* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download DSM-5 OVERVIEW FOR CLINICIANS
Major depressive disorder wikipedia , lookup
Schizoid personality disorder wikipedia , lookup
Substance use disorder wikipedia , lookup
Obsessive–compulsive personality disorder wikipedia , lookup
Gender dysphoria wikipedia , lookup
Reactive attachment disorder wikipedia , lookup
Mental status examination wikipedia , lookup
Rumination syndrome wikipedia , lookup
Emergency psychiatry wikipedia , lookup
Anxiety disorder wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
Factitious disorder imposed on another wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Personality disorder wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
Bipolar II disorder wikipedia , lookup
Excoriation disorder wikipedia , lookup
Panic disorder wikipedia , lookup
Separation anxiety disorder wikipedia , lookup
Bipolar disorder wikipedia , lookup
Autism spectrum wikipedia , lookup
Depersonalization disorder wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Mental disorder wikipedia , lookup
History of psychiatry wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Antisocial personality disorder wikipedia , lookup
Abnormal psychology wikipedia , lookup
Schizoaffective disorder wikipedia , lookup
Conversion disorder wikipedia , lookup
Conduct disorder wikipedia , lookup
Child psychopathology wikipedia , lookup
Spectrum disorder wikipedia , lookup
Asperger syndrome wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
History of mental disorders wikipedia , lookup
Narcissistic personality disorder wikipedia , lookup
Classification of mental disorders wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
DSM-5 OVERVIEW FOR CLINICIANS Developed and presented by: Roland Williams, MA, LAADC, ICADC, NCACII, CADCII, ACRPS, SAP President, Free Life Enterprises Roland Williams Consulting www.rolandwilliamsconsulting.com Agenda • To highlight the major changes from the DSM-IVTR, (text revision) to the DSM-5 • Is based on the assumption participants have a working knowledge of the DSM-IV • Will not define each of the almost 300 diagnosis not including modifiers • Will discuss some of the skepticism and critique • Will not read each slide, this handout is intended as a resource document for participants www.rolandwilliamsconsulting.com Who is in the Audience? • • • • • How many licensed clinicians? Primary substance abuse counselors? Students? Administrators? How many have already had some training on the new DSM-5? www.rolandwilliamsconsulting.com What is the DSM? • The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the APA’s classification and diagnostic tool. In the US the DSM serves as a universal authority for psychiatric diagnosis. Treatment recommendations as well as payment by health care providers are often determined by DSM classifications, so the appearance of a new version has significant practical importance. www.rolandwilliamsconsulting.com What is the DSM? (Cont.) • DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders. The American Psychiatric Association (APA) published DSM-5 in 2013, culminating a 14-year revision process. For more information, go to www.DSM5.org. • APA is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psychiatry.org. www.rolandwilliamsconsulting.com DSM-I (1952) • • • • • 132 pages Mental disorders as “reactions” Definitions were simple brief paragraphs with prototypical descriptions Terms like idiot, moron and imbecile Blacks referred to as insane in one study Homosexuality listed as a sociopathic personality disturbance www.rolandwilliamsconsulting.com DSM-II (1968) 134 pages • “Reaction” terminology dropped • Users encouraged to record multiple psychiatric diagnoses (in order of importance) and associated physical conditions • Coincided with ICD-8 (first time ICD included mental disorders) www.rolandwilliamsconsulting.com DSM-III (1980) 494 pp • Descriptive and neutral “atheoretical”) regarding etiology. • Coincided with ICD-9. • Multiaxial classification system. • Goal to introduce reliability. www.rolandwilliamsconsulting.com DSM-IV (1994) 886 pp • Inclusion of a clinical significance criterion • New disorders introduced (e.g., Acute Stress Disorder, PTSD Bipolar II Disorder, Asperger’s Disorder), • others deleted (e.g., Cluttering, Passive-Aggressive Personality Disorder). www.rolandwilliamsconsulting.com DSM-5 (2013) 947 pp “5” instead of “V” Anticipates change e.g. DSM 5.1 … 5.2 … www.rolandwilliamsconsulting.com Critique: 10 most potentially harmful changes • Psychiatrists like Allen Frances have been critical of the revisions and express concerns that it will medicalize normality and result in a glut of unnecessary and harmful drug prescriptions. – Disruptive Mood Disregulation Disorder, for temper tantrums – Major Depressive Disorder, includes normal grief – Minor Neurocognitive Disorder, for normal forgetting in old age – Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants – Binge Eating Disorder, for excessive eating www.rolandwilliamsconsulting.com Critique: 10 most potentially harmful changes (Cont.) – Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services – First time drug users will be lumped in with addicts – Behavioral Addictions, making a "mental disorder of everything we like to do a lot." – Generalized Anxiety Disorder, includes everyday worries – Post-traumatic stress disorder, changes opening "the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings." www.rolandwilliamsconsulting.com Medicalization and financial conflicts of interest • It has also been alleged that the way the categories of the DSM are structured, as well as the substantial expansion of the number of categories, are representative of an increasing medicalization of human nature, which may be attributed to “disease mongering” by psychiatrist and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades. Of the authors who selected and defined DSM-IV psychiatric disorders roughly half have had financial relationships with the pharmaceutical industry at one time, raising www.rolandwilliamsconsulting.com Medicalization and financial conflicts of interest (Cont.) the prospect of conflict of interest. The same article concludes that the connections between panel members and the drug companies were particularly strong in those diagnosis where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry. In 2005, the then APA president Steven Sharfstien released a statement in which he conceded that psychiatrist had “allowed the biopsychosocial model to become the biobio-bio model. www.rolandwilliamsconsulting.com Medicalization and financial conflicts of interest (Cont.) • However, although the number of identified diagnoses has increased by more than 300% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argue it almost entirely represents greater specification of the forms of pathology, thereby allowing better grouping of more similar patients.