Introduction Behavioral Health/Psychiatry and the DSM 5 TR PDF

Reveal Yourself and Complete the Attendance Survey 2/17/25 1  Course Overview: Introduction to Behavioral Health/ Psychiatry and the DSM 5 TR Dr. Levy Human Behavior and Psychiatry PHA 53...

Reveal Yourself and Complete the Attendance Survey 2/17/25 1  Course Overview: Introduction to Behavioral Health/ Psychiatry and the DSM 5 TR Dr. Levy Human Behavior and Psychiatry PHA 535 Spring 2025 2/17/25 2  Syllabus Review 2/17/25 3  Week Unit or Bloom’s Level Remember / Understand, Apply/ Module Analyze, Domain Instructional Objectives Evaluate/ Create Cognitive, Affective, Psychomotor Week 1 Classify prominent diagnoses and dimensional quantifiers while Lecture 1 discussing the prevalence of mental health diagnoses. Remember/ Understand Cognitive Week 1 Examine how racial, ethnic, socio-economic, and LGBTQIA+ Lecture 1 factors affect behavioral health and analyze the differences in the incidence of psychiatric diagnoses across these groups. Apply/ Analyze Cognitive Week 1 Differentiate between ego-syntonic and ego-dystonic concepts. Lecture 1 Apply/ Analyze Cognitive Week 1 List the advantages and challenges of utilizing the DSM-5-TR in Lecture 1 clinical practice. Remember/ Understand Cognitive 2/17/25 4  Behavioral Health Class Content Disclaimer Welcome to the Behavioral Health class. This course explores various aspects of mental health, emotional well-being, and behavioral patterns, including discussions on sensitive topics such as trauma, addiction, self-harm, and mental health disorders. The content aims to educate and foster understanding but may evoke strong emotional reactions or memories for some individuals. Please remember that your well-being is a priority. If you feel overwhelmed or triggered during the class, you are encouraged to take breaks or speak with the instructor privately. Additionally, we encourage you to reach out to campus counseling services or a trusted support system for further assistance. Thank you for participating, and we look forward to creating a supportive and respectful learning environment together. 2/17/25 5  Do you know someone close to you with a psychiatric illness? A. Yes B. No 2/17/25 6  “Am I Normal?” “Medical Student’s Disease” Everyone is diagnosable An undiscovered diagnosis/ “issue” and admitting a problem – Seek support and treatment The impossible task of living in duality and being “civilized” – “normal human neurosis” “Neurosis”: a general tendency toward negative emotions: easily disturbed, anxious, mood swings, irritability, feeling “blue” (low grade dysthymia) 2/17/25 7  Test Your Celebrity Mental Health Knowledge (not on the exam) 1. Adele (singer) a. Depression 2. Leonardo DiCaprio (actor) b. Post partum depression 3. Lady Gaga (singer/ actor) c. Post traumatic stress disorder (PTSD) 4. Daniel Radcliffe (Harry Potter) d. Bipolar disorder 5. John Nash (1994 Nobel Prize winner in e. Obsessive- Compulsive Disorder economics) (OCD) 6. Michael Phelps (Olympic Athlete) f. Post partum depression 7. Abraham Lincoln (16th US president) g. Attention Deficit Hyperactivity 8. Carrie Fisher (Star Wars’ Princess Leia) Disorder (ADHD) h. Paranoid schizophrenia 9. Everson Griffen (NFL, Vikings) 2/17/25 8  Introducing: DSM 5 TR Diagnostic and Statistical Manual 5th edition Text Revised (March 2022) Guide to diagnosis and treatment Used to code for medical billing insurance An evolving document – Some patients do not meet criteria or diagnosis will change 2/17/25 9  DSM 5 TR Definition of Mental Disorder “…clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.” “…associated with significant distress or disability in social, occupational, or other important activities.” 2/17/25 10  DSM 5 Diagnoses Caveats Not caused by a drug, unless it is a substance use disorder diagnosis Not caused by a medical condition (usually) Not better explained by another condition/ diagnosis All psychological disorders are caused by a combination of genetic, physical, environmental, and psychosocial (family, neighborhood, culture) influences 2/17/25 11  “Mental Illness” Imbalance Lack of peace and/ or well being Exact cause can not always be determined or has not yet been revealed 2/17/25 12  What Is Not A Mental Disorder “An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one….” “Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described (in mental disorder definition).” … more DSM 5 TR in a moment 2/17/25 13  Need for Behavioral Health Training Half of all care received for common psychiatric disorders is provided by primary care physicians: family medicine, internal medicine, emergency medicine, or general practice. 