning Properties • Specific Condition Properties • Treatment Properties • Diagnostic Criteria

  6. ICD-11 PD Classification (proposed/possible changes) • ICD-11 may include significant changes to the classification of Personality Disorder • Tyrer,P.,Crawford,M., & Mulder,R. (2011) Reclassification of personality disorder. Lancet, 377,1814-1815 • Tyrer,P. et al Personality and Mental Health 5: 246-259 (2011) Wiley Online Library

  7. ICD-11 PD Classification (proposed/possible changes) • Primary classification based on severity: • No PD • Personality Difficulty – some problems in some situations • Personality Disorder - definite well-demarcated problems in a range of situations • Complex Personality Disorder – definite problems in several domains across all situations • Severe Personality Disorder – as above plus significant risk to self or others

  8. ICD-11 PD Classification (proposed/possible changes) • Secondary Classification of five trait domains • Asocial/schizoid • Dyssocial/antisocial • Obsessional/anankastic • Anxious/dependent • Emotionally unstable Also: possibly no lower age limit

  9. DSM-5 Personality Disorder • No changes from DSM-IV • Cluster A • Paranoid, Schizoid, (Schizotypal) • Cluster B • Antisocial, Borderline, Histrionic, Narcissistic • Cluster C • Avoidant, Dependent, Obsessive-Compulsive

  10. DSM-5 Alternative Model for PD • Criterion A • Moderate or greater impairment in personality functioning • Self: • Identity • Self-direction • Interpersonal: • Empathy • Intimacy

  11. DSM-5 Alternative Model for PD • Criterion A • Five levels of impairment • 0 = little or no impairment • 1 = some impairment • 2 = moderate impairment • 3 = severe impairment • 4 = extreme impairment Rated using Level of Personality Functioning Scale (which uses the four elements – identity, self-direction, empathy, and intimacy)

  12. DSM-5 Alternative Model for PD • Criterion B • Pathological Personality Traits • 5 broad trait domains • Negative Affectivity • Detachment • Antagonism • Disinhibition • Psychoticism

  13. DSM-5 Alternative Model for PD • 25 trait facets • Emotional Lability • Anxiousness • Separation Insecurity • Submissiveness • Hostility (Negative Affectivity and Antagonism) • Perseveration • Depressivity (Negative Affectivity and Detachment) • Suspiciousness (Negative Affectivity and Detachment) • Restricted Affectivity (Negative Affectivity and Detachment)

  14. DSM-5 Alternative Model for PD • Withdrawal • Intimacy avoidance • Anhedonia • Manipulativeness • Deceitfulness • Grandiosity • Attention seeking • Callousness • Irresponsibility • Impulsivity

  15. DSM-5 Alternative Model for PD • Distractability • Rigid perfectionism (lack of) • Unusual beliefs and experiences • Eccentricity • Cognitive and perceptual dysregulation

  16. DSM-5 Alternative Model for PD Negative Affectivity Detachment • Emotional Lability • Anxiousness • Separation Insecurity • Submissiveness • Hostility • Perseveration • Depressivity • Suspiciousness • Restricted Affectivity (lack of) • Withdrawal • Intimacy Avoidance • Anhedonia • Depressivity • Restricted Affectivity • Suspiciosness

  17. DSM-5 Alternative Model for PD Antagonism Disinhibition • Manipulativeness • Deceitfulness • Grandiosity • Attention Seeking • Callousness • Hostility • Irresponsibility • Impulsivity • Distractability • Risk Taking • Rigid Perfectionism • PSYCHOTICISM • Unusual beliefs • Eccentricity • Cognitive/perceptual dysregulation

  18. DSM-5 Alternative Model for PD • And then: • Antisocial • Avoidant • Borderline • Narcissistic • Obsessive Compulsive • Schizotypal • Personality Disorder – Trait Specified

  19. DSM-5 Alternative Model for PD • For example – for Antisocial PD: • Moderate or greater impairment in 2 + of the 4 areas (identity, self-direction, empathy, intimacy) • 6 or more out of 7 pathological personality traits: • Manipulativeness • Callousness • Deceitfulness • Hostility • Risk Taking • Impulsivity • Irresponsibility

  20. DSM-5 Alternative Model for PD • Compared with: • Three or more out of the following 7 : • Failure to conform to social norms • Deceitfulness • Impulsivity • Irritability and aggressiveness • Reckless disregard for safety of self/others • Irresponsibility • Lack of remorse

