Ditching the bereavement - PowerPoint Presentation

Slide1

Ditching the bereavement clause, Asperger’s Disorder, & roman numerals: a DSM 5 Update   

Stephanie Nichols, PharmD, BCPS, BCPPAssociate Professor, Husson UniversityNicholss@husson.eduMaine Pharmacy Association – Fall 2015Slide2

Wakefield -

Harm and Dysfunction

HomosexualitySlide3

List the purpose of DSM-5 and its major limitations for use in patients with mental illness. Recite the meaning of the bereavement exclusion in MDD and the rationale for its removal from DSM-5.Describe how the change in the age of onset of symptoms of ADHD from DSM-IV to DSM-5 affects the prevalence of the disorder. Identify

the new terminology for Asperger's Disorder in DSM-5.Learning ObjectivesSlide4

List the purpose of DSM-5 and its major limitations for use in patients with mental illness.  Slide5

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) contains the following information:Pathology and Etiology

Diagnostic CriteriaPharmacotherapyAll of the aboveSlide6

Tracing (what is now considered to be) Major Depressive Disorder through the editions…Slide7

DSM -ISlide8

Psychotic DisordersWITHOUT CLEARLY DEFINED TANGIBLE CAUSE OR STUCTURAL CHANGE Affective reactionsManic depressive reaction, manic typeManic depressive reaction, depressive type Manic depressive reaction, other Psychotic depressive reaction Schizophrenic reactionsParanoid reactions

DSM-ISlide9

Major affective disorders ((Affective psychoses)) Involutional melancholiaManic-depressive illness, manic type Manic-depressive illness, depressed type Manic-depressive illness, circular typeOther major affective disorder

Unspecified major affective disorder Affective disorder not otherwise specifiedManic-depressive illness not otherwise specifiedDSM-IISlide10

AFFECTIVE DISORDERS Major affective disorders Bipolar disorderMajor depressionsingle episoderecurrentOther specific affective disordersCyclothymic disorder

Dysthymic disorder (or Depressive neurosis) Atypical affective disordersDSM-IIISlide11

Mood DisordersDEPRESSIVE DISORDERSMajor Depressive DisorderDysthymic Disorder Depressive Disorder NOS BIPOLAR DISORDERSBipolar

I DisorderBipolar II DisorderCyclothymic Disorder Bipolar Disorder NOS Mood Disorder Due to ...[Indicate the General Medical Condition]

Substance-Induced Mood Disorder

Mood

Disorder NOS

DSM-IVSlide12

DSM-5 Depressive DisordersDisruptive Mood Dysregulation DisorderMajor Depressive DisorderSingle episodeMildModerate

SevereWith psychotic featuresIn partial remissionIn full remissionRecurrent episodeSame classifications as single episodePersistent Depressive Disorder (Dysthymia)Premenstrual

Dysphoric Disorder

Substance/Medication-Induced

Depressive Disorder

Depressive

Disorder Due to Another Medical Condition

Other

Specified Depressive Disorder

Unspecified

Depressive DisorderSlide13

A. Dysphoric mood or loss of interest or pleasure in all or almost all usual activities and pastimes. B. At least four of the following symptoms nearly every day for a period of at least two weeks(1) poor appetite or significant weight loss or increased appetite or significant weight gain

(2) insomnia or hypersomnia(3) psychomotor agitation or retardation (4) loss of interest or pleasure in usual activities, or decrease in sexual drive(5) loss of energy; fatigue(6) feelings of worthlessness, self-reproach, or excessive or inappropriate guilt (7) complaints or evidence of diminished ability to think or concentrate

(

8) recurrent thoughts of death, suicidal ideation, wishes to be

dead, or

suicide

attempt

DSM-III

CriteriaSlide14

Five (or more) of the following symptoms, occurring nearly every day, during the same 2-week period; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (1) depressed mood most of the day(2) markedly

diminished interest or pleasure in almost all activities most of the day(3) significant weight loss or weight gain or decrease or increase in appetite(4) insomnia or hypersomnia

(5) psychomotor

agitation or

retardation

(6) fatigue

or loss of

energy

(7) feelings

of worthlessness or excessive or inappropriate guilt

(8) diminished

ability to think or concentrate, or

indecisiveness

(9) recurrent

thoughts of

death,

recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing

suicide

The

symptoms are not better accounted for by

Bereavement

DSM-IV CriteriaSlide15

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.(1) depressed mood most of the day(2) markedly diminished interest or pleasure in almost all activities most of the day(3) significant

weight loss or weight gain or decrease or increase in appetite(4) insomnia or hypersomnia(5) psychomotor agitation or retardation(6) fatigue or loss of energy(7) feelings of worthlessness or excessive or inappropriate guilt (8) diminished ability to think or concentrate, or indecisiveness(9) recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing

suicide

The

symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The episode is not attributable to the physiological effects of a substance or to another medical condition.

