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Old 12-04-12, 12:36 PM
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DSM-5 ADHD Criteria

The American Psychiatric Association (APA) has taken down most of the content from their website regarding revisions to the DSM diagnostic criteria "to avoid confusion or use of outdated categories and definitions".

But they apparently voted on the new criteria at their annual meeting sometime last week, so, barring surprises, the new diagnostic criteria for ADHD are set now.

According to this U.S. News / HealthDay article, they voted to increase the maximum age of onset of symptoms to 14 (was 7 in DSM-IV; 12 had also been floated as a new cutoff). This is supposed to account for the fact that some people who cannot document symptoms prior to the age of 7 -- but who also didn't suddenly develop ADHD in adulthood -- still experience marked impairment from their ADHD symptoms.

However, I have not heard anything about how or if the symptom thresholds for adult diagnosis will be changed.

There was apparently some back-and-forth between subcommittees, with an initial proposal to lower the number of symptoms required for diagnosis voted down. I understand the proposal was resubmitted in light of new evidence and a decision not to change the total number of symptoms listed in the diagnostic criteria.

Does anyone have inside info on this? Inquiring minds want to know...
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Old 12-04-12, 01:18 PM
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Re: DSM-5 ADHD Criteria

I saw that. I suspect we will have to wait a while before finding out anything.

Sigh, I don't look forward to buying a new DSM. The darn things are expensive.

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Old 12-04-12, 01:44 PM
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Re: DSM-5 ADHD Criteria

I don't know anything about this gentleman or his credibility, and yes, I realize it is HuffPo, but here is his take on some of the changes, including the ADHD stuff.

(DISCLAIMER: AGAIN - I DON'T KNOW THIS GUY OR HIS HISTORY OR CREDENTIALS - JUST RAN ACROSS THIS WHILE LOOKING FOR INDUSTRY REACTIONS TO DSM-5 CHANGES)

http://www.huffingtonpost.com/allen-...b_2227626.html

Quote:
4) DSM-5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.
I know there has been some controversy surrounding the DSM-5 anyway, but it doesn't sound like this bodes well.

UPDATE: Just ran across the same article in Psychology Today. This is what they have posted for this gentleman's info:

"Allen Frances, M.D., was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke."
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  #4  
Old 12-04-12, 01:55 PM
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Re: DSM-5 ADHD Criteria

Quote:
Originally Posted by DvlsAdv0c8 View Post
I don't know anything about this gentleman or his credibility, and yes, I realize it is HuffPo, but here is his take on some of the changes, including the ADHD stuff.

(DISCLAIMER: AGAIN - I DON'T KNOW THIS GUY OR HIS HISTORY OR CREDENTIALS - JUST RAN ACROSS THIS WHILE LOOKING FOR INDUSTRY REACTIONS TO DSM-5 CHANGES)

http://www.huffingtonpost.com/allen-...b_2227626.html

I know there has been some controversy surrounding the DSM-5 anyway, but it doesn't sound like this bodes well.

UPDATE: Just ran across the same article in Psychology Today. This is what they have posted for this gentleman's info:

"Allen Frances, M.D., was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke."
Thanks for the link. I don't know about his opinion on other disorders but point 5 in his list of the 10 worst mistakes that the DSM makes, killed this article for me.

Quote:
5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM-5 has instead turned it into a psychiatric illness called Binge Eating Disorder.
As someone who compulsively binge eats (and I don't use the word compulsively lightly) I know that it's not due to gluttony or the availability of tasty food. When I'm binge eating I will force myself to eat the most disgusting food (like just plain butter, as long as it's high enough in calories) even when I'm already feeling sick and have got stomach cramps from eating too much. I'm not sure it should be a separate disorder but anyone who puts a moralspin on issues that people deal with, seems more than dodgy to me.
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  #5  
Old 12-04-12, 06:01 PM
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Re: DSM-5 ADHD Criteria

"Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and 'behavioral addictions' will soon be mislabeled as psychiatrically sick and given inappropriate treatment. People with real psychiatric problems that can be reliably diagnosed and effectively treated are already badly shortchanged. DSM-5 will make this worse by diverting attention and scarce resources away from the really ill and toward people with the everyday problems of life who will be harmed, not helped, when they are mislabeled as mentally ill."


