DSM-5® Made Easy: The Clinician's Guide to Diagnosis - Hardcover

Morrison, James

Hardcover

ISBN 10: 1462514421 ISBN 13: 9781462514427

Publisher: Guilford Press, 2014

Synopsis

This book has been replaced by DSM-5-TR® Made Easy, ISBN 978-1-4625-5134-7.

About this title

About the Author

James Morrison, MD, is Affiliate Professor of Psychiatry at Oregon Health & Science University in Portland. He has extensive experience in both the private and public sectors. With his acclaimed practical books--including DSM-5 Made Easy; Diagnosis Made Easier, Second Edition; The First Interview, Fourth Edition; Interviewing Children and Adolescents, Second Edition; When Psychological Problems Mask Medical Disorders, Second Edition; and The Mental Health Clinician's Workbook--Dr. Morrison has guided hundreds of thousands of mental health professionals and students through the complexities of clinical evaluation and diagnosis.

Excerpt. © Reprinted by permission. All rights reserved.

DSM-5 Made Easy

The Clinician's Guide to Diagnosis

By James R. Morrison

The Guilford Press

Copyright © 2014 The Guilford Press
All rights reserved.

ISBN: 978-1-4625-1442-7

Contents

Cover, 
Also from James Morrison, 
Title Page, 
Copyright Page, 
Dedication Page, 
About the Author, 
Acknowledgments, 
FREQUENTLY NEEDED TABLES, 
INTRODUCTION, 
CHAPTER 1 Neurodevelopmental Disorders, 
CHAPTER 2 Schizophrenia Spectrum and Other Psychotic Disorders, 
CHAPTER 3 Mood Disorders, 
CHAPTER 4 Anxiety Disorders, 
CHAPTER 5 Obsessive–Compulsive and Related Disorders, 
CHAPTER 6 Trauma- and Stressor-Related Disorders, 
CHAPTER 7 Dissociative Disorders, 
CHAPTER 8 Somatic Symptom and Related Disorders, 
CHAPTER 9 Feeding and Eating Disorders, 
CHAPTER 10 Elimination Disorders, 
CHAPTER 11 Sleep–Wake Disorders, 
CHAPTER 12 Sexual Dysfunctions, 
CHAPTER 13 Gender Dysphoria, 
CHAPTER 14 Disruptive, Impulse-Control, and Conduct Disorders, 
CHAPTER 15 Substance-Related and Addictive Disorders, 
CHAPTER 16 Cognitive Disorders, 
CHAPTER 17 Personality Disorders, 
CHAPTER 18 Paraphilic Disorders, 
CHAPTER 19 Other Factors That May Need Clinical Attention, 
CHAPTER 20 Patients and Diagnoses, 
APPENDIX Essential Tables, 
Global Assessment of Functioning (GAF) Scale, 
Physical Disorders That Affect Mental Diagnosis, 
Classes (or Names) of Medications That Can Cause Mental Disorders, 
INDEX, 
About Guilford Press, 
Discover Related Guilford Books, 

CHAPTER 1

Neurodevelopmental Disorders

In earlier DSMs, the name of this chapter was even more of a mouthful: "Disorders Usually First Evident in Infancy, Childhood, or Adolescence." Now the focus is on the individual during the formative period, when the development of the nervous system takes place, hence, and logically enough, neurodevelopmental. However, DSM-5 Made Easy emphasizes the evaluation of older patients — later adolescence to maturity, and beyond. For that reason, I've taken some liberties in arranging the conditions discussed in this chapter — placing those that I discuss at length at the beginning, and listing later just the prototypes (with some discussion) for others.

Of course, many of the disorders considered in subsequent chapters can be first encountered in children or young adolescents; anorexia nervosa and schizophrenia are two examples that spring to mind. Conversely, many of the disorders discussed in this chapter can continue to cause problems for years after a child has grown up. But only a few commonly occupy clinicians who treat adults. For the remainder of the disorders DSM-5 includes in its first chapter, I provide introductions and Essential Features, but no illustrative case example.

Quick Guide to the Neurodevelopmental Disorders

In every Quick Guide, there's a link to the point at which the discussion begins. Also mentioned below, just as in any other competent differential diagnosis, are various conditions arising in early life that are discussed in other chapters.

