DSM-5: An Overview of Changes and Controversies

The DSM-5 offers many changes in the criteria and categories used in clinical diagnosis. The provocative and sometimes controversial nature of the changes has enlivened debate in the mental health field about how we should best understand our clients. I selectively survey what is new in DSM-5, why changes were made, and what about them is so controversial. First, I summarize the main metastructural and organizational changes, including elimination of the multiaxial system and changed chapter groupings. Second, I survey the most important new categories of disorder and the most important changes to the diagnostic criteria for existing categories of disorder. I focus on particularly controversial changes, such as those to substance use and addictive disorders, autism spectrum disorders, and posttraumatic stress disorder. Pros and cons are provided for changes in criteria as well as for the addition of new disorder categories, such as hoarding disorder and binge eating disorder. Finally, I offer a more in-depth review and analysis of the changes to the depressive disorders chapter, which was subject to some of the most intense controversies and had some of the most extensive changes.     

Caring for older adults with bipolar disorder

Bipolar disorder is a recurrent, chronic mental illness that has a profound impact on the lives of patients and their families and may require extensive use of mental health services. Although bipolar disorder is often considered an illness of young people, the disorder is being recognized as more common in older adults than previously thought. Much more research needs to be done to understand the impact of aging on the course and treatment of bipolar disorder. Evidence-based interventions for treatment of this disorder in older adults must be developed. Mental health nurses can play a key role in enhancing medication adherence, implementing structured psychosocial interventions, and carrying out research to enhance diagnosis and treatment of older adults with bipolar disorder.     

Screening for pediatric bipolar disorder in primary care

A child or adolescent with pediatric bipolar disorder (PBD) is at higher risk for suicide, violence, and impaired psychosocial functioning. The prevalence of diagnosed PBD has increased 40-fold in less than 2 decades, leading some to believe that PBD is inaccurately diagnosed. Complicating this issue, disagreements exist among clinicians as to the utility of current screening methods. The assessment picture is further muddied by the high rate of comorbid psychiatric conditions. A literature review was performed to describe the present understanding of PBD and identify current practices of screening for the disorder. Although screening tools are available, the literature suggests they lack validity. Awareness, a thorough interview, and expedient referral may assist clinicians in making a correct diagnosis. Accurate assessment will help ease the psychological and economic burden of PBD.     

Severe premenstrual syndrome and bipolar disorder: a tragic confusion

Bipolar disorder and severe premenstrual syndrome (PMS) have many symptoms in common, but it is important to establish the correct diagnosis between a severe psychiatric disorder and an endocrine disorder appropriately treatable with hormones. The measurement of hormone levels is not helpful in making this distinction, as they are all premenopausal women with normal follicle-stimulating hormone and estradiol levels. The diagnosis of PMS should come from the history relating the occurrence of cyclical mood and behaviour changes with menstruation, the improvement during pregnancy, postnatal depression and the presence of runs of many good days a month and the somatic symptoms of mastalgia, bloating and headaches. Young women with severe PMS do not respond to the antidepressants and mood-stabilizing drugs typically used for bipolar disorder.     

Learning from extremism in the history of mental health. The example of multiple personality disorder

This article reviews some of the history of the cultural forces that shaped the diagnosis of multiple personality disorder/dissociative identity disorder and the subsequent abuses that occurred at the time of its popularization. Some of the implications that can be drawn from these kinds of historical excesses in the field of mental health will be discussed. The article concludes by underscoring the ethical obligation inherent in maintaining healthy professional skepticism toward ideas driven by ideology and fad, rather than scientific empiricism.     

Laxative abuse: a hazardous habit for weight control

Laxative abuse is an increasingly popular weight-loss method on college campuses, particularly for individuals with eating disorders. It is a dangerous habit, which many mistakenly believe will prevent caloric absorption and weight gain. Serious medical problems that may occur with laxative abuse include electrolyte and fluid imbalance, structural and functional colonic changes, and allergic reactions. Because patients are often secretive about abusing laxatives, laxative abuse should be considered if there is suspicion about the use of potentially destructive weight-control methods or about an eating disorder. A complete history and physical exam are essential parts of an assessment that should also include questions about diet, eating and exercise habits, and body image. Laboratory tests may provide additional supportive data. Treatment includes education, discontinuation of laxatives, medical follow-up as necessary, and psychotherapy. A college campus is an ideal forum for education, referral, and prevention programs.     

Post-Traumatic Stress Disorder and Quality of Life in Sexually Abused Australian Children

The study used publicly available data on post-traumatic stress disorder in a sample of the Australian population with a history of sexual abuse to demonstrate how this evidence can inform economic analyses. The 2007 Australian Mental Health Survey revealed that 8.3% of 993 adolescents experienced childhood sexual abuse, of which 40.2% were diagnosed with post-traumatic stress disorder. Post-traumatic stress disorder diagnosis corresponded to a significant loss of quality of life. Survival analysis was used to estimate the lifetime persistence of post-traumatic stress disorder symptoms. The average time between post-traumatic stress disorder onset and remission was 11.4 years. Results suggest that successful treatment of post-traumatic stress disorder will save 2.05 quality adjusted life years per child or adolescent with post-traumatic stress disorder.     