[3] However, William Glasser refers to the DSM as “phony diagnostic categories” arguing that it was developed by psychiatrists to help psychiatrist to make more money”. The publishing of the DSM with tightly guarded copyrights has itself earned over $100 million for the APA. www.rolandwilliamsconsulting.com Table Of Contents (Cont.) • Section I: DSM-5 Basics • Introduction • Directions on How to Use the Updated Manual • Cautionary Statement for Forensic Use of DSM -5* • Section II: Essential Elements: – Outline of the Categorical Diagnosis – Diagnostic Criteria and Codes www.rolandwilliamsconsulting.com Table Of Contents • Section III: Emerging Measures and Models – Assessment Measures – Cultural Formulation – Alternative DSM-5 Model for Personality Disorders – Conditions for Further Study • Appendix www.rolandwilliamsconsulting.com Section I • Orientation • Historical back ground • Development of DSM-5 • How to use it www.rolandwilliamsconsulting.com *Cautionary Statement • Although the DSM-5 diagnostic criteria and text are primarily designed to assist clinicians in conducting clinical assessment, case formulation, and treatment planning, DSM-5 is also used as a reference for the courts and attorneys in assessing the forensic consequences of mental disorders. As a result, it is important to note that the definition of mental disorder included in DSM-5 was developed to meet the needs of clinicians, public health professionals, and research investigators rather than all of the technical needs of the courts and legal professionals. It is also important to note that DSM-5 does not provide treatment guidelines for any given disorder. www.rolandwilliamsconsulting.com Section II • Diagnostic Criteria and codes • “Medication-induced Movement Disorders” • “Other Conditions That May be a Focus of Clinical Attention.” www.rolandwilliamsconsulting.com Section III • • • • Emerging Measures and Models Assessment measures Cultural formulation Alternative DSM-5 model for personality disorders • “Criteria Sets for Conditions for Further Study” www.rolandwilliamsconsulting.com Appendix • Highlights of changes from DSM-IV to DSM-5 • Glossary of technical terms • Glossary of cultural terms • Alpha & numeric listings of diagnoses and codes • List of advisors and contributors www.rolandwilliamsconsulting.com STRUCTURE FOR EACH DIAGNOSIS • • • • Diagnostic Criteria Subtypes and/or Specifiers Severity rating Codes and recording procedures Explanatory text (new or expanded) www.rolandwilliamsconsulting.com STRUCTURE FOR EACH DIAGNOSIS Diagnostic and associated features • • • • Prevalence Development and course Risk and prognosis Culture- and gender-related factors www.rolandwilliamsconsulting.com STRUCTURE FOR EACH DIAGNOSIS • • • • Diagnostic and associated features Diagnostic markers Functional consequences Differential diagnosis Comorbidity www.rolandwilliamsconsulting.com SECTION 2: CHAPTERS • Neurodevelopmental disorders • Schizophrenia spectrum and other psychotic disorders • Bipolar and related disorders • Depressive disorders www.rolandwilliamsconsulting.com SECTION 2: CHAPTERS • Anxiety disorders • Obsessive-compulsive and related disorders • • • • Trauma- and stressor-related disorders Dissociative disorders Somatic symptom and related disorders Feeding and eating disorders www.rolandwilliamsconsulting.com SECTION 2: CHAPTERS • • • • • Elimination disorders Sleep-wake disorders Sexual dysfunctions Gender dysphoria Disruptive, impulse-control, and conduct disorders • Substance-related and addictive disorders www.rolandwilliamsconsulting.com SECTION 2: CHAPTERS • • • • • Neurocognitive disorders Personality disorders Paraphilic disorders Other Mental Disorders Medication-induced movement disorders and other adverse effects of medication • Other conditions that may be a focus of clinical attention (V/Z Codes) www.rolandwilliamsconsulting.com Neurodevelopmental Disorders • This group of disorders typically refers to those that manifest during early development, although diagnoses are sometimes not assigned until adulthood. Examples of neurodevelopmental disorders include intellectual disabilities, communication disorders, autism spectrum disorders (incorporating the former categories of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder), ADHD, specific learning disorders, motor disorders, and other neurodevelopmental disorders. www.rolandwilliamsconsulting.com Schizophrenia Spectrum and Other Psychotic Disorders. • The disorders that belong to this section all have one feature in common: psychotic symptoms, that is, delusions, hallucinations, grossly disorganized or abnormal motor behavior, and/or negative symptoms. The disorders include schizotypal personality disorder (which is listed again, and explained more comprehensively, in the category of Personality Disorders in the DSM-5), delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, substance/medication-induced psychotic disorders, psychotic disorders due to another medical condition, and catatonic disorders. www.rolandwilliamsconsulting.com No More Mood Disorders • Now referred to as Bipolar and Related Disorders, and Depressive Disorders www.rolandwilliamsconsulting.com Bipolar and Related Disorders. • The disorders in this category refer to disturbances in mood in which the client cycles through stages of mania or mania and depression. Both children and adults can be diagnosed with bipolar disorder, and the clinician can work to identify the pattern of mood presentation, such as rapid-cycling, which is more often observed in children. These disorders include bipolar I, bipolar II, cyclothymic disorder, substance/medicationinduced, bipolar and related disorder due to another medical condition, and other specified or unspecified bipolar and related disorders. www.rolandwilliamsconsulting.com Depressive Disorders. • Previously grouped into the broader category of “mood disorders” in the DSM-IV-TR, these disorders describe conditions where depressed mood is the overarching concern. They include disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder (also known as dysthymia), and premenstrual dysphoric disorder. www.rolandwilliamsconsulting.com Anxiety Disorders. • There are a wide range of anxiety disorders, which can be diagnosed by identifying a general or specific cause of unease or fear. This anxiety or fear is considered