Transcript University of Pittsburgh School of Social Work MH 2065 Fall term 2005

Forensic Behavioral Associates
DSM 5 Changes: an overview
Presenter: James H. Andrews, LCSW, BCD
SW 2065: HBMH - DSM5 Material
• Diagnostic Statistical Manual
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SW 2065: Human Behavior – Mental Health
Use of the DSM5 in Practice
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SW 2065: HBMH - DSM5 Material
• Diagnostic Statistical Manual
– DSM-I published in 1952. Subjective diagnosis.
– DSM-II published in 1968. Subjective diagnosis.
– 1974 homosexuality removed
– DSM-III published 1980. Objective diagnosis.
– DSM-III-R published in 1987.
– DSM-IV published in 1994.
– DSM-IV-TR published in 2000.
– DSM5 published July 2013
• 13 diagnostic workgroups. 6 issues study groups.
• Harmonization between the DSM and ICD (International
Classification of Diseases) coding
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DSM5 Changes: an overview
• DSM5 Revision Process REVIEW AND UPDATE
– Work Groups (13)
– ADHD and Disruptive Behavior Disorders
– Anxiety, Obsessive-Compulsive Spectrum, Post-Traumatic and
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Dissociative Disorders
Childhood and Adolescent Disorders
Eating Disorders
Mood Disorders
Neurocognitive Disorders
Neurodevelopmental Disorders
Personality and Personality Disorders
Psychotic Disorders
Sexual and Gender Identity Disorders
Sleep-Wake Disorders
Somatic Symptom Disorders
Substance-Related Disorders
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DSM5 Changes: an overview
• DSM5 Summary of Major Changes
– Number of Diagnoses
– DSM-IV-TR = 172
DSM5 = 157
Net diff = -15
– New & eliminated disorders net difference = +13
– Defense Mechanisms removed
– 27 defense mechanisms & coping styles removed
– Though ‘defense mechanism’ as a term is listed in the Technical Glossary
– Multi-Axial System removed
– Single or No-Axis system with subtypes/specifiers introduced
– ICD coding system transition
– 9  10  11 (2014  2015)
– Complete transition to ICD alpha-numeric system by ICD 11 in 2015
– Criteria for change
– Higher standard was set then previous editions; predominantly a research
focus.
– Issues of use
– Category changes, life span and developmental perspective , forensic
settings, ethnic/cultural focus, shift from functioning (GAF) to disability
rating and provision of assessment tools..
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DSM5 Changes: an overview
• DSM5 Summary of Major Changes
– New disorders in DSM5 (n=15)
• 1. Social (Pragmatic) Communication Disorder
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2. Disruptive Mood Dysregulation Disorder
3. Premenstrual Dysphoric Disorder (DSM-IV appendix)
4. Hoarding Disorder
5. Excoriation (Skin-Picking) Disorder
6. Disinhibited Social Engagement Disorder (split from Reactive
Attachment Disorder)
7. Binge Eating Disorder (DSM-IV appendix)
8. Central Sleep Apnea (split from Breathing-Related Sleep
Disorder)
9. Sleep-Related Hypoventilation (split from Breathing-Related Sleep
Disorder)
10. Rapid Eye Movement Sleep Behavior Disorder (Parasomnia
NOS)
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DSM5 Changes: an overview
• DSM5 Summary of Major Changes
– New disorders in DSM5 (n=15)
• 11. Restless Legs Syndrome (Dysomnia NOS)
• 12. Caffeine Withdrawal (DSM-IV Appendix)
• 13. Cannabis Withdrawal
• 14. Major Neurocognitive Disorder with Lewy Body Disease
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(Dementia Due to Other Medical Conditions)
15. Mild Neurocognitive Disorder (DSM-IV Appendix)
– Eliminated disorders in DSM5
• 1. Sexual Aversion Disorder
• 2. Polysubstance-Related Disorder
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DSM5 Changes: an overview
• DSM5 Summary of Major Changes
– Combined/merged Disorders in DSM5 (n=15)
• 1. Language Disorder (Expressive Language Disorder & Mixed Receptive
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Expressive Language Disorder)
2. Autism Spectrum Disorder (Autistic Disorder, Asperger’s Disorder,
Childhood Disintegrative Disorder, & Rett’s disorder—PDD-NOS is in the
NOS count)
3. Specific Learning Disorder (Reading Disorder, Math Disorder, &
Disorder of Written Expression)
4. Delusional Disorder (Shared Psychotic Disorder & Delusional Disorder)
5. Panic Disorder (Panic Disorder Without Agoraphobia & Panic Disorder
With Agoraphobia)
6. Dissociative Amnesia (Dissociative Fugue & Dissociative Amnesia)
7. Insomnia Disorder (Primary Insomnia & Insomnia Related to Another
Mental Disorder)
8. Non-Rapid Eye Movement Sleep Arousal Disorders (Sleepwalking