DSM-5 CriteriaSlide16

With SpecifiersSlide17

Diagnostic and Statistical Manual of Mental Disorders through the years

DSM-IDSM-IIDSM-III, III-RDSM-IV, IV-TRDSM-5

Year

1952

1968

1980; 1987

1994; 2000

2013

Diagnoses

128

193

228;

253

383; 383

541 (157)

Pages

132

119

494; 567

886; 943

947

Cost

$3

$4

$32

$49; $75

$199

Purpose &

change from previous edition

Glossary

of

psychiatric

diagnostic

terminology

Increased focus

on outpatient & added NOS

Major Revision;

Introduced multiaxial system

Depathologize

normal

via

functional

impairment

clauseConsolidate categories & reorganize structure. ICD-11 align.Picture

Blashfield RK, Keeley JW, Flannigan EH et al. Annu

. Rev. Clin. Psychol. 2014. 10:25–51Slide18

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) contains the following information:Pathology and Etiology

Diagnostic CriteriaPharmacotherapyAll of the aboveSlide19

Recite the meaning of the bereavement exclusion in MDD and the rationale for its removal from DSM-5.

Major Depressive Disorder(MDD) and the Bereavement

ExclusionSlide20

Exclusion of a diagnosis of MDD in all patients shortly after the death of a loved one, regardless of the presence of other symptoms of depression

Consideration of a diagnosis of MDD in all patients shortly after the death of a loved one, regardless of the presence of other symptoms of depressionThe diagnosis of MDD in a patient shortly after the death of a loved one is up to the provider’s clinical judgment and likely to be circumstance specificThe diagnosis of MDD in a patient shortly after the death of a loved one is made by administering antidepressants and monitoring for immediate

effect

The

removal of the bereavement clause from Major Depressive Disorder (MDD)

criteria results

in which of the following?Slide21

The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved oneUNLESSThe symptoms persist for longer than 2 monthsORAny of the following apply:marked

functional impairmentmorbid preoccupation with worthlessnesssuicidal ideationpsychotic symptomspsychomotor retardationDSM-IV MDD Bereavement ClauseSlide22

Note: Responses to a significant loss (e.g., bereavement…) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss…which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment

based on the individual’s history and the cultural norms for the expression of distress in the context of loss.DSM-5 – No Bereavement ExclusionSlide23

GriefMajor Depressive EpisodeAffectFeelings of emptiness and sadness

Depressed mood and inability to anticipate or experience pleasure or happinessPain/pleasurePain accompanied by pleasure and humor at timesPain and pervasive unhappiness and miseryMoodDysphoria increases over days to weeks, occurring in waves, and associated with thoughts or reminders of the deceased

Persistent

depressed mood and not tied to specific thoughts or preoccupations

Thought Content

preoccupation with thoughts and memories of the deceased

self critical or pessimistic ruminations

Self Esteem

Preserved self esteem, or if self-derogatory, it typically involves perceived failings vis-à-vis the deceased

Feelings of worthlessness and self-loathing

Thoughts of Death and Dying

focused on the deceased and about “joining” the deceased

focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depressionSlide24

Let’s Meet HV and BHHV, a 21 year old femaleNew onset worthlessness, pessimism, guilt, insomnia, and difficulty concentrating in classShe no longer enjoys playing her violin, which was has been source of great joy for her on a daily basis for 15 years. She last played 3.5 weeks ago. Mother tragically and suddenly passed away in a car accident 4 weeks agoPMH/PPH: GAD

Family history: Father has had MDD since his 20s with recurrent and severe depressive episodesSister has MDD and GADBH, a 72 year old femaleNew onset depressed mood, weight loss, guilt about fighting with her husband, hypersomnia, and difficulty paying bills. Husband of 53 years passed away from Lung Cancer 3 weeks ago, after a 2-year battle.She continues to attend church and participate in her usual activities and reports that once she “gets her mind off of things”, she does enjoy herself.