Maybe I am taking the above quotes out of context but Iīm with Fuzzy re the binge eating. I donīt know what it means by excessive eating but for me it was eating so much that I was about to explode, literally stomach bursting and then vomiting it all up so I could carry out eating and then vomiting again, whilst crying, hating myself and taking a handful of laxatives leaving me with agonising stomach cramps for 12 hours. does that sound like a normal person eating too much tasty food?
oh and old age distractability, well I ainīt that old and putting my hand in the oven to take out a hot dish because I "forget" to put oven gloves on and wiping my razor with my bare thumb and slicing it because I was "distracted", I mean distracted with what, itīs not like iīm doing any else, but hey thatīs normal I guess.


And temper tantrums, like my 17 year old daughter who feared that one day she would end up in jail because she would lose her temper and physically lash out. She was scared that one she started she wouldnīt be able to stop. teachers took her seriously though when she said she fantasies of killing one of them.
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Old 12-04-12, 06:05 PM
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Re: DSM-5 ADHD Criteria

hopefully significant emphasis will be placed on how impairing the symptoms are...
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Old 12-04-12, 06:50 PM
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Re: DSM-5 ADHD Criteria

There are several things on this that may need looking into.

Here is a fairly good article from medscape news that is a little more objective.

http://www.medscape.com/viewarticle/774475

I am to tired to comment right now but will try to digest this a little and perhaps discuss tomorrow but in the meantime I wanted to post this link.

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Old 12-04-12, 07:14 PM
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Re: DSM-5 ADHD Criteria

From another MedScape article (may be behind a subscription wall?) linked to the one DizFriz linked:

On how diagnoses will be documented:

"The new manual will remove the current mutiaxial system in favor of nonaxial documentation of diagnosis, which will combine the former Axes I, II, and III with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)."


On specific learning disabilities:

"The new manual will also broaden the criteria for learning disorders to represent distinct disorders that interfere with language acquisition and the use of use of oral language, reading, writing, or mathematics or a combination of these."

(The last revised criteria I saw included a single overarching LD diagnosis, with specific imparied skills like reading fluency, reading comprehension, handwriting, math reasoning, arithmetic calculations, etc. included as descriptors. I'm not sure how I feel about this. On the one hand, given frequent overlap in LDs, it's simpler, less confusing, and likely to be more stable. On the other hand, I know that some dyslexia advocates really wanted that to be a distinct, separate category, and I do think the LD category will be very heterogeneous.)


And from another article:
"Dr. Frances advised that clinicians ignore 10 diagnostic revisions "that make no sense." These include the following:

the inclusion of disruptive mood dysregulation;

[...] creating "a slippery slope" by introducing the concept of behavioral addictions;

introducing adult attention deficit disorder, which could lead to the misuse of stimulants;"


The DSM-5 site didn't make it look like there was serious consideration of adding a separate "Adult ADHD" category. Maybe he's just referring to the increase in the "age of onset criterion", but I wonder if this implies they did go ahead and approve a lower symptom threshold for diagnosing adults...we'll see!

"'Except for autism, all the DSM-5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation,' [Dr. Frances] writes.

Dr. Frances told Medscape Medical News that one of his biggest concerns is that 'real psychiatric problems' are already shortchanged and are not given enough attention and resources. The newly added, and he says unneeded, diagnoses in the DSM-5 will end up diverting away these precious resources."

Them's fighting words...

Dr. Frances, as noted above, was the editor of DSM-IV, so he has a unique perspective.

That said, some of his criticisms have also received pointed criticism from those involved in producing DSM-5, and I am certain that the debates about the validity, boundaries, prevalence, and significance of disorders will continue long after DSM-5 is released...
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Old 12-06-12, 07:13 AM
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Re: DSM-5 ADHD Criteria

I think he is right though in that the DSM shouldn't be used as a bible. If you could just strictly apply the DSM guidelines then we wouldn't need psychiatrists anymore. Anyone can do that. In fact, I've done that and diagnosed myself with ADHD.
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Old 12-06-12, 08:02 AM
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Re: DSM-5 ADHD Criteria

