New Diagnostic Considerations DSM-5, ICD10-11, PDM Review

1. New Diagnostic Considerations DSM-5, ICD10-11, PDM Review J&K Seminars 2013 Robert M. Gordon, Ph.D. ABPP

2. Objectives • Major new elements of DSM-5 • The highlights of ICD-10 and preparing for October 1, 2014 • The ICD-11 research • The PDM for better understanding of people and for informing psychological treatment • PDM Research • How do these various taxonomies help with ethical and risk management issues?

3. Exercise in Psychodiagnoses Learn about: • Personality organization • Personality patterns • Strengths and weaknesses • Emergent symptoms • Cultural and Contexual issues • Issues related to ethical and risk issues • Countertransference and boundary issues • Contribute to the science of psychological taxonomy. Participation is voluntary.

4. Which Taxonomic Organization for Mental and Behavioral Science? Like a Biological Organization? Like a Periodic Table?

5. The term “Diagnosis” is derived from Greek - meaning a distinguishing, to perceive, to know thoroughly.

6. What is Missing?

7. In 1854, after a major outbreak of cholera struck London, John Snow, a physician, linked the outbreak to contaminated water from this hand pump on Broadwick Street. He removed the handle and stopped the epidemic.

8. Reasons for a mental health taxonomy • Ethical and humanistic dilemmas with diagnosing personality • Nosologies: Different ways to characterize disease • Different nosologies for different folks • Risk managements issues • Need for a personality-based taxonomy that informs psychological treatments

9. Start with a good diagnostic formulation “Once I have a good feel for the person, the work is going well, I stop thinking diagnostically and simply immerse myself in the unique relationship that unfolds between me and the client…one can throw away the book and savor individual uniqueness.” Nancy McWilliams (2011) Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, Second Edition.

10. Main Reasons for Diagnosing 1. Its usefulness for treatment planning. “Understanding character styles help the therapist be more careful with boundaries with a histrionic patient, more pursuant of the flat affect with the obsessional person, and more tolerant of silence with a schizoid client.” 2. Its implications for prognosis. “Realistic goals protect patients from demoralization and therapists from burnout.”

11. Why Diagnose? 3. Its value in enabling the therapist to convey empathy. Once one knows that a depressed patient also has a Borderline, rather neurotic level personality structure, the therapist will not be surprised if during the second year of treatment she makes a suicide gesture. Or, once a borderline client starts to have hope of real change, that he often panics and flirts with suicide in an effort to protect himself from traumatic disappointment.

12. Why Diagnose? • Its role in reducing the probability that certain easily-frightened people will flee from treatment: It is helpful for the therapist to communicate to hypomanic or counter-dependent patients an understanding of how hard it may be for them to stay in therapy.

13. Why Diagnose? 5. Its value in risk management: Often therapists mistakenly used a presenting symptom as the only diagnosis and missed the borderline level of personality or psychopathic personality and got into trouble. 6. Its value in process and outcome research.

14. Ethical Standard in rendering diagnostic opinionsBy Dr. Stephen Behnke, APA Ethics Director • A good starting point is to reflect upon our values as psychologists and to consider the significance of rendering a diagnosis. • Principle A, Beneficence and Nonmaleficence, exhorts psychologists "to benefit those with whom they work and take care to do no harm.” • Promoting welfare and safeguarding from harm are thus values central to our profession. Rendering a diagnosis has direct relevance to each. Diagnoses, record reviews and the new Ethics Code, Ethical Standard 9.01 guides psychologists in rendering diagnostic opinions. By Dr. Stephen Behnke, APA Ethics Director January 2005, Vol 36, No.1

15. Rendering Diagnoses “In few areas of practice does a psychologist exercise greater authority and influence than to render a diagnosis, for in so doing the psychologist comes to know and convey information that may profoundly affect that individual's life.”

16. Implications of a Diagnosis: Clinical, Personal and Social “In the clinical context, a diagnosis reveals the nature of an illness. A correct diagnosis provides a basis for effective treatment. An incorrect diagnosis may delay or impede effective treatment or even exacerbate a situation by inviting inappropriate treatment. A diagnosis has personal significance insofar as it can become central to how a person experiences him- or herself. While a correct diagnosis of a severe disorder can be enormously difficult to integrate into one's sense of self, an incorrect diagnosis can be crippling. A diagnosis is also a label to which others respond and thus has profound social implications. Social judgments are made in response to a diagnosis of mental illness, and diagnoses can play an important role in awarding entitlements and determining placement.