PMH/PPH: DM2, GERD, HTN, HLD, OA

Family history:

Unknown, but mom had “heart problems”Slide25

Think about the removal of the bereavement exclusion for Major Depressive Disorder in DSM-5 as you consider these 2 cases.Pair with a neighbor.Briefly share your thoughts, ideas and opinions with one another regarding this change and what effect it might have on these patients. Think-Pair-Share:a 2 minute activitySlide26

Exclusion of a diagnosis of MDD in all patients shortly after the death of a loved one, regardless of the presence other symptoms of depressionConsideration of a diagnosis of MDD in all patients

shortly after the death of a loved one, regardless of the presence other symptoms of depressionThe diagnosis of MDD in a patient shortly after the death of a loved one is up to the provider’s clinical judgment and likely to be circumstance specificThe diagnosis of MDD in a patient shortly after the death of a loved one is made by administering antidepressants and monitoring for immediate effect

The

removal

of the bereavement clause from Major Depressive Disorder (MDD)

criteria results

in which of the following?Slide27

Describe how the change in the age of onset of symptoms of ADHD from DSM-IV to DSM-5 affects the prevalence of the disorder.

Attention Deficit–HyperactivityDisorder (ADHD) and Age of OnsetSlide28

How does the minimum age for symptomatology criteria in DSM-5 affect the amount of those diagnosed with Attention Deficit-Hyperactivity Disorder (ADHD), compared to using DSM-IV criteria?More patients are likely to be diagnosed with ADHD using DSM-5

Fewer patients are likely to be diagnosed with ADHD using DSM-5There is likely to be no change in the amount of patients who are diagnosed with ADHD between DSM-IV and DSM-5In DSM-5, ADHD is no longer recognized on its own, but rather as a subset of Obsessive-Compulsive DisordersSlide29

ADHD Diagnosis - Either (1) or (2):(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention(a) often fails to give close attention to details or makes careless mistakes

in schoolwork, work, or other activities(b) often has difficulty sustaining attention in tasks or play activities(c) often does not seem to listen when spoken to directly(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e) often has difficulty organizing tasks and activities (g) often loses things necessary for tasks or activities

(

h) is often easily distracted by extraneous stimuli

(i) is often forgetful in daily

activities

DSM-IV ADHD Diagnostic CriteriaSlide30

(2) six (or more) of the following symptoms of hyperactivity/impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:Hyperactivity(a) often fidgets with hands or feet or squirms in seat(b) often leaves seat in classroom or in other situations in which remaining seated is expected(c) often runs about or climbs excessively in situations in which it is inappropriate

(d) often has difficulty playing or engaging in leisure activities quietly(e) is often "on the go" or often acts as if "driven by a motor"(f) often talks excessivelyImpulsivity(g) often blurts out answers before questions have been completed

(h) often has difficulty awaiting turn

(i) often interrupts or intrudes on others (e.g., butts into

conversations or

games

)

DSM-IV ADHD Diagnostic CriteriaSlide31

B. Some symptoms that caused impairment were present before age 7 years.C. Some impairment is present in two or more settings.

D. clear evidence of clinically significant impairment in social, academic, or occupational functioning.E. The symptoms are not better accounted for by another mental disorder.

DSM-IV ADHD Diagnostic CriteriaSlide32

ADHD Diagnosis = Either (1) and/or (2):Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:Note: For older patients

(age 17 and older), at least five symptoms are required.Often fails to give close attention to details or makes careless mistakes Often has difficulty sustaining attention in tasks or play activitiesOften does not seem to listen when spoken to directlyOften does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplaceOften has difficulty organizing tasks and activities

Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental

effort

Often loses things necessary for tasks or

activities

Is often easily distracted by extraneous

stimuli

Is often forgetful in daily activities

DSM-5 ADHD Diagnostic CriteriaSlide33

(2) Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:Note:  For older patients (age 17 and older), at least five symptoms are required.Often fidgets with or taps hands or feet or squirms in seat.