2/17/25 14 Which of the following diagnosis is the leading cause of disability worldwide? A. Anxiety B. Depression C. Personality Disorders D. Bipolar Disorder E. Schizophrenia 2/17/25 15 The majority of chronic mental illness begins by which age? A. 14 B. 24 C. 50 D. 65 2/17/25 16  How Widespread Are Psychiatric illnesses? 2/17/25 17  One study of 9282 English speaking patients estimates a 46% lifetime prevalence of mood, impulse-control, and substance use 2/17/25 disorders.https://pubmed.ncbi.nlm.nih.gov/15939837/ 18 2/17/25 19 Which group has the highest prevalence of mental illness? A. “American Indians/ Alaskan Natives” B. "Hispanic or Latino“ C. Lesbian, Gay or Bisexual D. "Non- Hispanic Asians“ E. “Non- Hispanic Black or African- American“ F. Non-Hispanic white 2/17/25 20  LGBTQIA+ individuals are _______ likely as straight individuals to have a mental condition. A. equally B. 2 x less C. 2 x more 2/17/25 21  I will not ask you these numbers 2/17/25 22  50% or less don’t get treatment 2/17/25 23  42% of LGBTQ youth seriously considered attempting suicide in the past year, including >50% of transgender and nonbinary youth. Therefore, ask every visit in any setting if you are aware. 2/17/25 24 2/17/25 25  Co$t Of Mental Health Treatment $280 billion in 2022 up over 50% since 2009, Includes – therapy – prescription medications – stays in psychiatric or substance abuse rehabilitation facilities 2/17/25 26  Military Mental Distress In 2020, 26.2% 5.2 million Veterans had a mental illness and/or substance use disorder In those with a mental illness, 1/3 had a serious mental illness (See notes) 2/17/25 27  12% 1 out of 5 ~3/4 1/3 2/17/25 28  History of the Diagnostic and Statistical Manual (DSM) In 1840, only 2 psychiatric diagnoses: “idiot” or “insane” International Classification of Disease (ICD) appropriated from Veteran’s Administration (VA) and Army criteria used in WWII for screening enlisted personnel American Psychiatric Association (APA) reacted to ICD language and created: – DSM I published in 1952 – 5 Editions 2/17/25 – 3 Revisions 29  How Experts Decide to Update/ Edit the DSM Deeper understanding of the human condition Changing social norms Greater cross-cultural influence Improved scientific evidence science 2/17/25 30 2/17/25 31  Who Revises DSM? APA recruited 160 worldwide top researchers and clinicians Experts in neuroscience, biology, genetics, statistics, epidemiology, social and behavioral sciences, nosology, and public health. Participation on a strictly voluntary basis Multidiscipline practitioners including psychiatry, psychology, pediatrics, nursing and social work. 2/17/25 32  DSM 5 TR Provides: A common language understood by health professionals Assist in clinical documentation Provides information to third- party-payers Relief vs the burden of diagnosis 2/17/25 33 Previous Edition 34  Grouping of DSM 5 Diagnostic Categories 1. Neurodevelopmental disorders 8. Feeding and Eating Disorder 2. Schizophrenia and primary 9. Sleep Disorders psychotic disorders 10. Disorders of Sexual Function 3. Bipolar and Related Disorders 11. Antisocial and Disruptive 4. Mood Disorders Disorders 5. Anxiety Disorders 12. Substance Abuse-Related 6. Disorders Related to Disorders Environmental Stress 13. Neurocognitive Disorders 7. Obsessive Compulsive Spectrum 14. Personality Disorders 8. Somatic Symptom Disorder 15. Paraphilias 16. Other Disorders 2/17/25 35 A mental health patient who is ego dystonic is more likely to: A. see benefit is their symptoms B. be resigned to his/ her fate C. be angry about being told what to do D. be motivated for treatment/ therapy 2/17/25 36  Subtypes and/ or Specifiers for DSM 5 TR Diagnoses 1. Syntonic vs Dystonic 2. Associated Features & Suicide Risk 3. Respect for age, gender & culture 4. Severity index across time & circumstances 2/17/25 37  Dystonic vs Syntonic “Attitude of the client” regarding his mental illness – “I need help” vs “I don’t have a problem.” Document client’s eagerness and motivation for counseling/ therapy based on their understanding and insight 2/17/25 38  Ego Dystonic vs Syntonic Dystonic Syntonic Significant distress, disability or Defensive impairment in functioning Rationalizes behaviors: benefits Little or no capacity to cope with the No motivation to change condition at the current time, or Angry about being told what to do ultimately ineffective Resigned to his/ her fate Motivated for treatment/ therapy to improve the situation and condition Lacks