clinically significant when it is excessive and persistent over time. Examples of anxiety disorders that typically manifest earlier in development include separation anxiety and selective mutism. Other examples of anxiety disorders are specific phobia, social anxiety disorder (also known as social phobia), panic disorder, and generalized anxiety disorder. www.rolandwilliamsconsulting.com Obsessive-Compulsive and Related Disorders. • Disorders in this category all involve obsessive thoughts and compulsive behaviors that are uncontrollable and the client feels compelled to perform them. Diagnoses in this category include obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotillomania (or hair-pulling disorder), and excoriation (or skin-picking) disorder. www.rolandwilliamsconsulting.com Trauma- and Stressor-Related Disorders. • A new category for DSM-5, trauma and stress disorders emphasize the pervasive impact that life events can have on an individual’s emotional and physical well-being. Diagnoses include reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder, acute stress disorder, and adjustment disorders. www.rolandwilliamsconsulting.com Dissociative Disorders. • These disorders indicate a temporary or prolonged disruption to consciousness that can cause an individual to misinterpret identity, surroundings, and memories. Diagnoses include dissociative identity disorder (formerly known as multiple personality disorder), dissociative amnesia, depersonalization/derealization disorder, and other specified and unspecified dissociative disorders. www.rolandwilliamsconsulting.com Somatic Symptom and Related Disorders. • Somatic symptom disorders were previously referred to as “somatoform disorders” and are characterized by the experiencing of a physical symptom without evidence of a physical cause, thus suggesting a psychological cause. Somatic symptom disorders include somatic symptom disorder, illness anxiety disorder (formerly hypochondriasis), conversion (or functional neurological symptom) disorder, psychological factors affecting other medical conditions, and factitious disorder. www.rolandwilliamsconsulting.com Feeding and Eating Disorders • This group of disorders describes clients who have severe concerns about the amount or type of food they eat to the point that serious health problems, or even death, can result from their eating behaviors. Examples include avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, pica, and rumination disorder. www.rolandwilliamsconsulting.com Elimination Disorders. • These disorders can manifest at any point in a person’s life, although they are typically diagnosed in early childhood or adolescence. They include enuresis, which is the inappropriate elimination of urine, and encopresis, which is the inappropriate elimination of feces. These behaviors may or may not be intentional. www.rolandwilliamsconsulting.com Sleep-Wake Disorders. • This category refers to disorders where one’s sleep patterns are severely impacted, and they often co-occur with other disorders (e.g., depression or anxiety). Some examples include insomnia disorder, hypersomnolence disorder, restless legs syndrome, narcolepsy, and nightmare Disorder. A number of sleep-wake disorders involve variations in breathing, such as sleep-related hypoventilation, obstructive sleep apnea hypopnea, or central sleep apnea. See the DSM-5 for the full listing and descriptions of these disorders. www.rolandwilliamsconsulting.com Sexual Dysfunctions. • These disorders are related to problems that disrupt sexual functioning or one’s ability to experience sexual pleasure. They occur across sexes and include delayed ejaculation, erectile disorder, female orgasmic disorder, and premature (or early) ejaculation disorder, among others. www.rolandwilliamsconsulting.com Gender Dysphoria. • Formerly termed, “gender identity disorder,” this category includes those individuals who experience significant distress with the sex they were born and with associated gender roles. This diagnosis has been separated from the category of sexual disorders, as it is now accepted that gender dysphoria does not relate to a person’s sexual attractions. www.rolandwilliamsconsulting.com Disruptive, Impulse Control, and Conduct Disorders. • These disorders are characterized by socially unacceptable or otherwise disruptive and harmful behaviors that are outside of the individual’s control. Generally, more common in males than in females, and often first seen in childhood, they include oppositional defiant disorder, conduct disorder, intermittent explosive disorder, antisocial personality disorder (which is also coded in the category of personality disorders), kleptomania, and pyromania. www.rolandwilliamsconsulting.com Substance-Related and Addictive Disorders. • Substance use disorders include disruptions in functioning as the result of a craving or strong urge. Often caused by prescribed and illicit drugs or the exposure to toxins, with these disorders the brain’s reward system pathways are activated when the substance is taken (or in the case of gambling disorder, when the behavior is being performed). Some common substances include alcohol, caffeine, nicotine, cannabis, opioids, inhalants, amphetamine, phencyclidine (PCP), sedatives, hypnotics or anxiolytics. Substance use disorders are further designated with the following terms: intoxication, withdrawal, induced, or unspecified. www.rolandwilliamsconsulting.com Neurocognitive Disorders. • These disorders are diagnosed when one’s decline in cognitive functioning is significantly different from the past and is usually the result of a medical condition (e.g., Parkinson’s or Alzheimer’s disease), the use of a substance/medication, or traumatic brain injury, among other phenomena. Examples of neurocognitive disorders (NCD) include delirium, and several types of major and mild NCDs such as frontotemporal NCD, NCD due to Parkinson’s disease, NCD due to HIV infection, NCD due to Alzheimer’s disease, substance- or medication-induced NCD, and vascular NCD, among others. www.rolandwilliamsconsulting.com Personality Disorders. • The 10 personality disorders in DSM-5 all involve a pattern of experiences and behaviors that are persistent, inflexible, and deviate from one’s cultural expectations. Usually, this pattern emerges in adolescence or early adulthood and causes severe distress in one’s interpersonal relationships. The personality disorders are grouped into three following clusters based on similar behaviors: www.rolandwilliamsconsulting.com • Cluster A: Paranoid, schizoid, and schizotypal. These individuals seem bizarre or unusual in their behaviors