Often leaves seat in situations when remaining seated is expected Often runs about or climbs in situations where it is inappropriate. Often unable to play or engage in leisure activities quietly.Is often “on the go,” acting as if “driven by a motor” Often talks excessively.Often blurts out an answer before a question has been completed Often has difficulty waiting his or her turn

Often

interrupts or intrudes on

others

DSM-5 ADHD Diagnostic CriteriaSlide34

Several symptoms were present prior to age 12 years.Several inattentive or hyperactive-impulsive symptoms are present in two or more settings There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.The symptoms are not better explained by another mental disorderDSM-5 ADHD Diagnostic CriteriaSlide35

13 year old male Disruptive and disrespectful behaviorRepeatedly getting in trouble and described as distracted Began having problems at school by the age of 9Forgets to finish homework due to difficulty sustaining attentionRiddled with careless mistakesDifficulty focusing in conversations Easily distracted by minute disruptions

Blurts out answers before being called uponMisplaces his chore list and his school booksGreat difficulty remaining seated and non-fidgety Introducing MG…Slide36

Think about MG’s story.Pair with a neighbor.Does MG meet DSM-5 criteria for ADHD? Did he meet DSM-IV criteria? Why or why not?Think-Pair-Share:a 2 minute activitySlide37

How does the minimum age for symptomatology criteria in DSM-5 affect the amount of those diagnosed with Attention Deficit-Hyperactivity Disorder (ADHD), compared to using DSM-IV criteria?More patients are likely to be diagnosed with ADHD using DSM-5

Fewer patients are likely to be diagnosed with ADHD using DSM-5There is likely to be no change in the amount of patients who are diagnosed with ADHD between DSM-IV and DSM-5In DSM-5, ADHD is no longer recognized on its own, but rather as a subset of Obsessive-Compulsive DisordersSlide38

Identify the new terminology for Asperger's Disorder in DSM-5.

Reclassification of Asperger’s Disorder and Creation of Autism

Spectrum Disorders (ASD)Slide39

LJ is a patient who met DSM-IV criteria for Asperger’s Disorder. According to DSM-5, what is LJ’s diagnosis?Autism Spectrum Disorder

Asperger’s DisorderAttention Deficit-Hyperactivity DisorderTourette’s DisorderSlide40

DSM Classification of Autism/Asperger's DisorderDSM-IVPERVASIVE DEVELOPMENTAL DISORDERS Autistic DisorderRett's Disorder

Childhood Disintegrative Disorder Asperger's Disorder Pervasive Developmental Disorder NOSDSM-5Neurodevelopmental Disorders

Intellectual Disabilities

Communication

Disorders

Autism

Spectrum Disorder

Attention-Deficit/Hyperactivity

Disorder

Motor Disorders

Tic

Disorders

Other

Neurodevelopmental DisordersSlide41

Asperger's Disorder in DSM-IVQualitative impairment in social interaction, as manifested by at least two:(1) impairment in the use of nonverbal behaviors (2) failure to develop peer

relationships(3) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (4) lack of social or emotional reciprocityRestricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one:(1) encompassing preoccupation with patterns of

interest that

are

abnormal

(

2) apparently inflexible adherence to specific, nonfunctional

routines or

rituals

(3) stereotyped and repetitive motor

mannerisms

(4) persistent preoccupation with parts of objects

There

is no clinically significant general delay in

language.

There

is no clinically significant delay in cognitive development or

in the

development of age-appropriate self-help skills, adaptive

behavior, and

curiosity about the

environment in

childhood

.

Need 3Slide42

Autism in DSM-IVA total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):(1) qualitative impairment in social interactions (need 2)(

2) qualitative impairments in communication as manifested by at least one:(a) delay in, or total lack of, the development of spoken language(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others(c) stereotyped and repetitive use of language or idiosyncratic language(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental

level

(3) restricted repetitive and stereotyped patterns of behavior,

interests, and activities (need 1)

Delays

or abnormal functioning in at least one of the following

areas, with

onset prior to age 3 years: (1) social interaction, (2) language

as used

in social communication, or (3) symbolic or imaginative play

.

Need 6Slide43

Autism Spectrum Disorders in DSM-5Slide44

LJ is a patient who met DSM-IV criteria for Asperger’s Disorder. According to DSM-5, what is LJ’s diagnosis?Autism Spectrum Disorder

Asperger’s DisorderAttention Deficit-Hyperactivity DisorderTourette’s DisorderSlide45

What’s the deal with the snubbing of Roman Numerals?

DSM -ISlide46

Thank you! Stephanie Nichols, Pharm.D., BCPS, BCPPHusson University School of PharmacyNicholss@husson.edu