17. Throw Away Occam’s Razor (law of parsimony) • Clinicians should follow the general rule of recording as many diagnoses as are necessary to cover the clinical picture. • Hickam's Dictum: "Patients can have as many diseases as they damn well please." John Hickam, MD. • When recording more than one diagnosis, it is usually best to give the main diagnosis, and to label any others as subsidiary or additional diagnoses.

18. Risk Factors in Litigious Patients Borderline Personality Organization Psychopathic traits History of acting out

19. “I have often served as an expert witness in malpractice cases where psychologists had missed the psychopathic or borderline traits in patients. The DSM classifies antisocial and borderline personality disorders by precise and narrow symptoms. This is often misleading. Psychopathy can be a complex personality pattern that combines with or is obscured by other personality patterns, and borderline can be viewed as an entire level of personality organization that can be applied to the various personality disorders.” Gordon, R.M., (2007) PDM Valuable in Identifying High-Risk Patients. The National Psychologist, 16, 6, November/December, page 4.

20. Which Diagnostic Taxonomy Should We Use? • DSM-5? • ICD-10? • PDM?

21. DSM-5 • The DSM-5 May 2013. • Research started in 1999. • The DSM makes the American Psychiatric Association over $5 million a year, historically adding up to over $100 million.

22. DSM-5 Moves from Multi-axial system to a similar ICD-10 System

23. Main DSM-5 Categories • 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 • Dissociative Disorders • Somatic Symptom Disorders • Feeding and Eating Disorders • Elimination Disorders • Sleep-Wake Disorders • Sexual Dysfunctions • Gender Dysphoria • Disruptive, Impulse Control, and Conduct Disorders • Substance Use and Addictive Disorders • Neurocognitive Disorders • Personality Disorders • Paraphilic Disorders • Other Disorders

24. DSM-5 has major reliability problems • Only 5 diagnoses achieved kappa levels of agreement between 0.60-0.79. • The nine DSM-5 disorders in the kappa range of 0.40-0.59 previously would have been considered just plain poor, but DSM-5 puffs these up as "good.” • Then DSM-5 calls “acceptable” 6 disorders that achieved unacceptable reliabilities with kappas of 0.20-0.39. • Major Depressive Disorder and Generalized Anxiety Disorder were among those that achieved the unacceptable kappas in 0.20-0.39 range.

25. Originally proposedonly 6 personality disorders and a complex trait system The six specific types are as follows: • T 00 Borderline Personality Disorder • T 01 Obsessive-Compulsive Personality Disorder • T 02 Avoidant Personality Disorder • T 03 Schizotypal Personality Disorder • T 04 Antisocial Personality Disorder (Dyssocial Personality Disorder) • T 05 Narcissistic Personality Disorder • T 06 Personality Disorder Trait Specified

26. DSM5: T 04 Antisocial Personality Disorder A.Significant impairments in personality functioning manifest by: 1.   Impairments in self functioning (a or b): a.   Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure. b.   Self-direction: Goal-setting based on personal gratification; absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behavior. 2.   Impairments in interpersonal functioning (a or b): a.   Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another. b.   Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.

27. B.   Pathological personality traits in the following domains: 1.   Antagonism, characterized by: a.   Manipulativeness b.   Deceitfulness c.   Callousness d.   Hostility 2.   Disinhibition, characterized by: a.   Irresponsibility b.   Impulsivity c.   Risk taking

28. DSM-5: T 00 Borderline Personality Disorder- now Degree A.   Significant impairments in personality functioning manifest by: 1.  Impairments in self functioning (a or b): a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.  b.Self-direction: Instability in goals, aspirations, values, or career plans. 2.   Impairments in interpersonal functioning (a or b): a.   Empathy b.   Intimacy B.  Pathological personality traits in the following domains: 1.   Negative Affectivity, characterized by: a.   Emotional lability b.   Anxiousness c.   Separation insecurity d.   Depressivity 2.   Disinhibition, characterized by: a.   Impulsivity b.   Risk taking 3.   Antagonism, characterized by: a.   Hostility