Disorder & Sleep Terror Disorder)
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DSM5 Changes: an overview
• DSM5 Summary of Major Changes
– Combined/merged Disorders in DSM5 (n=15)
• 9. Alcohol Use Disorder (Alcohol Abuse and Alcohol Dependence)
• 10. Cannabis Use Disorder (Cannabis Abuse and Cannabis
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Dependence
11. Inhalant Use Disorder (Inhalant Abuse and Inhalant
Dependence)
12. Opioid Use Disorder (Opioid Abuse and Opioid Dependence)
13. Stimulant Use Disorder (Amphetamine Abuse; Amphetamine
Dependence; Cocaine Abuse; Cocaine Dependence)
14. Stimulant Intoxication (Amphetamine Intoxication and Cocaine
Intoxication)
15. Stimulant Withdrawal (Amphetamine Withdrawal and Cocaine
Withdrawal)
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DSM5 Changes: an overview
• DSM-IV-TR
– Mental disorder: is a syndrome characterized by 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. Mental disorders are usually
associated with significant distress or disability in social, occupational, or
other important activities. An expectable or culturally approved response to a
common stressor or loss, such as the death of a loved one, is not a mental
disorder.1 Socially deviant behavior (e.g. political, religious, or sexual) and
conflicts that are primarily between individual and society are not mental
disorders unless the deviance or conflicts results from a dysfunction in the
individual, as described above.”
(DSM5, p 20)
– What stands out to you in the above definition??
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DSM5 Changes: an overview
• DSM-IV-TR
– Mental disorder: is a syndrome characterized by 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. Mental disorders are usually
associated with significant distress or disability in social, occupational, or
other important activities. An expectable or culturally approved response to a
common stressor or loss, such as the death of a loved one, is not a mental
disorder.1 Socially deviant behavior (e.g. political, religious, or sexual) and
conflicts that are primarily between individual and society are not mental
disorders unless the deviance or conflicts results from a dysfunction in the
individual, as described above.”
(DSM5, p 20)
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DSM5 Changes: an overview
• DSM-IV-TR Classification System (old)
– Axis I: Clinical disorders.
• Schizophrenia, Mood, Substance Abuse.
– Axis II: Personality/Developmental disorders
• The personality disorders & Developmental
– Axis III: Medical conditions relevant to case.
• Any medical condition that impacts or contributes to case
– Axis IV: Psychosocial/environmental stressors.
• Family, economic, occupational, legal etc.
– Axis V: GAF=Global Assessment of Function
• 100 point scale range 100 (superior) thru 1 Persistent danger
harming self or 0 Inadequate info
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DSM5 Changes: an overview
• DSM-IV-TR Classification System (old)
– Axis I: Clinical disorders.
• Schizophrenia, Mood, Substance Abuse.
– Axis II: Personality/Developmental disorders
• The personality disorders & Developmental
– Axis III: Medical conditions relevant to case.
• Any medical condition that impacts or contributes to case
– Axis IV: Psychosocial/environmental stressors.
• Family, economic, occupational, legal etc.
– Axis V: GAF=Global Assessment of Function
• 100 point scale range 100 (superior) thru 1 Persistent danger
harming self or 0 Inadequate info
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Clinical Formulation
• Involves a careful clinical history
• Concise summary of the social, psychological and
biological factors contributing to the mental
disorder(s)
• Not sufficient to check off the symptoms
• Relevant severity and valence of individual criteria
contribution as important
• Current diagnostic categories do not fully capture
the full range of psychopathology possible
– “other specified” and/or unspecified categories
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DSM5 Changes: an overview
• DSM5 diagnosis system (new)
– Five digit system 123.45 (until 2015)
• Coordinated with ICD codes
• 123: indicate type of disorder
• XXX.4X and XXX.X5 are subtype and severity specifiers to
more accurately record the diagnostic category and
condition.
– Not all dx uses 5 digits, 311.0 Depression NOS
– GAF: Replaced with WHODAS – World Health
Organization Disability Assessment Scale
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DSM5 Changes: an overview
• DSM5 diagnosis system (new)
– What is ICD?