The neurobiology of PTSD: implications for nurses

Posttraumatic stress disorder (PTSD) is a disabling and prevalent psychiatric disorder. Researchers and scientists have developed a neurobiological basis, which provides a framework for understanding the complexities of PTSD, for many symtoms of the disorder. The estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women twice as likely as men to have PTSD. Onset of symptoms can occur years after exposure to trauma, and the duration of the illness can last a lifetime. Patients with PTSD often encounter multiple psychosocial problems that result from the symptoms they experience, and their distorted perceptions can affect relationships within the family and the workplace. Nurses in various roles (e.g., educator, therapist, prescriber, case manager, staff nurse) may encounter individuals with PTSD. The nursing profession has traditionally sought to explain sophisticated language to patients in understandable terms, and nurses serve in encouraging, supporting, and evaluating roles, all of which will be increasingly important as science and technology discover more information about the neurobiological basis for mental illnesses.     

Bipolar disorder in children

This article presents an overview of bipolar disorder (BPD) in children, a condition that only recently has been recognized as a legitimate diagnosis. Bipolar disorder in children is underrecognized for many reasons including lack of awareness, diagnostic confusion, and the different clinical picture in children. Available data strongly suggest that prepubertal childhood BPD is a non-episodic, chronic, rapid cycling, mixed manic state. It may be comorbid with attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) or it may demonstrate features of ADHD and CD, further complicating recognition and subsequent treatment. Treatment issues are discussed, and some reasons for the urgency of early recognition and treatment are explained.     

Bipolar disorder and the college student: A review and implications for universities

Abstract

Objective: This brief report provides a review of the prevalence and expression of bipolar disorder in the college student population. Implications for college teachers and universities working with students with bipolar disorder are presented. Methods: Responses from the National College Health Assessment (2009–2017) reference groups were collated to estimate whether the prevalence of students with bipolar disorder has been increasing over time. Results: Data indicate that although overall prevalence is low, the presence of students with bipolar disorder has increased over the past decade. Conclusions: To help students with serious mental illness, including bipolar disorder, succeed in higher education, practices consistent with the philosophy of supported education should be adopted. Special attention will need to be paid to students’ financial and academic challenges.     

Do the DSM-5 diagnostic revisions affect the psychometric properties of the Brief Biosocial Gambling Screen?

Several significant changes in the diagnostic criteria for gambling disorder occurred with the newest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The changes aim to simplify and streamline the diagnosis without compromising its validity. Yet many of the tools used to screen and diagnose the disorder are based upon the prior fourth edition of the DSM, and it is unclear how they perform with the revised diagnostic criteria. The aim of this study is to examine the psychometric properties of a common pathological gambling screen, the Brief Biosocial Gambling Screen (BBGS; Gebauer, LaBrie, & Shaffer, 2010), in the context of DSM-5 criteria within a help-seeking sample. Gamblers calling a helpline (N = 2750) completed a semi-structured interview assessing DSM-IV past-year pathological gambling criteria with a trained clinician. Sensitivity, specificity, positive predictive value, negative predictive value and differences by sex were examined. The BBGS had high sensitivity as well as positive and negative predictive values. In light of the revisions made to the diagnostic criteria in DSM-5, the BBGS remains a psychometrically supported instrument for gambling disorder.     

How useful is the term "Cumulative Trauma Disorder"?

Cumulative trauma disorder is a widely accepted construct that refers to illnesses of the soft tissues which supposedly occur due to biomechanical workplace risk factors. However, is the term "cumulative trauma disorder" a useful term for describing the illness attributed to it? This paper will scrutinize this question by specifying the meaning of "cumulative trauma disorder" and examining this construct to see if the belief in it is justified, and if this belief is leading to the elucidation of the phenomenon it is purporting to notate. Anomalous findings will be identified and used to help evaluate the accuracy of the belief system currently surrounding the term. Finally the ability of the construct "cumulative trauma disorder" to provide an adequate foundation for research in this area will be explored. A model of alternate pathomechanisms for this illness is advanced to provide a method of studying the disorders associated with the term.     

Psychiatric Rehospitalization of Children and Adolescents: Implications for Social Work Intervention

This study explored factors associated with the psychiatric rehospitalization of children and adolescents. A retrospective archival review was conducted on 403 children and adolescents admitted into an inpatient psychiatric hospital. Results indicated that 16% were readmitted in the same year. Children and adolescents who had a prior history of psychiatric rehospitalization, lived in a residential treatment facility, and had a diagnosis of oppositional/defiant or conduct disorder were more likely to be rehospitalized. Psychosocial factors must be considered in predicting and preventing psychiatric rehospitalization. Clinical social workers should include therapeutic foster care as an option for aftercare placements of youth exhibiting externalizing behaviors and/or with a history of multiple restrictive care placements.     

