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DSM 5 Anxiety Disorders Obsessive-Compulsive and Related Disorders

!  What are Anxiety Disorders?

!  DSM-5 no longer includes Obsessive-Compulsive Disorders (has it’s own chapter now), Posttraumatic Stress Disorder or Acute Stress Disorder (now in the Trauma and Stressor-Related Disorder chapter) in the Anxiety Disorders Chapter. !  Obsessive-Compulsive Disorders are a separate chapter !  Posttraumatic Stress Disorder and Acute Stress Disorder are now in the Trauma and

Stressor-Related Disorder chapter

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+ Anxiety Disorders !  Separation Anxiety Disorder

!  Selective Mutism !  Both moved from the

eliminated Disorders in Infancy, Childhood, or Adolescence

!  Specific Phobia !  Animal !  Natural Environment !  Situational !  Other !  Blood-injection-injury

!  Fear of Blood !  Fear of injections &

transfusions !  Fear of other medical care !  Fear of injury

!  Social Anxiety Disorder (Social Phobia)

!  Panic Disorder

!  Panic Attack Specifier

!  Agoraphobia

!  Generalized Anxiety Disorder – NO CHANGES

!  Substance/Medication-Induced Anxiety Disorder

!  Anxiety Disorder Due to Another Medical Condition

!  Other Specified Disorder

!  Other Unspecified Anxiety Disorder

+ Separation Anxiety Disorder (p.190)

!  This was moved from the Disorders first diagnosed in Infancy, Childhood, or Adolescence (This chapter is actually completely gone –it’s Neurodevelopmental Disorders now)

!  Excessive fear of being separated from attachment figures; anticipating it or experiencing separation

!  Fear and anxiety is persistent lasting at least 4 weeks in children and adolescents; 6 months or longer in adults;

!  Onset no longer has to be before the age of 18

!  These changes reflect the new understanding that separation anxiety symptoms can occur in adults.

!  309.21 (F93.0) Separation Anxiety Disorder

!  No specifiers

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+ Specific Phobia (p.197) Unreasonable or irrational fear when exposed or thinking about the feared stimulus: Basic criteria listed on page 197 Then code based on the phobic stimulus; these are consider specifiers now. The Core Features remain the same however the individual must recognize that the fear is unreasonable no matter the age [use to be over 18]

!  300.29 (F40.218) Animal- ex. Rats, mice, pigs, spiders, snakes

!  300.29 (F40.228) Natural environment type- Like the fear of heights (acrophobia), the fear of lightning and thunderstorms (astraphobia), and the fear of aging (gerascophobia).

!  300.29 (F40.23x) Blood/injection/injury type- Like the fear of medical procedures including needles and injections (Trypanophobia): code according to the specifiers on page 198

!  300.29 (F40.248) Situational type- Like the fear of small confined spaces (claustrophobia) and being "afraid of the dark," (nyctophobia) airplanes

!  300.29 (F40.298) Other- Like the fear of the number 13 (triskaidekaphobia), and the fear of clowns (coulrophobia).

!  **If more than one is present must code each one separately. This is common-about 75% of people with phobias have more than 1!

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+ Social Anxiety Disorder (Social Phobia)pg. 202

Marked fear of social situations resulting in avoiding social situations Social situations are almost always avoided or endured with intense fear and anxiety Fear, anxiety, and avoidance is persistent lasting at least 6 months or longer Core Features remain the same however the individual must recognize that the fear is unreasonable no matter the age [use to be over 18] 300.23 (F40.10) Social Anxiety Disorder (Social Phobia) Specify if the fear is restricted to speaking or performing in public by using the

Performance only specifier This is recognized as a distinct subset of social anxiety disorder

+ Panic Disorder pg 208

!  300.01 (F41.0) Panic Disorder Essential features remain unchanged however the confusing terminology for describing the different types of attacks has changed.

Situationally bound/cued, situationally predisposed, etc. is now replaced with unexpected and expected panic attacks.

Panic Attack Specifier: (Pg 214) Panic Attacks are not a mental disorder and are not diagnosable alone; the specificier can be used with any of the anxiety disorders as well as other mental disorders.

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+ Agoraphobia pg 217

300.22 (F40.00) Agoraphobia

Fear of the “marketplace”

Main CHANGE:

Panic Disorder and Agoraphobia are UNLINKED in the DSM-5. Each are a separate diagnosis now. The co-occurrence of these disorders is coded separately.

+Generalized Anxiety Disorder pg 222

300.02 (F41.1) Generalized Anxiety Disorder

!  NO CHANGES!!!

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+ Anxiety Disorders Substance/Medication -Induced Anxiety Disorder (pg 226) Must have evidence that substance intoxication or withdrawal is present Anxiety Disorder Due to Another Medical Condition (pg 230)

Anxiety as a result of a medical issue or condition

Other Specified Anxiety Disorder (pg.233) Full criteria not met for any specific

Anxiety disorder; clinician wishes to specify the reasons.

Unspecified Anxiety Disorder (pg 233)

Full criteria not met for any specific Anxiety disorder; clinician does not wish to specify the reasons.

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DSM 5 Obsessive-Compulsive and Related Disorders

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!  What are Obsessive-Compulsive and Related Disorders?