and interpersonal relations. • Cluster B: Antisocial, borderline, histrionic, and narcissistic. These individuals seem overly emotional, are melodramatic, or unpredictable in their behaviors and interpersonal relations. • Cluster C: Avoidant, dependent, and obsessivecompulsive (not to be confused with obsessivecompulsive disorder). These individuals tend to appear anxious, worried, or fretful in their behaviors. • In addition to these clusters, one can be diagnosed with other specified or unspecified personality disorder, as well as a personality change due to another medical condition, such as a head injury. www.rolandwilliamsconsulting.com Paraphilic Disorders. • These disorders are diagnosed when the client is sexual aroused to circumstances that deviate from traditional sexual stimuli and when such behaviors result in harm or significant emotional distress. The disorders include exhibitionistic disorder, voyeuristic disorder, frotteuristic disorder, sexual sadism and sexual masochism disorders, fetishistic disorder, transvestic disorder, pedophilic disorder, and other specified and unspecified paraphilic disorders. www.rolandwilliamsconsulting.com Other Mental Disorders. • This diagnostic category includes mental disorders that did not fall within one of the previously mentioned groups and do not have unifying characteristics. Examples include other specified mental disorder due to another medical condition, unspecified mental disorders due to another medical condition, other specified mental disorder, and unspecified mental disorder. www.rolandwilliamsconsulting.com Medication-Induced Movement Disorders and Other Adverse Effects of Medications • These disorders are the result of adverse and severe side effects to medications, although a causal link cannot always be shown. Some of these disorders include neuroleptic-induced parkinsonism, neuroleptic malignant syndrome, medication-induced dystonia, medicationinduced acute akathisia, tardive dyskinesia, tardive akathisia, medication-induced postural tremor, other medication-induced movement disorder, antidepressant discontinuation syndrome, and other adverse effect of medication. www.rolandwilliamsconsulting.com Other Conditions That May Be a Focus of Clinical Assessment. • Reminiscent of Axis IV of the previous edition of the DSM, this last part of Section II ends with a description of concerns that could be clinically significant, such as abuse/neglect, relational problems, psychosocial, personal, and environmental concerns, educational/occupational problems, housing and economic problems, and problems related to the legal system. These conditions, which are not consider mental disorders, are generally listed as V codes, which correspond to ICD-9, or Z codes, which correspond to ICD-10. www.rolandwilliamsconsulting.com DSM-5 and ICD-10 • Codes in the DSM-IVTR were ICD-9CM codes • e.g. Generalized Anxiety Disorder (300.02) • Because U.S. healthcare providers will be Required to use ICD-10CM (alphanumeric) codes effective October 1, 2015, the DSM-5 includes ICD-10 codes in parentheses • e.g. Generalized Anxiety Disorder 300.02 (F41.1) www.rolandwilliamsconsulting.com Changes from the DSM IV-TR to the DSM 5 • Terminology • The phrase “general medical condition” is replaced in DSM-5 with “another medical condition” where relevant across all disorders. www.rolandwilliamsconsulting.com Neurodevelopmental Disorders www.rolandwilliamsconsulting.com Major Changes Change Comment Elimination of multi-axial system and GAF Clinicians wanted simplified, diagnosis-based system; distinctions between Axis I and Axis II disorders were never clearly justified; clinicians can still specify external stressors; new assessment measures will be introduced Establishes 20 diagnostic classes or categories of mental disorders Categories based on groupings of disorders sharing similar characteristics; some categories represent spectrums of related disorders Introduction of new diagnostic category Neurodevelopmental Disorders to include Autism Spectrum Disorder and ADHD and other disorders reflecting abnormal brain development Increasing emphases on neurobiological bases of mental disorders and the developing understanding that abnormal brain development underlies many types of disorders www.rolandwilliamsconsulting.com Major Changes Change Comment Introduces more dimensionality (severity ratings) but does not restructure personality disorders as some had proposed Major changes in personality disorders held over until next revision, the DSM 5.1 (or maybe 5.2) in Section III identifies alternative methods to Diagnose Personality Disorders Roman numerals dropped: DSM-5, not DSM-V Allows for easier nomenclature for midcourse revisions, 5.1, 5.2, etc. Removes obsessive-compulsive disorder from category of Anxiety Disorders and places it in new category of ObsessiveCompulsive and Related Disorders Recognizes a spectrum of obsessivecompulsive type disorders, including body dysmorphic disorder; however, anxiety remains the core feature of OCD, so questions remain about separating it from anxiety disorders www.rolandwilliamsconsulting.com Major Changes Change Comment Removes ASD (Acute Stress Disorder) and PTSD from Anxiety Disorders and places them in new category of Trauma and Stressor-Related Disorders Groups all stress-related psychological disorders under the same umbrella; Adjustment Disorders may now be coded in context of traumatic stressors Substance use disorder will combine the DSM-IV categories of substance abuse and substance dependence. In this one overarching disorder, the criteria have not only been combined, but strengthened. Previous substance abuse criteria required only one symptom while the DSM-5’s mild substance use disorder requires two to three symptoms. Eliminates distinction between substance abuse and dependence disorders, collapsing them into single category of substance use disorders Recognizes that there is no clear line between substance abuse and dependence disorders; also brings certain compulsive patterns of behavior into a spectrum of addictive disorders www.rolandwilliamsconsulting.com Major Changes Change Comment Hoarding disorder is new to DSM-5 Its addition to DSM is supported by extensive scientific research on this disorder. This disorder will help characterize people with persistent difficulty discarding or parting with possessions, regardless of their actual value. The behavior usually has harmful effects—emotional, physical, social, financial and even legal— for a hoarder and family members. Now includes Gambling Disorder (previously Pathological Gambling) Other forms of nonchemical addiction, such as compulsive