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
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