insight into the condition – typical for children Resistant to therapy/ treatment and often needs motivation to do so 2/17/25 39  Syntonic vs Dystonic 1. Good /Fair Insight = Dystonic 2. Poor Insight = Ambivalence 3. Absent Insight = Syntonic 2/17/25 40  DSM 5 TR Age and Gender 1. Some diagnoses are age related – Patient must be at least 18 years old to diagnose borderline personality disorder 2. Gender specific disorders – premenstrual dysphoric syndrome 2/17/25 41  DSM 5 TR Culture 3. Cultural sensitivity regarding certain behaviors and diagnoses – No word for “depression” in some languages Might describe ”tiredness” or “pain” – Peyote use in native American rituals – Language idioms, cultural symptoms “Thinking too much” “Hot and cold imbalance” – Cultural Formulation Interview (CFI) 2/17/25 42  DSM 5 TR Severity Index Across Time & Circumstances Time: major depression diagnoses must have 2 weeks of symptoms Circumstances: PTSD diagnosis can be made if a person is told about a violent death of a friend or family member 2/17/25 43  DSM 5 TR: Severity and TR Course Specifiers Types Mild, moderate, severe In partial remission, full remission, recurrent With poor insight Provisional: full diagnostic With suicidal intent criteria not met – Acute Distress Disorder vs Post Traumatic Stress Disorder (PTSD) Unspecified 44  Example of Coding Specifiers ICD-10 codes Current or most recent episode manic F31.11 Mild F31.12 Moderate F31.13 Severe F31.2 With psychotic features F31.73 In partial remission F31.74 In full remission F31.9 Unspecified 2/17/25 45 CONTROVERSY ABOUT DSM-5 2/17/25 46  Regarding the DSM 5 “This is the saddest moment in my 45-year career of studying, practicing, and teaching psychiatry.” Allen Francis MD, psychiatrist Coordinated DSM IV-TR Edition 2/17/25 47  1. Pathologizes normal, expected behavior – Disruptive Mood Dysregulation Disorder will DSM 5 turn temper tantrums into a mental disorder Potential – Normal grief will become Major Depressive Disorder or Prolonged Grief Reaction, Problems medicalizing and trivializing expectable and necessary emotional reactions to the loss of a loved one 2/17/25 48  1. Pathologizes normal, expected behavior DSM 5 – Everyday life diagnosed as ‘general anxiety disorder” Potential creates millions of anxious new “patients” and Problems inappropriately prescribing addicting anti-anxiety medications The state of the world is anxiety provoking 2/17/25 49  2. Encouraging medication use with pressure from pharmaceutical companies – Substituting pills and superficial medical rituals for the deep consolations of family, DSM 5 friends, religion, ritual, personal growth, and the resiliency that comes with time and the Potential acceptance of the limitations of life Problems – Adult Attention Deficit Disorder leads to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs. 2/17/25 50  3. Under diagnosing – New definition of Autism could result in lowered rates- 10% according to estimates by the DSM 5 work group, DSM 5 perhaps 50% according to outside research groups with potential loss Potential of financial and educational Problems resources – A patient with only a week of depressive symptoms will not meet the criteria for major depression 2/17/25 51  4. Over diagnosing – Possible inflation of PTSD diagnosis in DSM 5 court: “learning that the event(s) occurred Potential to a close relative or close friend; in such cases, the actual or threatened death must Problems have been violent or accidental.” 2/17/25 52  5. The DSM era has not decreased large-scale reductions in the morbidity associated with major DSM 5 mental disorders Potential Problems Example: cardiovascular disease, colon cancer, chronic respiratory disease https://www.psychiatrictimes.com/view/is-dsm5tr-worth-buying 2/17/25 53  DSM 5 TR Shortcomings: What do we all need to be mentally well? Shelter Healthy food Clean water and air Clothing Meaning in life Someone to love Support systems/ acceptance Emotional self regulation 54  DSM 5 TR Shortcomings Environmental Affects on Mental Health Early childhood trauma Divorce Poverty Abuse Racism Oppressive working conditions Other difficult environments and threatening experiences, past and present. 2/17/25 55  DSM 5 TR: Still the Standard PANCE/ PANRE/ EOR PAEA Exams Diagnoses widely used by practitioners and noted in publications Electronic medical records Billing for services included in ICD codes, i.e. Medicare 2/17/25 56  Assignments Please view Dr. Insel’s video in Canvas; 1 test question at least 2/17/25 57  Secular 2/17/25 58  References DSM 5 TR As noted 2/17/25 59