Dr Caroline Bradley

Diagnosis ICD-11 DSM-5

Diagnostic tests

Risk Assessment – HCR v3

Clustering/PbR

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)

ICD Entity Title Classification Properties Textual Definitions Terms Body System/Structure Description Temporal Properties Severity of Subtype Properties Manifestation Properties Causal Properties

Functioning Properties Specific Condition Properties Treatment Properties Diagnostic Criteria

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

Primary classification based on severity:

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

Secondary Classification of five trait domains

Asocial/schizoid Dyssocial/antisocial Obsessional/anankastic Anxious/dependent Emotionally unstable

Also: possibly no lower age limit

No changes from DSM-IV

Cluster A Paranoid, Schizoid, (Schizotypal)

Cluster B Antisocial, Borderline, Histrionic, Narcissistic

Cluster C Avoidant, Dependent, Obsessive-Compulsive

Criterion A

Moderate or greater impairment in personality functioning

Self: Identity Self-direction

Interpersonal: Empathy Intimacy

Criterion A

Five levels of impairment

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)

Criterion B

Pathological Personality Traits

5 broad trait domains

Negative Affectivity Detachment Antagonism Disinhibition Psychoticism

25 trait facets 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

Distractability Rigid perfectionism (lack of) Unusual beliefs and experiences Eccentricity Cognitive and perceptual dysregulation

NEGATIVE AFFECTIVITY DETACHMENT

Emotional Lability Anxiousness Separation Insecurity Submissiveness Hostility Perseveration Depressivity Suspiciousness Restricted Affectivity

(lack of)

Withdrawal Intimacy Avoidance Anhedonia Depressivity Restricted Affectivity Suspiciosness

ANTAGONISM DISINHIBITION

Manipulativeness Deceitfulness Grandiosity Attention Seeking Callousness Hostility

Irresponsibility Impulsivity Distractability Risk Taking Rigid Perfectionism

PSYCHOTICISM Unusual beliefs Eccentricity Cognitive/perceptual

dysregulation

And then:

Antisocial Avoidant Borderline Narcissistic Obsessive Compulsive Schizotypal Personality Disorder – Trait Specified

For example – for Antisocial PD: 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

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

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

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

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

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: Delusions, hallucinations, disorganized

speech, grossly disorganised or catatonic behaviour, and negative symptoms

Autistic Spectrum Disorder replaces four previously separate disorders (autism, Asperger’s, childhood disintegrative disorder, and pervasive developmental disorder NOS)

ASD is characterised by: 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

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”

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)

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

Stephen D. Hart, Christine Michie, David J. Cooke BJP 2007, 190:s60s65 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 The efficacy of violence prediction: a meta-

analytic comparison of nine risk assessment tools

Coid J et al The Journal of Forensic Psychiatry & Psychology Vol22, No. 1, February 2011 3-21 Most items in structured risk assessment

instruments do not predict violence

Alec Buchanan; Renee Binder; Michael Norko; Martin Swartz Am J Psychiatry 2012; 169:340-340 Psychiatric Violence Risk Assessment

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)

Historical Scale:

H1 – History of Problems with Violence 3 age ranges

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 H3 – History of Problems with Relationships

Broadened to include general social relationships

H4 – History of Problems with Employment No substantive changes

H5 – History of Problems with Substance Use No substantive changes

H6 – History of Problems with Major Mental Disorder No substantive changes

H7 – History of Problems with Personality Disorder Broadened from Psychopathy: PCL-R not needed

H8 – History of Problems with Traumatic Experiences Narrowed in respect of focus on trauma

experiences Broadened to include adult experiences

H9 – History of problems with Violent Attitudes Includes information rated in C2 in v2

H10 – History of Problems with Treatment or Supervision Response Broadened to include treatment as well as

supervision

C1 – Recent problems with Insight No substantive changes

C2 – Recent Problems with Violent Ideation or Intent Narrowed to focus on thoughts/plans

concerning perpetration of violence C3 – Recent Problems with Symptoms of

Major Mental Disorder No substantive changes

C4 – Recent Problems with Instability No substantive changes

C5 – Recent Problems with Treatment or Supervision Response Broadened to include problems with response

to institutional or community supervision R1 – Future Problems with Professional

Services and Plans Narrowed to focus on difficulties implementing

professional services and making adequate plans

R2 – Future Problems with Living Situation Narrowed to focus on difficulties finding a living

situation that would help avoid potential destabilising influences

R3 – Future problems with Personal Support No substantive changes

R4 – Future problems with Treatment or Supervision Response Broadened to include treatment refractoriness

R5 – Future problems with Stress or Coping No substantive changes

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)

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)

Suicide Substance Misuse Cognitive Problems Physical Illness Hallucinations +

Delusions Depressed Mood Other Symptoms Relationships

Activities of Daily Living

Living Conditions Occupation/Activities Strong Unreasonable

Beliefs Mental Capacity Carer Needs Cultural/

communication Physical Security

Agitated behaviour/expansive mood Repeat Self-harm Safeguarding Engagement Vulnerability Interpersonal Dynamics Drink/Drug Taking Antisocial Attitudes

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

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)

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

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

I Treatment Responsive Group II Treatment Resistant – challenging

behaviour

III Treatment Resistant - continuing care

IV Personality Disorder – prison transfer V Personality Disorder – co-morbidity