Autism and Intellectual Disability

Intellectual disability. This condition usually begins in infancy; people with it have low intelligence that causes them to need special help in coping with life.

Borderline intellectual functioning. This term indicates persons nominally ranked in the IQ range of 71–84 who do not have the coping problems associated with intellectual disability.

Autism spectrum disorder. From early childhood, the patient has impaired social interactions and communications, and shows stereotyped behaviors and interests.

Global developmental delay. Use when a child under the age of 5 seems to be falling behind developmentally but you cannot reliably assess the degree.

Unspecified intellectual disability. Use this category when a child 5 years old or older cannot be reliably assessed, perhaps due to physical or mental impairment.

Communication and Learning Disorders

Language disorder. A child's delay in using spoken and written language is characterized by small vocabulary, grammatically incorrect sentences, and/or trouble understanding words or sentences.

Social (pragmatic) communication disorder. Despite adequate vocabulary and the ability to create sentences, these patients have trouble with the practical use of language; their conversational interactions tend to be inappropriate.

Speech sound disorder. Correct speech develops slowly for the patient's age or dialect.

Childhood-onset fluency disorder (stuttering). The normal fluency of speech is frequently disrupted.

Selective mutism. A child chooses not to talk, except when alone or with select intimates. DSM-5 lists this as an anxiety disorder.

Specific learning disorder. This may involve problems with reading, mathematics, or written expression.

Academic or educational problem. This Z-code is used when a scholastic problem (other than a learning disorder) is the focus of treatment.

Unspecified communication disorder. Use for communication problems where you haven't enough information to make a specific diagnosis.

Tic and Motor Disorders

Developmental coordination disorder. The patient is slow to develop motor coordination; some also have attention-deficit/hyperactivity disorder or learning disorders.

Stereotypic movement disorder. Patients repeatedly rock, bang their heads, bite themselves, or pick at their own skin or body orifices.

Tourette's disorder. Multiple vocal and motor tics occur frequently throughout the day in these patients.

Persistent (chronic) motor or vocal tic disorder. A patient has either motor or vocal tics, but not both.

Provisional tic disorder. Tics occur for no longer than 1 year.

Other or unspecified tic disorder. Use one of these categories for tics that do not meet the criteria for any of the preceding.

Attention-Deficit and Disruptive Behavior Disorders

Attention-deficit/hyperactivity disorder. In this common condition (usually abbreviated as ADHD), patients are hyperactive, impulsive, or inattentive, and often all three.

Other specified (or unspecified) attention-deficit/hyperactivity disorder. Use these categories for symptoms of hyperactivity, impulsivity, or inattention that do not meet full criteria for ADHD.

Oppositional defiant disorder. Multiple examples of negativistic behavior persist for at least 6 months.

Conduct disorder. A child persistently violates rules or the rights of others.

Disorders of Eating, Sleeping, and Elimination

Pica. The patient eats material that is not food.

Rumination disorder. There is persistent regurgitation and chewing of food already eaten.

Encopresis. At age 4 years or later, the patient repeatedly passes feces into clothing or onto the floor.

Enuresis. At age 5 years or later, there is repeated voiding of urine (it can be voluntary or involuntary) into bedding or clothing.

Non-rapid eye movement sleep arousal disorder, sleep terror type. During the first part of the night, these patients cry out in apparent fear. Often they don't really wake up at all. This behavior is considered pathological only in adults, not children.

Other Disorders or Conditions That Begin in the Developmental Period

Parent–child relational problem. This Z-code is used when there is no mental disorder, but a child and parent have problems getting along (for example, overprotection or inconsistent discipline).

Sibling relational problem. This Z-code is used for difficulties between siblings.

Problems related to abuse or neglect. A variety of Z-codes can be used to cover difficulties that arise from neglect or from physical or sexual abuse of children.

Disruptive mood dysregulation disorder. A child's mood is persistently negative between severe temper outbursts.

Separation anxiety disorder. The patient becomes anxious when apart from parent or home.

Posttraumatic stress disorder in preschool children. Children repeatedly relive a severely traumatic event, such as car accidents, natural disasters, or war.

