Transcript New Stuff in Psychiatry - Mental Health Lawyers Association

Dr Caroline Bradley
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Diagnosis
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ICD-11
DSM-5
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Diagnostic tests
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Risk Assessment – HCR v3
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Clustering/PbR
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ICD-10 published 1992 (DCR-10: 1993)
DSM-IV published 1994
DSM-IV-TR published 2000
DSM-5 published 2013
ICD-11 to be released in 2015
free to download (paper version for a fee)
 Compatible with electronic health records
 100 word definition of each entity
 Content Model (13 parameters)
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ICD Entity Title
Classification Properties
Textual Definitions
Terms
Body System/Structure Description
Temporal Properties
Severity of Subtype Properties
Manifestation Properties
Causal Properties
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Functioning Properties
Specific Condition Properties
Treatment Properties
Diagnostic Criteria
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ICD-11 may include significant changes to the
classification of Personality Disorder
Tyrer,P.,Crawford,M., & Mulder,R. (2011)
Reclassification of personality disorder. Lancet,
377,1814-1815
Tyrer,P. et al Personality and Mental Health 5:
246-259 (2011) Wiley Online Library
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Primary classification based on severity:
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No PD
Personality Difficulty – some problems in some
situations
Personality Disorder - definite well-demarcated
problems in a range of situations
Complex Personality Disorder – definite problems in
several domains across all situations
Severe Personality Disorder – as above plus
significant risk to self or others
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Secondary Classification of five trait domains
Asocial/schizoid
Dyssocial/antisocial
Obsessional/anankastic
Anxious/dependent
Emotionally unstable
Also: possibly no lower age limit
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No changes from DSM-IV
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Cluster A
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Cluster B
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Paranoid, Schizoid, (Schizotypal)
Antisocial, Borderline, Histrionic, Narcissistic
Cluster C
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Avoidant, Dependent, Obsessive-Compulsive
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Criterion A
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Moderate or greater impairment in personality
functioning
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Self:
 Identity
 Self-direction
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Interpersonal:
 Empathy
 Intimacy
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Criterion A
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Five levels of impairment
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0 = little or no impairment
1 = some impairment
2 = moderate impairment
3 = severe impairment
4 = extreme impairment
Rated using Level of Personality Functioning Scale
(which uses the four elements – identity, self-direction, empathy,
and intimacy)
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Criterion B
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Pathological Personality Traits
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5 broad trait domains
 Negative Affectivity
 Detachment
 Antagonism
 Disinhibition
 Psychoticism
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25 trait facets
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Emotional Lability
Anxiousness
Separation Insecurity
Submissiveness
Hostility (Negative Affectivity and Antagonism)
Perseveration
Depressivity (Negative Affectivity and Detachment)
Suspiciousness (Negative Affectivity and Detachment)
Restricted Affectivity (Negative Affectivity and
Detachment)
Withdrawal
 Intimacy avoidance
 Anhedonia
 Manipulativeness
 Deceitfulness
 Grandiosity
 Attention seeking
 Callousness
 Irresponsibility
 Impulsivity
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Distractability
 Rigid perfectionism (lack of)
 Unusual beliefs and experiences
 Eccentricity
 Cognitive and perceptual dysregulation
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NEGATIVE AFFECTIVITY
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Emotional Lability
Anxiousness
Separation Insecurity
Submissiveness
Hostility
Perseveration
Depressivity
Suspiciousness
Restricted Affectivity
(lack of)
DETACHMENT
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Withdrawal
Intimacy Avoidance
Anhedonia
Depressivity
Restricted Affectivity
Suspiciosness
ANTAGONISM
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Manipulativeness