I don't get the changing of the age thing. You're born with ADHD. It doesn't suddenly appear in your teens or when you go to college. You've generally been out of sync with the world your whole life.
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Old 12-06-12, 08:15 AM
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Re: DSM-5 ADHD Criteria

Quote:
Originally Posted by tudorose View Post
I don't get the changing of the age thing. You're born with ADHD. It doesn't suddenly appear in your teens or when you go to college. You've generally been out of sync with the world your whole life.
It's not because anyone expects ADHD to manifest later, but to increase the window of evidence available and account for the fact that some people simply can't produce evidence that early.
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Old 12-06-12, 09:49 AM
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Re: DSM-5 ADHD Criteria

Quote:
Originally Posted by tudorose View Post
I don't get the changing of the age thing. You're born with ADHD. It doesn't suddenly appear in your teens or when you go to college. You've generally been out of sync with the world your whole life.
One of the bigger reasons in my opinion is that there are a significant number of children that are missed at the earlier ages. ADHD is there but not caught until later in childhood.

Take for example a child whose ADHD is not in the severe category. The child could live in a setting where ADHD does not show up much. Say, for example, a farm child who goes to a small school where the teachers adjust to the needs and behaviors of the child.

It could be a very bright child who does well in school and is not severe enough to have the symptoms of ADHD caught until later grades. If a child is doing well in school the teachers will see little impairment. It is after the third grade or so that being simply bright starts to become not enough.

School tends to get serious in the third grade. It is after that that many cases of ADHD are caught and many not until junior high where the child has to keep track of classes in different rooms and with different teachers. ADHD is often caught when the child's organizational mechanisms began to break apart.

It could be a child that starts to school older than classmates. By comparison, the kid would be seen as acting appropriate for school mates but not when compared to age mates.

It could be a girl with inattentive presentation, for instance, who does not cause problems in the classroom and manages to pass. No referral, no diagnosis.

There are other things that could influence recognition of ADHD symptoms and impairments until a later age.

The previous age 7 was arbitrary and had no real justification. The later age is much more appropriate for accurate diagnostic purposes.

Something else to keep in mind is usually it is a case of no referral, no assessment and no diagnosis. Sometimes the parents pick up on ADHD before the schools but most times ADHD shows up more clearly in school and that is where the idea of ADHD first occurs.

I don't have the stats but I suspect that most ADHD assessments for children are a result of the school either suggesting this to the parent or directly requesting an assessment from the school district.

Good question,

Dizfriz
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Old 12-06-12, 10:27 AM
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Re: DSM-5 ADHD Criteria

I remember when the DSM IV came out. There were a number of criticisms similar to what we are seeing now with the DSM 5.

I suspect the DSM or anything of its kind will always be controversial to a point.

We shall have to see how it will shake down.

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Old 12-06-12, 12:18 PM
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Re: DSM-5 ADHD Criteria

I agree with the age change. Thing is if a patient knows nothing about adhd and goes to the doc with symptoms that point to adhd, then itīs very likely that the patient may fail to realise the importance of childhood and school, or have forgotten a lot of stuff. The doc may not ask the right questions either.

I say this because itīs only now that I know so much more about adhd that I can look back and remember the relevant stuff. This is 6 weeks after diagnosis and treatment. All the examples of others on this forum are connected to the dsm iv but making the connection to question is difficult.

I would have said that I had no problems in primary school but I am slowly remembering comments that teachers made about my brain working to fast, and doing my work really fast and carelessly with lots of mistakes. I also remember that my mum was told that I would struggle in high school because I couldnīt study properly.
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Old 12-06-12, 12:52 PM
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Re: DSM-5 ADHD Criteria

Dr. Frances thinks that the inclusion of disruptive mood dysregulation makes no sense? Really?

Maybe I have a unique perspective on this, but it seems as though there is a divide in the way that bipolar disorder is diagnosed in children. There are children who present with disruptive mood problems, who never cycle. . . they hardly ever have periods of time when they are "normal" mood. . . it's difficult to diagnose bipolar disorder in children for a number of reasons.

If used correctly, I think that the disruptive mood dysregulation will capture children who would have been diagnosed as "childhood bipolar disorder" but who don't show the cycling necessary for the adult diagnosis.

Some of these children might very well grow into a more classic bipolar presentation, but others might either stay the same or develop some *other* mental disorder as an adult.
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