  21. DSM-5: New Diagnoses (1) • 15 new mental disorders (1-8): • Social (Pragmatic) Communication Disorder • Disruptive Mood Dysregulation Disorder (u18) • Premenstrual Dysphoric Disorder • Hoarding Disorder • Caffeine Withdrawal • Cannabis Withdrawal • Excoriation (skin-picking) Disorder • Binge Eating Disorder

  22. DSM-5: New Diagnoses (2) • 15 new mental disorders (9-15): • REM Sleep Disorder • Restless Legs Syndrome (not really new) • Major Neurocognitive Disorder (replaces dementia) • Mild Neurocognitive Disorder • Disinhibited Social Engagement Disorder (children) • Central Sleep Apnea • Sleep-related hypoventilation

  23. Premenstrual Dysphoric Disorder • One or more of: • Affective lability (mood swings etc) • Marked irritability/anger/interpersonal conflict • Marked depressed mood • Marked anxiety/tension • PLUS: one or more of the following to a total of 5: • Decreased interest in activities; difficulty concentrating; lethargy; hypersomnia/insomnia; change in appetite; feeling overwhelmed; physical symptoms such as “bloating”.

  24. Hoarding Disorder • Difficulty getting rid of possessions • Due to a perceived need to save them and distress associated with discarding • Resulting in the accumulation of items that clutter living areas and compromise their use • Causes distress or impairment Note to self: could be time to confront partner about 37 years’ worth of football programmes

  25. DSM-5 Schizophrenia • No subtypes • No Schneiderian special attribution (running commentary; voices conversing) • No special attribution for bizarre delusions • Two or more of the following present for a significant period during a month: • Delusions, hallucinations, disorganized speech, grossly disorganised or catatonic behaviour, and negative symptoms

  26. DSM- 5 ASD • Autistic Spectrum Disorder replaces four previously separate disorders (autism, Asperger’s, childhood disintegrative disorder, and pervasive developmental disorder NOS) • ASD is characterised by: • 1. deficits in social communication and social interaction • 2. restricted repetitive behaviours, interests, or activities (RRBs) Note: if 1. but not 2. diagnosis is Social (Pragmatic) Communication Disorder

  27. DSM-5 Miscellany • Intellectual Disability replaces Mental Retardation • Panic Disorder and Agoraphobia “unlinked” • Removal of the requirement (in phobic disorders) that adults recognise that their anxiety is unreasonable or excessive • New separate chapters for OCD and Trauma/Stress related disorders • Distinction between Paraphilia and Paraphilic Disorder and addition of “controlled environment” and “in remission”

  28. Diagnostic Test for Schizophrenia • Philip J Benson, Sara A Beedie, Elizabeth Shephard, Ina Giegling, Dan Rujescu, David St Clair Biological Psychiatry Vol 72 Issue 9, pp 716-724 1 November 2012 • Case Control study • Eye movement tests (gaze, following, viewing and image) • Total 298 assessments (whole data set) • Near perfect accuracy (discriminating between people with SCZ and those without)

  29. The future for Clozapine? • Pharmacogenetics may lead to a way to identify those patients more likely to respond to Clozapine and those more likely to suffer Clozapine-induced Agranulocytosis • Use of bone marrow stimulating factors to treat the neutropenia caused by Clozapine

  30. Protection of Others (1) • Stephen D. Hart, Christine Michie, David J. Cooke BJP 2007, 190:s60s65 • Precision of actuarial risk assessment instruments: Evaluating the ‘margins of error’ of group v individual predictions of violence • Yang M, Wong SC, Coid J. Psychol Bull 2010 Sept; 136(5): 740-67 • The efficacy of violence prediction: a meta-analytic comparison of nine risk assessment tools

  31. Protection of Others (2) • Coid J et al The Journal of Forensic Psychiatry & Psychology Vol22, No. 1, February 2011 3-21 • Most items in structured risk assessment instruments do not predict violence • Alec Buchanan; Renee Binder; Michael Norko; Martin Swartz Am J Psychiatry 2012; 169:340-340 • Psychiatric Violence Risk Assessment

  32. HCR-20 v3 • Primary Changes from HCR-20 v2: • Changes to names of Basic Risk Factors • Changes to content of some Basic Risk Factors • Addition of Sub-Items for complex risk factors • Addition of Indicators (examples) to Risk Factor Definitions • Elaboration of administration procedure (7 steps)

  33. HCR-20 v3 • Historical Scale: • H1 – History of Problems with Violence • 3 age ranges • H2 – History of Problems with Other Antisocial Behaviour • Incorporates information that in v2 was rated under H8 Early maladjustment, H10 Supervision Failure, and C2 Negative Attitudes • 3 age ranges • H3 – History of Problems with Relationships • Broadened to include general social relationships