– International Classification of Disease (WHO)
– ICD uses an alpha-numerical system
– 3-7 characters; DSM will use 6
– All letters except ‘U’ used. First position is letter. Not case-sensitive
– DSM will mostly utilize F (Mental and behavioural disorders)
– Decimal after third character
– Provides more accuracy than DSM coding
– ICD9 codes were limited in capturing clinical data
– ICD10 far more accurate and comprehensive
– Implementation date ICD10: 10.01.2014
• 2015 – ONLY ICD codes in DSM
– The transition to ICD-10 is required for everyone covered
by the Health Insurance Portability Accountability Act
(HIPAA).
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Diagnosis – formerly Axis I, II & III
– Stressors – formerly Axis IV now V & Z Codes DSM5
(pp. 715-727)
– Disability – formerly GAF now WHODAS score (pp. 745748)
– Cross-Cutting Symptom Measures – various
assessment tools in DSM5 (pp. 734-748)
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DSM5 Changes: an overview
• DSM5 Classification System (new)
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Diagnosis – formerly Axis I, II & III
Multi-axial system removed
DSM5 utilizes a non-axial documentation of diagnosis
Separate notations for psychosocial and contextual
factors (formerly Axis IV) and Disability (formerly Axis
V = GAF)
– Axis III (related medical diagnosis) has been
combined with former Axis I & II diagnosis in the
listing of diagnoses
– Axis IV issues are addressed by ICD V-codes and
ICD-10 Z codes.
– Axis V GAF scale is replaced by the WHODAS 2.0
score
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Elements of a diagnosis – formerly Axis I, II & III
• Diagnostic criteria are “guidelines” for making a diagnosis.
• Diagnostic criteria usage should be informed by clinical
judgment.
• Severity & course specifiers are applied to denote the current
presentation of the individual’s diagnosis.
– Only when full criteria are met, i.e. not in unspecified diagnoses
• Descriptors
– Severity:
 Mild, moderate, severe
– Descriptive features:
 With good insight, in controlled environment
– Course:
 In partial remission, in full remission, recurrent
• Final Diagnosis = clinical interview + text description +
criteria met + clinician judgment
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Elements of a diagnosis – formerly Axis I, II & III
• Subtypes
– Mutually exclusive and jointly exhaustive phenomenological
subgroupings in a diagnosis.
– Indicated by the instruction – “Specify whether. . . . “ in the criterion
set.
• Specifiers
– Are not intended to be mutually exclusive nor jointly exhaustive so
more than one may be given.
– Indicated by the instruction “Specify . . . .” or Specify if . . . “ in the
criteria set.
• The fifth digit can sometimes serve this purpose. However
the majority of subtypes and specifiers are codable in OCD 9
or 10 systems and must be indicated after the diagnostic
label.
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Elements of a diagnosis – formerly Axis I, II & III
• Subtypes & Specifiers (cont’d)
– Diagnosis is applied to current presentation though past
diagnoses in remission or recovered should be indicated.
– Specifiers indicating course should be listed after the diagnosis.
– Severity specifiers are often provided to guide clinicians in
rating – intensity, frequency, duration, symptom count or other
severity indicators.
– Descriptive features specifiers provided in the criteria set can
provide additional information that can inform treatment
planning.
– NOTE: Not all disorders include specifiers for course, severity,
and/or descriptives.
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Elements of a diagnosis – formerly Axis I, II & III
• NOS replaced by “Other Specified” or “Unspecified” pp.15-16
• Other Specified:
– Allows the clinician to present the reason the client presentation does
not meet diagnostic class criteria.
– Format: record the diagnosis name followed by the specific reason, e.g.
“Other specified depressive disorder, depressive episode with
insufficient symptoms”.
• Unspecified:
– The clinician may choose not to indicate the reason the criteria are not
met for a disorder.
– Format: record the diagnosis as for example :unspecified depressive
disorder”.
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DSM5 Changes: an overview
• DSM5 Classification System (new)
• Elements of a diagnosis – formerly Axis I, II & III
• Principal diagnosis
– The principal diagnosis is the condition which is chiefly responsible
for the client's presentation to treatment and will be the primary
focus of treatment and intervention.
– The principal diagnosis is indicated by listing it first with the
balance of disorders listed in order of focus of attention and
treatment.
– If the principal diagnosis is a mental disorder “due to another
medical condition”, then the medical condition must be listed first.1
– Best practice: the principal diagnosis is followed by the notation
“Principal Diagnosis) or “Reason for Visit”.
– NOTE: In dual-diagnosis or co-occurring treatment, under PA law,
the principal diagnosis MUST be a substance use disorder.
