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Navigating the Kraepelinian Vortex: Changes in the Diagnoses for Children from DSM-IV to DSM-V. James A. Burns PhD. 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. - PowerPoint PPT Presentation
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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.