!  New Chapter in the DSM-5 based on the findings that these disorders are related to one another in terms of diagnostic indicators and clinical utility

!  Several new Disorders are included in this chapter

+ Obsessive-Compulsive and Related Disorders (pg 235-264) !  Obsessive-Compulsive

Disorder

!  Body Dysmorphic Disorder

!  **Hoarding Disorder

!  Trichotillomania (Hair-Pulling Disorder) added the descriptor

!  **Excoriation (Skin-Picking Disorder)

!  **Substance/Medication-Induced Obsessive-Compulsive and Related Disorder

!  **Obsessive-Compulsive and Related Disorder Due to Another Medical Condition

!  Other Specified Obsessive-Compulsive and Related Disorder

!  Unspecified Obsessive-Compulsive and Related Disorder

** = new disorders

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+New Disorder Alert!! !  300.3 (F42) Hoarding Disorder

!  Use to be one of the criteria for Obsessive-Compulsive Personality Disorder, however the data supported a separate diagnosis as is has unique neurobiological correlates, is associated with significant impairment, and responds to clinical intervention.

! I blame A&E

+New Disorder Alert!! !  698.4(L98.1) Excoriation (Skin-

Picking) Disorder

!  Was added due to the strong evidence for its diagnostic validity and clinical utility

! I blame “My Strange Addiction” TLC

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+Body Dysmorphic Disorder !  300.7 (F45.22) Body

Dysmorphic Disorder

!  Diagnostic Criteria added that describes repetitive behaviors or mental acts in response to preoccupations with perceived defects of flaws in physical appearance.

!  A “with Muscle Dysmorphia” specifier has been added

+New Specifiers

!  New specifiers have been added for Obsessive-Compulsive and Related Disorders !  With Poor Insight

!  Insight Specifiers have been added to the Body Dysmorphic Disorder

!  Tic-related Specifier has also been added to the Obsessive-Compulsive Disorder

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DSM 5 Disruptive, Impulse-Control, and Conduct Disorders

NEW CHAPTER! Disruptive, Impulse-Control, and Conduct

Disorders !  What are the Disruptive, Impulse-Control, and Conduct Disorders?

!  These disorders come from the previous DSM-IV chapters Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence and Impulse Control Disorders Not Elsewhere Classified

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+Disruptive, Impulse-Control, and Conduct Disorders

(pg 461-480) All these disorders are characterized by problems

in emotional and behavioral self-control ! Disorders in the category (see xxiv) ! Oppositional Disorder ! Intermittent Explosive Disorder ! Conduct Disorder ! Antisocial Personality Disorder

!  [* Also in the Personality Disorders Chapter]

! Pyromania ! Kleptomania ! Other Specified Disruptive, Impulse-Control, and

Conduct Disorder !  Unspecified Disruptive, Impulse-Control, and

Conduct Disorder

Oppositional Defiant Disorder !  313.81 (F91.3) Oppositional Defiant Disorder (pg 462-466)

!  4 refinements have been made to the criteria in ODD 1. Symptoms are grouped into 3 types: (Excludes Siblings!)

Angry/irritable Mood Argumentative/defiant behavior Vindictiveness

2. The exclusion criteria has been removed for conduct disorder 3. Added frequency information to distinguish normal developmental

defiance from symptomatic behaviors 4. Specifiers for intensity added based on the number of settings the

behavior occurs in: !  Mild=one setting; Moderate=two settings; Severe=three or more

settings

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+ Disruptive, Impulse-Control, and Conduct Disorders

312.34 (F63.81) Intermittent Explosive Disorder (pg 466-469)

!  CHANGE~~~ Failure to control aggressive impulses manifested by either verbal aggression or physical aggressive (criteria A) !  The verbal aggression and nondestructive/non-injurious

physical aggression are added in DSM-5 !  Minimum age of 6 is required to be diagnosed

!  Occurs mostly commonly in late childhood or adolescence; rarely after the age of 40

!  More prevalent in those with a high school education or less – why??

! Conduct Disorder (pg 469-475) !  CODED based on the specifier of age of onset. !  Largely unchanged, however a specifier was added for limited

prosocial emotions

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+ Disruptive, Impulse-Control, and Conduct Disorders

!  312.33 (F63.1) Pyromania (pg 476-477) !  Deliberate fire setting that is accompanied by emotional tension

and arousal !  Occurs most often in males with poorer social skills and

learning difficulties

!  312.32 (F63.3) Kleptomania (pg 478-479) !  Recurrent stealing, failure to resist the impulse or urge to steal

for reasons not needed for personal use or for monetary value !  There is emotional tension and relief that occur with the stealing

behavior !  Occurs more in females than males 3:1. !  There are Shoplifting Anonymous meetings for support and self-

help.

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+ Disruptive, Impulse-Control, and Conduct Disorders

! 312.89 (F91.8) Other Specified Disruptive, Impulse-Control, and Conduct Disorder (pg 479) ! Symptoms are characteristic of a disorder in this

category but do not meet the full criteria and the clinician wants to specify the reason

! 312.9 (F91.9) Unspecified Disruptive, Impulse-Control,

and Conduct Disorder (pg 480) ! Symptoms are characteristic of a disorder in this

category but do not meet the full criteria, used when clinician does not want to specify the reason

+ Treatment Basics !  Oppositional Defiant Disorder

!  Parent Management Training

!  Family Therapy

!  Cognitive Behavioral Therapy

!  Social Skills Training

!  Medication

!  Impulse Control Disorders: Kleptomania !  Cognitive Behavioral Therapy

!  Learn relaxation, coping skills, changing negative thoughts and thinking, learn cause and effect; challenging thinking errors

!  Emotional Regulation and Distress Tolerance Skills

!  Medication: Antidepressants

!  Treatment "manual” example

!  12 Step support groups can be a helpful addition to treatment