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DSM5 Changes: an overview
• DSM5 Classification System (new)
• Elements of a diagnosis – formerly Axis I, II & III
– Provisional diagnosis – two uses
• FIRST:
• When there a strong presumption that full criteria will be met but
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sufficient information currently lacking for a firm diagnosis.
Format: The term “Provisional” follows the diagnostic label, e.g.
Post-Traumatic Stress Disorder (Provisional)
• SECOND
• When the differential diagnosis of a disorder depends exclusively on
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the duration of the illness.
Format: The term “Provisional” follows the diagnostic label, e.g.
Schizophrenia (Provisional)
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DSM5 Changes: an overview
• DSM5 Classification System (new)
• Elements of a diagnosis – formerly Axis I, II & III
• Coding & Reporting procedures
• Each disorder is delineated by both a
– Diagnostic or nominal label, and a
– Statistical or numerical code; often used for data collection and billing
purposes (i.e. ICD 9 & 10 coding).
– The diagnostic designation is incomplete unless BOTH designations are
used.
– ICD-10: Adoption in US will occur 10/01/2014
 Parenthetical codes inDSM5 should not be utilized until that time.
 For 2015 and thereafter, only the current ICD codes will be listed
in the DSM.
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Stressors – formerly Axis IV; now V & Z Codes DSM5
• DSM5 pp 715-727 for detail. Broad categories include:
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Problems related to family upbringing
Other problems related to primary support group
Child maltreatment and neglect problems
Adult maltreatment and neglect problems
Educational problems
Occupational problems
Housing problems
Economic problems
Other problems related to social environment
Problems related to crime or interaction with legal system
Other health service encounters for counseling and advice
Problems related to other psychosocial, personal and environmental
circumstance
– Problems related to access to medical and other health care
– Non-adherence to medical treatment
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Assessment of Disability: formerly GAF now WHODAS
• World Health Organization Disability Assessment Schedule 2.0
– Recommended (but not required) assessment for
disability. . . yet it’s the one included in the DSM5. . .
– Corresponds to International Classification of Functioning
(ICF).1
– For use in all clinical and general population groups
– Tested world-wide through DSM5 field trials
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– WHODAS 2.0
• 36 questions self administered with clinical social work
interview
• For adult patients
• Child version developed by DSM5 Taskforce is pending WHO
approval
• Domains: 6
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Understanding and communicating
Getting around
Self care
Getting along with other people
Life activities
 Household
 Work or school
– Participation in society
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Assessment – Cross-Cutting Symptom Measures
– Level 1: Calls attention to symptoms relevant to most
psychiatric disorders.
– 13 Symptom domains for adults
– 12 symptoms domains for children aged 11+ and for
parents of children 6-11.
– Brief as there are 1-3 questions per symptom domain
– Screens for important symptoms, not specific diagnoses
– Self administered by patient
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Assessment – Cross-Cutting Level 1:
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Assessment – Cross-Cutting Level 2:
– Used when the corresponding level 1 assessment
ranks as mild or greater.
– Used to give a more detailed assessment of the given
symptom domain.
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DSM5 Changes: an overview
• DSM5
Classification
System (new)
– Assessment –
Cross-Cutting
Level 2:
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Critical Caveats for diagnosing:
• There must be “clinically significant disturbance”,
“significant distress or disability” or “dysfunction
in the individual”.
• The disturbance, distress, disability or
dysfunction is not attributable to physiological
effects of a substance (used as prescribed,
abused or used illicitly).
• The disturbance, distress, disability or
dysfunction is not attributable to some other
medical condition.
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DSM5 Changes: an overview
• DSM5 Classification System (new)
• Developmental & Lifespan organization
– Diagnoses that reflect developmental processes early
in life
– Diagnoses that typically manifest in adolescence
young adulthood
– Diagnoses that usually manifest in adulthood and
later life
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DSM5 Changes: an overview
• DSM5 Classification System (new)
• Cultural issues
– Disorders are defined in relation to cultural social and familial norms.
– Experience and expression of symptoms, signs and behaviors are
viewed through the interpretative framework of culture.
– The decision that a given behavior is abnormal requires intervention
and/or treatment is dependent upon cultural norms.
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• DSM5 Cultural Concepts
– Cultural syndrome: a cluster of group of symptoms not viewed by the
native culture as an illness but recognized by external observers.
– Cultural idiom of distress: a linguistic term, phrase or way of talking
about distress in a culture independent of an illness or disorder.
– Cultural explanation of perceived cause: a label, attribution of feature
that provides a culturally conceived cause for an illness.