Deceitfulness
Grandiosity
Attention Seeking
Callousness
Hostility
DISINHIBITION
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Irresponsibility
Impulsivity
Distractability
Risk Taking
Rigid Perfectionism
PSYCHOTICISM
Unusual beliefs
Eccentricity
Cognitive/perceptual
dysregulation
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And then:
Antisocial
 Avoidant
 Borderline
 Narcissistic
 Obsessive Compulsive
 Schizotypal
 Personality Disorder – Trait Specified
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For example – for Antisocial PD:
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Moderate or greater impairment in 2 + of the 4 areas
(identity, self-direction, empathy, intimacy)
6 or more out of 7 pathological personality traits:
 Manipulativeness
 Callousness
 Deceitfulness
 Hostility
 Risk Taking
 Impulsivity
 Irresponsibility
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Compared with:
Three or more out of the following 7 :
Failure to conform to social norms
 Deceitfulness
 Impulsivity
 Irritability and aggressiveness
 Reckless disregard for safety of self/others
 Irresponsibility
 Lack of remorse
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15 new mental disorders (1-8):
Social (Pragmatic) Communication Disorder
 Disruptive Mood Dysregulation Disorder (u18)
 Premenstrual Dysphoric Disorder
 Hoarding Disorder
 Caffeine Withdrawal
 Cannabis Withdrawal
 Excoriation (skin-picking) Disorder
 Binge Eating Disorder
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15 new mental disorders (9-15):
REM Sleep Disorder
 Restless Legs Syndrome (not really new)
 Major Neurocognitive Disorder (replaces dementia)
 Mild Neurocognitive Disorder
 Disinhibited Social Engagement Disorder (children)
 Central Sleep Apnea
 Sleep-related hypoventilation
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One or more of:
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Affective lability (mood swings etc)
Marked irritability/anger/interpersonal conflict
Marked depressed mood
Marked anxiety/tension
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PLUS: one or more of the following to a total of 5:
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Decreased interest in activities; difficulty
concentrating; lethargy; hypersomnia/insomnia;
change in appetite; feeling overwhelmed; physical
symptoms such as “bloating”.
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Difficulty getting rid of possessions
Due to a perceived need to save them and
distress associated with discarding
Resulting in the accumulation of items that
clutter living areas and compromise their use
Causes distress or impairment
Note to self: could be time to confront partner about 37 years’ worth
of football programmes
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No subtypes
No Schneiderian special attribution (running
commentary; voices conversing)
No special attribution for bizarre delusions
Two or more of the following present for a
significant period during a month:
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Delusions, hallucinations, disorganized speech,
grossly disorganised or catatonic behaviour, and
negative symptoms
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Autistic Spectrum Disorder replaces four
previously separate disorders (autism,
Asperger’s, childhood disintegrative disorder,
and pervasive developmental disorder NOS)
ASD is characterised by:
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1. deficits in social communication and social
interaction
2. restricted repetitive behaviours, interests, or
activities (RRBs)
Note: if 1. but not 2. diagnosis is Social (Pragmatic)
Communication Disorder
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Intellectual Disability replaces Mental
Retardation
Panic Disorder and Agoraphobia “unlinked”
Removal of the requirement (in phobic
disorders) that adults recognise that their
anxiety is unreasonable or excessive
New separate chapters for OCD and
Trauma/Stress related disorders
Distinction between Paraphilia and Paraphilic
Disorder and addition of “controlled
environment” and “in remission”
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Philip J Benson, Sara A Beedie, Elizabeth Shephard, Ina
Giegling, Dan Rujescu, David St Clair Biological
Psychiatry Vol 72 Issue 9, pp 716-724 1 November 2012
Case Control study
Eye movement tests (gaze, following, viewing
and image)
Total 298 assessments (whole data set)
Near perfect accuracy (discriminating between
people with SCZ and those without)
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Pharmacogenetics may lead to a way to
identify those patients more likely to respond
to Clozapine and those more likely to suffer
Clozapine-induced Agranulocytosis
Use of bone marrow stimulating factors to treat
the neutropenia caused by Clozapine
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Stephen D. Hart, Christine Michie, David J.