29. The History, Politics and Assumptions of DSM-5

30. What Should Have Been

31. What Actually Occurred

32. How Not to Refine a Diagnostic SystemLessons from DSM-5Work in Isolation Encourage SecrecyIgnore Contradictory Evidence

37. December 1, 2012The Proposal is Rejected by the American Psychiatric Association

40. Why Will DSM-5 Cost $199 a Copy? By Allen Frances, M.D. 1/24/13 Huffington Post DSM-5 has just announced its price -- an incredible $199 • First, APA has sunk more than $25 million into DSM-5 and wants to recoup as much of its investment as it can. • DSM-IV cost one fifth as much -- just $5 million -- of which half came from external grants. • APA is probably counting on having captive buyers who are forced to pay its price, however exorbitant it may be. • DSM-5 boycotts are sprouting up all over the place • The codes clinicians need for insurance purposes are available for free on the internet • DSM-5 is so clunkily written, no teacher will ever want to assign it to students • People are not likely to rush out to buy a ridiculously expensive DSM-5 that has already been discredited as unsafe and scientifically unsound.

41. DSM-5 Is Guide Not Bible—Ignore Its Ten Worst ChangesBy Allen J. Frances, M.D. Psychology Today Dec 2 2012 • More than fifty mental health professional associations petitioned for an outside review of DSM-5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits. Professional journals, the press, and the public also weighed in - expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense.

42. Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably 'psychosis risk', mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, 'hebephilia', cumbersome personality ratings, and sharply lowered thresholds for many existing disorders).

43. 1) Disruptive Mood DysregulationDisorder will turn temper tantrums into a mental disorder. 2) Normal grief will become Major Depressive Disorder. 3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor NeurocognitiveDisorder. 4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs. 5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony but it is a psychiatric illness called Binge Eating Disorder.

44. 6) The changes in the DSM-5 definition of Autism will result in lowered rates - perhaps by 50% according to outside research groups.   7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause. 8) Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets. 9) DSM-5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. 10) DSM-5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

45. Neurodevelopmental Disorders Intellectual Disability (Intellectual Developmental Disorder) • Diagnostic criteria for intellectual disability (intellectual developmental disorder) emphasize the need for an assessment of both cognitive capacity (IQ) and adaptive functioning. • Severity is determined by adaptive functioning rather than IQ score. Moreover, a federal statue in the United States (Public Law 111-256, Rosa’s Law) replaces the term “mental retardation” with intellectual disability. • The term intellectual developmental disorder was placed in parentheses to reflect the ICD-11 (to be released in 2015).

46. Intellectual Disability(Intellectual Developmental Disorder) • DSM-IV criteria had required an IQ score of 70 as the cutoff for diagnosis; the new criteria recommend IQ testing and describe “deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility.” • The new criteria also include severity measures for mild, moderate, severe, and profound intellectual disability.

47. Autism Spectrum Disorder (ASD) • Consolidation of DSM-IV criteria for autism, Asperger’s, childhood disintegrative disorder, and pervasive developmental disorder-not otherwise specific (PDD-NOS)—into one diagnostic category called autism spectrum disorder (ASD). • The new criteria describetwo principal symptoms: “deficits in social communication and social interaction” and “restrictive and repetitive behavior patterns”

48. Communication Disorders The DSM-5 communication disorders include: • language disorder • speech sound disorder • childhood-onset fluency disorder (a new name for stuttering) • social (pragmatic) communication disorder, a new condition for persistent difficulties in the social uses of verbal and nonverbal communication.

49. Attention-Deficit/Hyperactivity Disorder • The same 18 symptoms are used as in DSM-IV • the onset criterion has been changed from “symptoms that caused impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”; • subtypes have been replaced with presentation specifiers that map directly to the prior subtypes; • a comorbid diagnosis with autism spectrum disorder is now allowed; • a symptom threshold change has been made for adults with the cutoff for ADHD of five symptoms, instead of six required for younger persons,

50. Specific Learning Disorder • Specific learning disorder combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Because learning deficits in the areas of reading, written expression, and mathematics commonly occur together, coded specifiers for the deficit types in each area are included.