Confronting Myths and Stereotypes About Borderline Personality Disorder

SUMMARY

The clinician treating a patient with borderline personality disorder (BPD) is often faced with complicated challenges, from making and communicating an accurate diagnosis, to implementing an appropriate, informed plan for treatment. Myths and stereotypes about BPD, and the individuals who may carry the diagnosis, likely complicate effective recognition and treatment of the disorder. BPD has been a controversial diagnosis among clinicians since its inception, and it is poorly understood among the general public. Pressures to avoid an explicit exploration of the diagnosis stemming from myths and stereotypes about the disorder can come from a number of sources, including other clinicians, family members and patients themselves. The results of minimizing or ignoring the contribution of borderline pathology may be detrimental. Clinical decisions based on outmoded thinking about diagnosis, prognosis, treatment efficacy, and availability of resources may deny patients optimal care. Integrating current findings into consideration of a BPD diagnosis and design of appropriate treatment, free of misconceptions about the condition, may help limit the untoward effects associated with failure to appreciate elements of borderline personality.     

Stimulants for preschool ADHD down,A2As up

The diagnosis of attention deficit hyperactivity disorder (ADHD) is decreasing among children ages 2 to 5 in Kentucky, but the use of alpha‐2 agonists (A2As, such as clonidine and guanfacine) is increasing, and the use of stimulants is decreasing. The researchers urge long‐term follow‐up of these children, as well as vigilance in checking diagnosis and treatment. For the study, published in the Journal of Child and Adolescent Psychopharmacology and based on Medicaid claims, the researchers were not able to ascertain whether the diagnoses or the treatments were appropriate.     

The theory of change of the evaluation support program: Enhancing the role of community organizations in providing an ecology of care for neurological disorders

This paper discusses the Ontario Brain Institute’s theory of change for the Evaluation Support Program, a program designed to enhance the role of community organizations in providing care and services for people living with a brain disorder. This is done by helping community organizations build evaluation capacity and foster the use of evidence to inform their activities and services. Helping organizations to build capacities to track the ‘key ingredients’ of their successes will help ensure that successes are replicated and services can be improved to maximize the benefit that people receive from them. This paper describes the hypothesized outcomes and early impacts of the Evaluation Support Program, as well as how the program will contribute to the field of evaluation capacity building.     

Attention Deficit‐Hyperactivity Disorder as the Medicalization of Childhood: Challenges from and for Sociology

Sociology has problematized the expanding province of medicine for several decades, and it is important to clarify some of the central questions regarding the medicalization question for those new to this subset of the discipline. With a primary focus on the diagnosis of attention deficit‐hyperactivity disorder (ADHD), this paper seeks to accomplish four goals. First, this paper will summarize the general concept of medicalization, including the way that medical practitioners attribute children’s behavioral problems to disease entities. Second, this paper argues that the medicalization of childhood and the rise of the disease entity of ADHD stems from the transformation of children and childhood into objects of scientific study. Third, using the example of ADHD, this paper will attempt to demystify the premise that medicalization emanates from the “monolith” of medicine, but is instead, a process rife with internal contradiction and epistemological disagreement. Fourth, following the uncertainty of etiological positions toward childhood behavior problems, this paper will discuss some of the external critiques of medicalization, including the way that lay actors push back against the medicalization process, and concerns about the effectiveness of technologies used to diagnose and treat ADHD.     

A Review of the Effectiveness and Mechanisms of Change for Three Psychological Interventions for Borderline Personality Disorder

The therapeutic uncertainty common in much of the early literature on borderline personality disorder (BPD) has given way to a growing research base with findings indicating the effectiveness of a number of psychological treatments. This article will review three major evidence-based treatments for BPD: dialectical behavior therapy, schema-focused therapy and mentalization-based treatment. While not a panacea, these treatments have provided, to differing degrees, a reasonable level of evidence indicating therapeutic effectiveness. The evidence base for each of these models is discussed as well as possible mechanisms of change. The article highlights similarities between the differing modalities as well as the features that distinguish the models. The article contends that increasing mentalization skills may be a common underlying factor in all treatments for individual with BPD. The authors conclude by discussing the difficulties and potential benefits of treatment integration.     

Barriers to treating youth with medications for OUDs

Strategies to get medications to treat opioid use disorder (OUD) to young people immediately after diagnosis are urgently needed, a study published in the September issue of JAMA Pediatrics concluded. Young people with OUDs who receive naltrexone, methadone or buprenorphine are more likely to stay in treatment, yet these medications are underused. Only one in four youths receive medications for OUD shortly after diagnosis. For youths under 18, it's one in 21.     

Order in the Secondary School: Strategies for Control and Their Consequences1

Whether one looks at concerns expressed in response to surveys or at the allocation of effort on a day to day basis, teachers and administrators give order a high priority. Order dominates attention because the fundamental character of schools as organizations makes disorder always an imminent possibility. In the first part of this paper, I will consider the reasons that order is consistently problematic in public secondary schools. I will then analyze varying policies for pursuing order in four junior high schools, indicating why different strategies were chosen and with what effects they were practiced.