Gender dysphoria in children. A boy or girl wants to be of the other gender.

Factitious disorder imposed on another. A caregiver induces symptoms in someone else, usually a child, with no intention of material gain.

Other specified (or unspecified) neurodevelopmental disorder. These categories serve for patients whose difficulties don't fulfill criteria for one of the above disorders.

AUTISM AND INTELLECTUAL DISABILITY

Intellectual Disability (Intellectual Developmental Disorder)

Individuals with intellectual disability (ID), formerly called mental retardation, have two sorts of problems, one resulting from the other. First, there's a fundamental deficit in their ability to think. This will be some combination of problems with abstract thinking, judgment, planning, problem solving, reasoning, and general learning (whether from academic study or from experience). Their overall intelligence level, as determined by a standard individual test (not one of the group tests, which tend to be less accurate), will be markedly below average. In practical terms, this generally means an IQ of less than 70. (For infants, you can only subjectively judge intellectual functioning.)

Most people with such a deficit need special help to cope. This need defines the other major requirement for diagnosis: The patient's ability to adapt to the demands of normal life — in school, at work, at home with family — must be impaired in some important way. We can break down adaptive functioning into three areas: (1) the conceptual, which depends on language, math, reading, writing, reasoning, and memory to solve problems; (2) the social, which includes deploying such abilities as empathy, communication, awareness of the experiences of other people, social judgment, and self-regulation; and (3) the practical, which includes regulating behavior, organizing tasks, managing finances, and managing personal care and recreation. How well these adaptations succeed depends on the patient's education, job training, motivation, personality, support from significant others, and of course intelligence level.

By definition, ID begins during the developmental years (childhood and adolescence). Of course, in most instances the onset is at the very beginning of this period — usually in infancy, often even before birth. If the behavior begins at age 18 or after, it is often called a major neurocognitive disorder (dementia); of course, dementia and ID can coexist. Diagnostic assessment must be done with caution, especially in younger children who may have other problems that interfere with accurate assessment. Some of these patients, once they have overcome, for example, sensory impairments of hearing or vision, will no longer appear intellectually challenged.

Various behavioral problems are commonly associated with ID, but they don't constitute criteria for diagnosis. Among them are aggression, dependency, impulsivity, passivity, self-injury, stubbornness, low self-esteem, and poor frustration tolerance. Gullibility and naïveté can lead to risk for exploitation by others. Some patients with ID also suffer from mood disorders (which often go undiagnosed), psychotic disorders, poor attention span, and hyperactivity. However, many others are placid, loving, pleasant people whom others find enjoyable to live and associate with.

Although many patients with ID appear normal, others have physical characteristics that seem obvious, even to the untrained observer. These include short stature, seizures, hemangiomas, and malformed eyes, ears, and other parts of the face. A diagnosis of ID is likely to be made earlier when there are associated physical abnormalities (such as those associated with Down syndrome). ID affects about 1% of the general population. Males outnumber females roughly 3:2.

The many causes of ID include genetic abnormalities, chemical effects, structural brain damage, inborn errors of metabolism, and childhood disease. An individual's ID may have biological or social causes, or both. Some of these etiologies (with the approximate percentages of all patients with ID they represent) are given below:

Genetic causes (about 5%). Chromosomal abnormalities, Tay–Sachs, tuberous sclerosis.

Early pregnancy factors (about 30%). Trisomy 21 (Down syndrome), maternal substance use, infections.

Later pregnancy and perinatal factors (about 10%). Prematurity, anoxia, birth trauma, fetal malnutrition.

Acquired childhood physical conditions (about 5%). Lead poisoning, infections, trauma.

Environmental influences and mental disorders (about 20%). Cultural deprivation, early-onset schizophrenia.

No identifiable cause (about 30%).

Though measurement of intelligence no longer figures in the official DSM-5 criteria, in the prototypes below I have included IQ ranges to provide some anchoring for the several severity specifiers. However, remember that adaptive functioning, not some number on a page, is what determines the actual diagnosis given to any individual.