Cooke BJP 2007, 190:s60s65
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Precision of actuarial risk assessment instruments:
Evaluating the ‘margins of error’ of group v
individual predictions of violence
Yang M, Wong SC, Coid J. Psychol Bull 2010
Sept; 136(5): 740-67
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The efficacy of violence prediction: a meta-analytic
comparison of nine risk assessment tools
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Coid J et al The Journal of Forensic Psychiatry
& Psychology Vol22, No. 1, February 2011 3-21
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Most items in structured risk assessment
instruments do not predict violence
Alec Buchanan; Renee Binder; Michael Norko;
Martin Swartz Am J Psychiatry 2012; 169:340340
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Psychiatric Violence Risk Assessment
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Primary Changes from HCR-20 v2:
Changes to names of Basic Risk Factors
 Changes to content of some Basic Risk Factors
 Addition of Sub-Items for complex risk factors
 Addition of Indicators (examples) to Risk Factor
Definitions
 Elaboration of administration procedure (7 steps)
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Historical Scale:
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H1 – History of Problems with Violence
 3 age ranges
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H2 – History of Problems with Other Antisocial
Behaviour
 Incorporates information that in v2 was rated under H8
Early maladjustment, H10 Supervision Failure, and C2
Negative Attitudes
 3 age ranges
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H3 – History of Problems with Relationships
 Broadened to include general social relationships
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H4 – History of Problems with Employment
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H5 – History of Problems with Substance Use
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No substantive changes
H6 – History of Problems with Major Mental
Disorder
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No substantive changes
No substantive changes
H7 – History of Problems with Personality
Disorder
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Broadened from Psychopathy: PCL-R not needed
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H8 – History of Problems with Traumatic
Experiences
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H9 – History of problems with Violent
Attitudes
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Narrowed in respect of focus on trauma experiences
Broadened to include adult experiences
Includes information rated in C2 in v2
H10 – History of Problems with Treatment or
Supervision Response
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Broadened to include treatment as well as
supervision
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C1 – Recent problems with Insight
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C2 – Recent Problems with Violent Ideation or
Intent
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No substantive changes
Narrowed to focus on thoughts/plans concerning
perpetration of violence
C3 – Recent Problems with Symptoms of Major
Mental Disorder
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No substantive changes
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C4 – Recent Problems with Instability
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C5 – Recent Problems with Treatment or
Supervision Response
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No substantive changes
Broadened to include problems with response to
institutional or community supervision
R1 – Future Problems with Professional
Services and Plans
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Narrowed to focus on difficulties implementing
professional services and making adequate plans
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R2 – Future Problems with Living Situation
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R3 – Future problems with Personal Support
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No substantive changes
R4 – Future problems with Treatment or
Supervision Response
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Narrowed to focus on difficulties finding a living
situation that would help avoid potential
destabilising influences
Broadened to include treatment refractoriness
R5 – Future problems with Stress or Coping
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No substantive changes
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Change in coding from 0 1 2 to N P Y
NB: rating is a mean to an end; not an end
The 7 Steps:
Gather information
 Presence of Risk Factors
 Relevance (to risk management strategies)
 Formulation (theoretical basis; 4 P’s etc)
 Scenarios
 Management
 Final Opinions (case prioritization etc)
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Mental Health Clustering Tool (MHCT)
Groups service users according to level of need
Developed from HoNOS and SARN
Additional items for forensic services
Five Forensic Pathways (FFP)
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Suicide
Substance Misuse
Cognitive Problems
Physical Illness
Hallucinations +
Delusions
Depressed Mood
Other Symptoms
Relationships
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Activities of Daily
Living
Living Conditions
Occupation/Activities
Strong Unreasonable
Beliefs
Mental Capacity
Carer Needs
Cultural/communicatio
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Physical Security
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Agitated behaviour/expansive mood
Repeat Self-harm
Safeguarding
Engagement
Vulnerability
Interpersonal Dynamics
Drink/Drug Taking
Antisocial Attitudes
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0 – no cluster but in need of care and will get a
service
1 Common MH Problems (low severity)
2 Common MH Problems (low severity;
greater need)
3 Non Psychotic (moderate severity)
4 Non-Psychotic (severe)
5 Non-Psychotic (very severe)
6 Non Psychotic Disorder of Overvalued Ideas
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7 Enduring Non-psychotic (high disability)
8 Non-Psychotic Chaotic and Challenging
8b Non-Psychotic challenging and antisocial
8c Non-Psychotic socially avoidant, disaffected
10 First Episode Psychosis
11 Ongoing recurrent psychosis (low
symptoms)
12 Ongoing or Recurrent Psychosis (high
disability)
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13 Ongoing or Recurrent Psychosis (high
symptom and disability)
14 Psychotic Crisis
15 Severe Psychotic Depression
16 Dual Diagnosis
17 Psychosis and Affective Disorder – Difficult
to Engage
18 – 21 Cognitive Impairment and Dementia
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Each cluster has:
Indicative episode of care - e.g. 3+ years
 A defined frequency of review – e.g. annually
 Step-Down criteria
 Step-up criteria
 Description of which transitions are most likely,
possible, rare, and clinically impossible
 Discharge Criteria
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I
II
Treatment Responsive Group
Treatment Resistant – challenging
behaviour
III Treatment Resistant - continuing care
IV Personality Disorder – prison transfer
V Personality Disorder – co-morbidity