Internet use, sexual behavior and compulsive shopping, don’t make it into the manual and remain under study. Binge eating disorder will be moved from DSM-IV’s Appendix B Criteria Sets and Axes Provided for Further Study to DSM-5 Section 2. The change is intended to better represent the symptoms and behaviors of people with this condition. www.rolandwilliamsconsulting.com Major Changes Change Comment Provides a means of rating severity of symptoms. Encourages clinicians to recognize the dimensionality of disorders Greater emphasis on comorbidity; e.g., use of anxiety ratings in diagnosing depressive and bipolar disorders Provides more explicit recognition of comorbidity in having clinicians rate level of anxiety in mood disorders www.rolandwilliamsconsulting.com Major Changes Change Comment Elimination of term “somatoform disorders” (now Somatic Symptom and Related Disorders) Eliminates a term few people understood (somatoform disorders) and now emphasizes the psychological reactions to physical symptoms, not whether they are medically based Reorganization of mood disorders into two separate diagnostic categories of Depressive Disorders and Bipolar and Related Disorders No additional major changes anticipated. www.rolandwilliamsconsulting.com Major Changes Change Comment Removal of developmental trajectory in organizing classification of disorders: Eliminates category of “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” May make it easier to diagnose traditional childhood disorders like ADHD and even separation anxiety disorder in adults. Conversely, it may also make it easier to diagnose disorders typically seen in adults, like bipolar disorder, in children. Elimination of bereavement exclusion from major depression Recognizes that a major depressive episode may overlay a normal reaction to loss; critics claim it may pathologize bereavement The new category of Neurodevelopmental Disorders includes many disorders previously classified as childhood onset disorders, however it excludes disorders involving abnormal emotional development, such as separation anxiety disorder and selective mutism. www.rolandwilliamsconsulting.com Major Changes Change Comment Hypochondriasis dropped as distinct disorder Eliminates the pejorative term “hypochondriasis”; people formerly diagnosed with hypochondriasis may now be diagnosed with Somatic Symptom Disorder if their physical symptoms are severe or with Illness Anxiety Disorder if their symptoms are moderate or mild, Factitious Disorder moved to Somatic Symptom and Related Disorders Associated with other somatic symptom disorders, but is distinguished by intentional fabrication of symptoms for no apparent gain other than assuming medical patient role www.rolandwilliamsconsulting.com Intellectual Disability (Intellectual Developmental Disorder) • Diagnostic criteria for intellectual disability (intellectual developmental disorder) emphasize the need for an assessment of both cognitive capacity (IQ) and adaptive functioning. • Severity is determined by adaptive functioning rather than IQ score. • The term mental retardation has been replaced with intellectual disability. www.rolandwilliamsconsulting.com Communication Disorders • The DSM-5 communication disorders include: • language disorder (which combines DSM-IV expressive and mixed receptive-expressive language disorders), • speech sound disorder (a new name for phono-logical disorder), and • childhood-onset fluency disorder (a new name for stuttering). www.rolandwilliamsconsulting.com Communication Disorders (Cont.) • Also included is social (pragmatic) communication disorder, a new condition for persistent difficulties in the social uses of verbal and nonverbal communication. • Because social communication deficits are one component of autism spectrum disorder (ASD), it is important to note that social (pragmatic) communication disorder cannot be diagnosed in the presence of restricted repetitive behaviors, interests, and activities (the other component of ASD). www.rolandwilliamsconsulting.com Autism Spectrum Disorder • Autism spectrum disorder is a new DSM-5 name that reflects a scientific consensus that four previously separate disorders are actually a single condition with different levels of symptom severity in two core domains. • ASD now encompasses the previous DSM-IV • autistic disorder (autism), • Asperger’s disorder, • childhood disintegrative disorder, and • pervasive developmental disorder not otherwise specified. www.rolandwilliamsconsulting.com • ASD is characterized by 1) deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities (RRBs). Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present. www.rolandwilliamsconsulting.com Attention-Deficit/Hyperactivity Disorder • The diagnostic criteria for attentiondeficit/hyperactivity disorder (ADHD) in DSM5 are similar to those in DSM-IV. The same 18 symptoms are used as in DSM-IV, and continue to be divided into two symptom domains (inattention and hyperactivity/impulsivity), of which at least six symptoms in one domain are required for diagnosis. However, several changes have been made in DSM-5: www.rolandwilliamsconsulting.com • 1) examples have been added to the criterion items to facilitate application across the life span; • 2) the cross-situational requirement has been strengthened to “several” symptoms in each setting; • 3) the onset criterion has been changed from “symptoms that caused impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”; • 4) subtypes have been replaced with presentation specifiers that map directly to the prior subtypes; www.rolandwilliamsconsulting.com • 5) a comorbid diagnosis with autism spectrum disorder is now allowed; and • 6) a symptom threshold change has been made for adults, to reflect their substantial evidence of clinically significant ADHD impairment, with the cutoff for ADHD of five symptoms, instead of six required for younger persons, both for inattention and for hyperactivity and impulsivity. • Finally, ADHD was placed in the neurodevelopmental disorders chapter to reflect brain developmental correlates with ADHD and the DSM-5 decision to eliminate the DSM-IV chapter that includes all diagnoses usually first made in infancy, childhood, or adolescence. www.rolandwilliamsconsulting.com Specific Learning Disorder • Specific learning disorder combines the DSMIV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Because learning deficits in the areas of reading, written expression, and mathematics commonly occur together, coded specifiers for the deficit types in each area are included. www.rolandwilliamsconsulting.com Motor Disorders • The following motor disorders