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DSM5 Changes: an overview
• DSM5 Classification System (new)
• Gender differences
– Sex and gender differences are applicable to several
disorders in the DSM5
– Sex differences: variations of individual’s reproductive
organs and XX/XY chromosomal distribution
– Gender differences: variations resulting from both an
individual's biological sex and self-representation of
one’s perceived gender
– Gender influences illness determines risk, moderates
risk of development and likelihood of particular
symptoms being experienced.
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DSM5 Changes: an overview
• DSM5 Classification System (new)
• Online enhancements
– http://www.psychiatry.org/practice/dsm/dsm5/onlineassessment-measures
– Tablet app available
• iTunes - $69.99 (regular updates included)
– Regular online updates will be maintained.
– DSM5 online subscription from psychiatryonline.org
• APA Member: $291
• APA Nonmember: $420 annually
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DSM5 Changes: an overview
• DSM5 Classification System (new)
– Cautionary Statement for Forensic Use of DSM5
• DSM5 is a reference tool for courts in determining
forensic consequences of mental disorders.
• There is an imperfect fit between the questions of
concern for the law and clinical diagnosis.
• Diagnosis does not imply a specific level of
impairment or disability.
• Diagnosis does not carry any implication regarding
culpability, causes of behavior, behavioral control
(or lack of) or aspects of control at a particular
time (e.g. at commission of an alleged crime).
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DSM5 Changes: an overview
• DSM5 Section Organization (new)
– Section I
• Brief DSM-5 developmental history
• Guidance on use of the manual
• Definition of a mental disorder
• Cautionary forensic statement
• Brief DSM-5 classification summary
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DSM5 Changes: an overview
• DSM5 Section Organization (new)
– Section II: Chapter Structure – 20 Disorders
• Neurodevelopmental Disorders (31)
• Schizophrenia Spectrum and Other Psychotic
Disorders (87)
• Bipolar and Related Disorders (123)
• Depressive Disorders (155)
• Anxiety Disorders (189)
• Obsessive-Compulsive and Related Disorders (235)
• Trauma- and Stressor-Related Disorders (265)
• Dissociative Disorders (291)
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DSM5 Changes: an overview
• DSM5 Section Organization (new)
– Section II: Chapter Structure – continued
• Somatic Symptom and Related Disorders (309)
• Feeding and Eating Disorders (329)
• Elimination Disorders (355)
• Sleep-Wake Disorders (361)
• Sexual Dysfunctions (423)
• Gender Dysphoria (451)
• Disruptive, Impulse-Control, and Conduct
Disorders (461)
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DSM5 Changes: an overview
• DSM5 Section Organization (new)
– Section II: Chapter Structure – continued
• Substance-Related and Addictive Disorders (481)
• Neurocognitive Disorders (591)
• Personality Disorders (645)
• Paraphilic Disorders (685)
• Other Disorders (707)
• Medication-Induced Movement Disorders and
Other Adverse Effects of Medication (709)
• Other Conditions that may be a Focus of Clinical
Attention (715)
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DSM5 Changes: an overview
• DSM5 Chapter Organization (new)
– Section III: Purpose
• Section III serves as a designated location for items that
appear to have initial support in terms of clinical use but
require further research before being officially recommended
as part of the main body of the manual.
• This separation conveys that the content may be clinically
useful and warrants review, but is not a part of an official
diagnosis of a mental disorder and cannot be used as such.
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DSM5 Changes: an overview
• DSM5 Chapter Organization (new)
– Section III: Emerging Measures and Models
• Assessment Measures
• Cultural Formulation
• Alternative DSM-5 Model for Personality Disorders
• Conditions for Further Study
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Attenuated Psychosis Syndrome
Depressive Episodes With Short Duration Hypomania
Persistent Complex Bereavement Disorder
Caffeine Use Disorder
Internet Gaming Disorder
Neurobehavioral Disorder Due to Prenatal Alcohol Exposure
Suicidal Behavior Disorder
Non-suicidal Self-Injury
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DSM5 Changes: an overview
• DSM5 Chapter Organization (new)
– Appendix: Content
• Separate from Section III is an Appendix, which
includes
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Highlights of Changes From DSM-IV to DSM-5
Glossary of Technical Terms
Glossary of Cultural Concepts of Distress
A list of DSM-5 Diagnoses and Codes
A list of ICD-9-CM codes
A list of ICD-10-CM codes
A crosswalk of the ICD-9-CM to the ICD-10-CM
DSM-5 Advisors and Other Contributors
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DSM5 Changes: an overview
QUESTIONS
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