Even individually administered IQ tests will have a few points of error. That's one reason why patients with measured IQs as high as 75 can sometimes be diagnosed as having ID: They still have problems with adaptive functioning that help define the condition. On the other hand, an occasional person with an IQ of less than 70 may function well enough not to qualify for this diagnosis. In addition, cultural differences, illness, and mental set can all affect the accuracy of IQ testing.

Interpretation of IQ scores also must consider the possibility of scatter (better performance on verbal tests than on performance tests, or vice versa), as well as physical, cultural, and emotional disabilities. These factors are not easy to judge; some test batteries may require the help of a skilled psychometrist. Such factors are among the reasons why definitions of ID have moved away from relying solely on the results of IQ testing.

Essential Features of Intellectual Disability

From their earliest years, people with ID are in cognitive trouble. Actually, it's trouble of two sorts. First, as assessed both clinically and with formal testing, they have difficulty with cognitive tasks such as reasoning, making plans, thinking in the abstract, making judgments, and learning from formal studies or from life's experiences. Both clinical judgment and the results of one-on-one intelligence tests are required to assess intellectual functioning. Second, their cognitive impairment leads to difficulty adapting their behavior so that they can become citizens who are independent and socially accountable. These problems occur in conceptual, social interaction, and practical living skills. To one degree or another, depending on severity, they affect the patient across multiple life areas — family, school, work, and social relations.

F70 [317] Mild. As children, these individuals learn slowly and lag behind schoolmates, though they can be expected to attain roughly sixth-grade academic skills by the time they are grown. As they mature, deficiencies in judgment and solving problems cause them to require extra help managing everyday situations — and personal relationships may suffer. They usually need help with such tasks as paying their bills, shopping for groceries, and finding appropriate accommodations. However, many work independently, though at jobs that require relatively little cognitive involvement. Though memory and the ability to use language can be quite good, these patients become lost when confronted with metaphor or other examples of abstract thinking. IQ typically ranges from 50 to 70. They constitute 85% of all patients with ID.

F71 [318.0] Moderate. When they are small children, these individuals' differences from nonaffected peers are marked and encompassing. Though they can learn to read, to do simple math, and to handle money, language use is slow to develop and relatively simple. Far more than mildly affected individuals do, in early life they need help in learning to provide their own self-care and engage in household tasks. Relationships with others (even romantic ones) are possible, though they often don't recognize the cues that govern ordinary personal interaction. Although they require assistance making decisions, they may be able to work (with help from supervisors and co-workers) at relatively undemanding jobs, typically at sheltered workshops. IQ will range from the high 30s to low 50s. They represent about 10% of all patients with ID.

F72 [318.1] Severe. Though these people may learn simple commands or instructions, communication skills are rudimentary (single words, some phrases). Under supervision, they may be able to perform simple jobs. They can maintain personal relationships with relatives, but require supervision for all activities; they even need help dressing and with personal hygiene. IQs are in the low 20s to high 30s. They make up roughly 5% of the total of all patients with ID.

F73 [318.2] Profound. With limited speech and only rudimentary capacity for social interaction, much of what these individuals communicate may be through gestures. They rely completely on other people for their needs, including activities of daily living, though they may help with simple chores. Profound ID usually results from a serious neurological disorder, which often carries with it sensory or motor disabilities. IQ ranges from the low 20s downward. About 1–2% of all patients with ID are so profoundly affected.

The Fine Print

Don't forget the D's: • Duration (from early childhood) • Differential diagnosis (autism spectrum disorder, cognitive disorders, borderline intellectual functioning, specific learning disorders)

Coding Notes

Specify level of severity (and code numbers) according to descriptions above.

Grover Peary

Grover Peary was born when his mother was only 15. She was an obese girl who hadn't even realized she was pregnant until she was 6 months along. Even then, she hadn't bothered to seek prenatal care. Born after 30 hours of hard labor, Grover hadn't breathed right away. After the delivery, his mother had lost interest in him; he had been reared alternately by his grandmother and an aunt.

(Continues...)

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Edition details

• Publisher: Guilford Press
• Publication date: 2014
• Language: English
• ISBN 10: 1462514421
• ISBN 13: 9781462514427
• Binding: Hardcover
• Edition number: 1
• Number of pages: 652