are included in the DSM-5 neurodevelopmental disorders chapter: • developmental coordination disorder, • stereotypic movement disorder, • Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, • provisional tic disorder, other specified tic disorder, and unspecified tic disorder. The tic criteria have been standardized across all of these disorders in this chapter. • Stereotypic movement disorder has been more clearly differentiated from body-focused repetitive behavior disorders that are in the DSM-5 obsessivecompulsive disorder chapter. www.rolandwilliamsconsulting.com Schizophrenia Spectrum and Other Psychotic Disorders • Two changes were made to DSM-IV Criterion A for schizophrenia. The first change is the elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing). In DSM-IV, only one such symptom was needed to meet the diagnostic requirement for Criterion A, instead of two of the other listed symptoms. This special attribution was removed due to the nonspecificity of Schneiderian symptoms and the poor reliability in distinguishing bizarre from non-bizarre delusions. www.rolandwilliamsconsulting.com Schizophrenia Spectrum and Other Psychotic Disorders (Cont.) • Therefore, in DSM-5, two Criterion A symptoms are required for any diagnosis of schizophrenia. • The second change is the addition of a requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech. www.rolandwilliamsconsulting.com Schizophrenia subtypes • The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual types) are eliminated due to their limited diagnostic stability, low reliability, and poor validity. These subtypes also have not been shown to exhibit distinctive patterns of treatment response or longitudinal course. • Instead, a dimensional approach to rating severity for the core symptoms of schizophrenia is included in Section III. www.rolandwilliamsconsulting.com Schizoaffective Disorder • The primary change to schizoaffective disorder, (schizophrenia and a mood disorder) is the requirement that a major mood episode be present for a majority of the disorder’s total duration after Criterion A has been met. It makes schizoaffective disorder a longitudinal instead of a cross-sectional diagnosis more comparable to schizophrenia, bipolar disorder, and major depressive disorder, which are bridged by this condition. • The change was also made to improve the reliability, diagnostic stability, and validity of this disorder, while recognizing that the characterization of patients with both psychotic and mood symptoms, either concurrently or at different points in their illness, has been a clinical challenge. www.rolandwilliamsconsulting.com Delusional Disorder • Criterion A for delusional disorder no longer has the requirement that the delusions must be nonbizarre. A specifier for bizarre type delusions provides continuity with DSM-IV. The demarcation of delusional disorder from psychotic variants of obsessive-compulsive disorder and body dysmorphic disorder is explicitly noted with a new exclusion criterion, which states that the symptoms must not be better explained by conditions such as obsessivecompulsive or body dysmorphic disorder with absent insight/delusional beliefs. www.rolandwilliamsconsulting.com Delusional Disorder (Cont.) • DSM-5 no longer separates delusional disorder from shared delusional disorder. If criteria are met for delusional disorder then that diagnosis is made. If the diagnosis cannot be made but shared beliefs are present, then the diagnosis “other specified schizophrenia spectrum and other psychotic disorder” is used. www.rolandwilliamsconsulting.com Catatonia • The same criteria are used to diagnose catatonia whether the context is a psychotic, bipolar, depressive, or other medical disorder, or an unidentified medical condition. In DSM-IV, two out of five symptom clusters were required if the context was a psychotic or mood disorder, whereas only one symptom cluster was needed if the context was a general medical condition. • In DSM-5, all contexts require three catatonic symptoms (from a total of 12 characteristic symptoms). • In DSM-5, catatonia may be diagnosed as a specifier for depressive, bipolar, and psychotic disorders; as a separate diagnosis in the context of another medical condition; or as an other specified diagnosis. www.rolandwilliamsconsulting.com Bipolar and Related Disorders www.rolandwilliamsconsulting.com Bipolar Disorders • Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood. • The DSM-IV diagnosis of bipolar I disorder, mixed episode, requiring that the individual simultaneously meet full criteria for both mania and major depressive episode, has been removed. • Instead, a new specifier, “with mixed features,” has been added that can be applied to episodes of mania or hypomania when depressive features are present, and to episodes of depression in the context of major depressive disorder or bipolar disorder when features of mania/hypomania are present. www.rolandwilliamsconsulting.com Other Specified Bipolar and Related Disorder • DSM-5 allows the specification of particular conditions for other specified bipolar and related disorder, including categorization for individuals with a past history of a major depressive disorder who meet all criteria for hypomania except the duration criterion (i.e., at least 4 consecutive days). • A second condition constituting an other specified bipolar and related disorder is that too few symptoms of hypomania are present to meet criteria for the full bipolar II syndrome, although the duration is sufficient at 4 or more days. www.rolandwilliamsconsulting.com Anxious Distress Specifier • In the chapter on bipolar and related disorders and the chapter on depressive disorders, a specifier for anxious distress is delineated. This specifier is intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria. www.rolandwilliamsconsulting.com Depressive Disorders • DSM-5 contains several new depressive disorders, including disruptive mood dysregulation disorder and premenstrual dysphoric disorder. To address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is included for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol. Based on strong scientific evidence, premenstrual dysphoric disorder has been moved from DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study,” to the www.rolandwilliamsconsulting.com Depressive Disorders (Cont.) main body of DSM-5. Finally, DSM-5 conceptualizes chronic forms of depression in a somewhat modified way. What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive dis- order, which includes both chronic major depressive disorder and the previous dysthymic disorder. An inability to