  34. HCR-20 v3 • H4 – History of Problems with Employment • No substantive changes • H5 – History of Problems with Substance Use • No substantive changes • H6 – History of Problems with Major Mental Disorder • No substantive changes • H7 – History of Problems with Personality Disorder • Broadened from Psychopathy: PCL-R not needed

  35. HCR-20 v3 • H8 – History of Problems with Traumatic Experiences • Narrowed in respect of focus on trauma experiences • Broadened to include adult experiences • H9 – History of problems with Violent Attitudes • Includes information rated in C2 in v2 • H10 – History of Problems with Treatment or Supervision Response • Broadened to include treatment as well as supervision

  36. HCR-20 v3 • C1 – Recent problems with Insight • No substantive changes • C2 – Recent Problems with Violent Ideation or Intent • Narrowed to focus on thoughts/plans concerning perpetration of violence • C3 – Recent Problems with Symptoms of Major Mental Disorder • No substantive changes

  37. HCR-20 v3 • C4 – Recent Problems with Instability • No substantive changes • C5 – Recent Problems with Treatment or Supervision Response • Broadened to include problems with response to institutional or community supervision • R1 – Future Problems with Professional Services and Plans • Narrowed to focus on difficulties implementing professional services and making adequate plans

  38. HCR-20 v3 • R2 – Future Problems with Living Situation • Narrowed to focus on difficulties finding a living situation that would help avoid potential destabilising influences • R3 – Future problems with Personal Support • No substantive changes • R4 – Future problems with Treatment or Supervision Response • Broadened to include treatment refractoriness • R5 – Future problems with Stress or Coping • No substantive changes

  39. HCR-v3 • Change in coding from 0 1 2 to N P Y • NB: rating is a mean to an end; not an end • The 7 Steps: • Gather information • Presence of Risk Factors • Relevance (to risk management strategies) • Formulation (theoretical basis; 4 P’s etc) • Scenarios • Management • Final Opinions (case prioritization etc)

  40. Payment by Results (PbR) • Mental Health Clustering Tool (MHCT) • Groups service users according to level of need • Developed from HoNOS and SARN • Additional items for forensic services • Five Forensic Pathways (FFP)

  41. Clustering Tool Items (current) • Suicide • Substance Misuse • Cognitive Problems • Physical Illness • Hallucinations + Delusions • Depressed Mood • Other Symptoms • Relationships • Activities of Daily Living • Living Conditions • Occupation/Activities • Strong Unreasonable Beliefs • Mental Capacity • Carer Needs • Cultural/communication • Physical Security

  42. Clustering Tool Items (historical) • Agitated behaviour/expansive mood • Repeat Self-harm • Safeguarding • Engagement • Vulnerability • Interpersonal Dynamics • Drink/Drug Taking • Antisocial Attitudes

  43. The Clusters • 0 – no cluster but in need of care and will get a service • 1 Common MH Problems (low severity) • 2 Common MH Problems (low severity; greater need) • 3 Non Psychotic (moderate severity) • 4 Non-Psychotic (severe) • 5 Non-Psychotic (very severe) • 6 Non Psychotic Disorder of Overvalued Ideas

  44. The Clusters • 7 Enduring Non-psychotic (high disability) • 8 Non-Psychotic Chaotic and Challenging • 8b Non-Psychotic challenging and antisocial • 8c Non-Psychotic socially avoidant, disaffected • 10 First Episode Psychosis • 11 Ongoing recurrent psychosis (low symptoms) • 12 Ongoing or Recurrent Psychosis (high disability)

  45. The Clusters • 13 Ongoing or Recurrent Psychosis (high symptom and disability) • 14 Psychotic Crisis • 15 Severe Psychotic Depression • 16 Dual Diagnosis • 17 Psychosis and Affective Disorder – Difficult to Engage • 18 – 21 Cognitive Impairment and Dementia

  46. Clustering • Each cluster has: • Indicative episode of care - e.g. 3+ years • A defined frequency of review – e.g. annually • Step-Down criteria • Step-up criteria • Description of which transitions are most likely, possible, rare, and clinically impossible • Discharge Criteria

  47. Five Forensic Pathways • I Treatment Responsive Group • II Treatment Resistant – challenging behaviour • III Treatment Resistant - continuing care • IV Personality Disorder – prison transfer • V Personality Disorder – co-morbidity

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