find scientifically meaningful differences between these two conditions led to their combination with specifiers included to identify different pathways to the diagnosis and to provide continuity with DSM-IV. www.rolandwilliamsconsulting.com Major Depressive Disorder • Neither the core criterion symptoms applied to the diagnosis of major depressive episode nor the requisite duration of at least 2 weeks has changed from DSM-IV. • Criterion A for a major depressive episode in DSM-5 is identical to that of DSM-IV, as is the requirement for clinically significant distress or impairment in social, occupational, or other important areas of life, although this is now listed as Criterion B rather than Criterion C. www.rolandwilliamsconsulting.com Major Depressive Disorder (Cont.) • The coexistence within a major depressive episode of at least three manic symptoms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier “with mixed features.” The presence of mixed features in an episode of major depressive disorder increases the likelihood that the illness exists in a bipolar spectrum; however, if the individual concerned has never met criteria for a manic or hypomanic episode, the diagnosis of major depressive disorder is retained. www.rolandwilliamsconsulting.com Bereavement Exclusion • In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons: – The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. www.rolandwilliamsconsulting.com Bereavement Exclusion (Cont.) – Second, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section III. www.rolandwilliamsconsulting.com Bereavement Exclusion (Cont.) – Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes. www.rolandwilliamsconsulting.com Specifiers for Depressive Disorders • A new specifier to indicate the presence of mixed symptoms has been added across both the bipolar and the depressive disorders, allowing for the possibility of manic features in individuals with a diagnosis of unipolar depression. A substantial body of research conducted over the last two decades points to the importance of anxiety as relevant to prognosis and treatment decision making. The “with anxious distress” specifier gives the clinician an opportunity to rate the severity of anxious distress in all individuals with bipolar or depressive disorders. www.rolandwilliamsconsulting.com Anxiety Disorders • The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (which is included with the obsessivecompulsive and related disorders) or posttraumatic stress disorder and acute stress disorder (which is included with the traumaand stressor-related disorders). However, the sequential order of these chapters in DSM-5 reflects the close relationships among them. www.rolandwilliamsconsulting.com Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia) • Changes in criteria for agoraphobia, specific phobia, and social anxiety disorder (social phobia) include deletion of the requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable. This change is based on evidence that individuals with such disorders often overestimate the danger in “phobic” situations and that older individuals often misattribute “phobic” fears to aging. www.rolandwilliamsconsulting.com Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia) (Cont.) • Instead, the anxiety must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account. • In addition, the 6-month duration, which was limited to individuals under age 18 in DSM-IV, is now extended to all ages. This change is intended to minimize overdiagnosis of transient fears. www.rolandwilliamsconsulting.com Panic Attack • The essential features of panic attacks remain unchanged, although the complicated DSM-IV terminology for describing different types of panic attacks (i.e., situationally bound/cued, situationally predisposed, and unexpected/uncued) is replaced with the terms unexpected and expected panic attacks. • Panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders, including but not limited to anxiety disorders. Hence, panic attack can be listed as a specifier that is applicable to all DSM-5 disorders. www.rolandwilliamsconsulting.com Panic Disorder and Agoraphobia • Panic disorder and agoraphobia are unlinked in DSM5. Thus, the former DSM-IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses, panic disorder and agoraphobia, each with separate criteria. • The co-occurrence of panic disorder and agoraphobia is now coded with two diagnoses. This change recognizes that a substantial number of individuals with agoraphobia do not experience panic symptoms. www.rolandwilliamsconsulting.com Separation Anxiety Disorder • Although in DSM-IV, separation anxiety disorder was classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence,” it is now classified as an anxiety disorder. • The core features remain mostly unchanged, although the wording of the criteria has been modified to more adequately represent the expression of separation anxiety symptoms in adulthood. www.rolandwilliamsconsulting.com Separation Anxiety Disorder (Cont.) • Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that age at onset must be before 18 years, because a substantial number of adults report onset of separation anxiety after age 18. Also, a duration criterion—“typically lasting for 6 months or more”—has been added for adults to minimize overdiagnosis of transient fears. www.rolandwilliamsconsulting.com Selective Mutism • In DSM-IV, selective mutism was classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” • It is now classified as an anxiety disorder, given that a large majority of children with selective mutism are anxious. The diagnostic criteria are largely unchanged from DSM-IV. www.rolandwilliamsconsulting.com Obsessive-Compulsive and Related Disorders • The chapter on obsessive-compulsive and related disorders, which is new in DSM-5, reflects the increasing evidence that these disorders are related to one another. • New disorders include hoarding disorder, excoriation (skin-picking) disorder, substance-/medicationinduced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. The DSM-IV diagnosis of trichotillomania is now termed trichotillomania (hairpulling disorder) and has been moved from a DSM-IV classification of impulse-control disorders not elsewhere classified to obsessive-compulsive and related disorders in DSM-5. www.rolandwilliamsconsulting.com Specifiers for Obsessive-Compulsive and Related Disorders • The “with poor insight” specifier for obsessivecompulsive disorder has been refined in DSM-5 to allow a distinction between individuals with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compulsive disorder beliefs (i.e., complete conviction that obsessivecompulsive disorder beliefs are true). • Analogous “insight” specifiers have been included for body dysmorphic disorder and hoarding disorder. • The “tic-related” specifier for obsessive-compulsive disorder reflects a growing literature on the diagnostic validity and clinical utility of identifying individuals with a current or past comorbid tic disorder. www.rolandwilliamsconsulting.com Body Dysmorphic Disorder • For DSM-5 body dysmorphic disorder, a diagnostic criterion describing repetitive behaviors or mental acts in response to preoccupations with perceived defects or flaws in physical appearance has been added, consistent with data indicating the prevalence and importance of this symptom. • The delusional variant of body dysmorphic disorder (which identifies individuals who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delusional disorder, somatic type, and body dysmorphic disorder; in DSM-5 this presentation is designated only as body dysmorphic disorder with the absent insight/delusional beliefs specifier. www.rolandwilliamsconsulting.com Hoarding Disorder • Hoarding disorder is a new diagnosis in DSM-5. DSMIV lists hoarding as one of the possible symptoms of obsessive-compulsive personality disorder and notes that extreme hoarding may occur in obsessivecompulsive disorder. However, available data do not indicate that hoarding is a variant of obsessivecompulsive disorder or another mental disorder. Instead, there is evidence for the diagnostic validity and clinical utility of a separate diagnosis of hoarding disorder, which reflects persistent difficulty discarding or parting with possessions due to a perceived need to save the items and distress associated with discarding them. Hoarding disorder may have unique neurobiological correlates, is associated with significant impairment, and may respond to clinical intervention. www.rolandwilliamsconsulting.com • Trichotillomania (Hair-Pulling Disorder) • Trichotillomania was included in DSM-IV, although “hair-pulling disorder” has been added parenthetically to the disorder’s name in DSM-5. • Excoriation (Skin-Picking) Disorder • Excoriation (skin-picking) disorder is newly added to DSM-5, with strong evidence for its diagnostic validity and clinical utility. www.rolandwilliamsconsulting.com • Substance/Medication-Induced ObsessiveCompulsive and Related Disorder and ObsessiveCompulsive and Related Disorder Due to Another Medical Condition • DSM-IV included a specifier “with obsessivecompulsive symptoms” in the diagnoses of anxiety disorders due to a general medical condition and substance-induced anxiety disorders. Given that obsessive-compulsive and related disorders are now a distinct category, DSM-5 includes new categories for substance medication-induced obsessive-compulsive and related disorder and for obsessive-compulsive and related disorder due to another medical condition. This change is consistent with the intent of DSM-IV, and it reflects the recognition that substances, medications, and medical conditions can present with symptoms similar to primary obsessive-compulsive and related disorders. www.rolandwilliamsconsulting.com • Other Specified and Unspecified ObsessiveCompulsive and Related Disorders • DSM-5 includes the diagnoses other specified obsessive-compulsive and related disorder, which can include conditions such as body-focused repetitive behavior disorder and obsessional jealousy, or unspecified obsessive-compulsive and related disorder. Body-focused repetitive behavior disorder is characterized by recurrent behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors. Obsessional jealousy is characterized by nondelusional preoccupation with a partner’s perceived infidelity. www.rolandwilliamsconsulting.com Trauma and Stressor Related Disorders www.rolandwilliamsconsulting.com Acute Stress Disorder • In DSM-5, the stressor criterion (Criterion A) for acute stress disorder is changed from DSM-IV. The criterion requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. Also, the DSM-IV Criterion A2 regarding the subjective reaction to the traumatic event (e.g., “the person’s response involved intense fear, helplessness, or horror”) has been eliminated. Based on evidence that acute posttraumatic reactions are very heterogeneous and that DSM-IV’s emphasis on dissociative symptoms is overly restrictive, individuals may meet diagnostic criteria in DSM-5 for acute stress disorder if they exhibit any 9 of 14 listed symptoms in these categories: intrusion, negative mood, dissociation, avoidance, and arousal. www.rolandwilliamsconsulting.com Posttraumatic Stress Disorder • DSM-5 criteria for posttraumatic stress disorder differ significantly from those in DSM-IV. The stressor criterion (Criterion A) is more explicit with regard to how an individual experienced “traumatic” events. Also, Criterion A2 (subjective reaction) has been eliminated. • Whereas there were three major symptom clusters in DSM-IV—reexperiencing, avoidance/numbing, and arousal—there are now four symptom clusters in DSM-5, because the avoidance/ numbing cluster is divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood. www.rolandwilliamsconsulting.com Posttraumatic Stress Disorder (Cont.) • This latter category, which retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as persistent negative emotional states. • The final cluster—alterations in arousal and reactivity—retains most of the DSM-IV arousal symptoms. It also includes irritable or aggressive behavior and reckless or self-destructive behavior. • Posttraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder. www.rolandwilliamsconsulting.com Reactive Attachment Disorder • The DSM-IV childhood diagnosis reactive attachment disorder had two subtypes: emotionally withdrawn/inhibited and indiscriminately social/disinhibited. • In DSM-5, these subtypes are defined as distinct disorders: reactive attachment disorder and disinhibited social engagement disorder. • Both of these disorders are the result of social neglect or other situations that limit a young child’s opportunity to form selective attachments.. The two disorders differ in other important ways, including correlates, course, and response to intervention, and for these reasons are considered separate disorders. www.rolandwilliamsconsulting.com Dissociative Disorders • Major changes in dissociative disorders in DSM-5 include the following: • 1) derealization is included in the name and symptom structure of what previously was called depersonalization disorder and is now called depersonalization/derealization disorder, • 2) dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis, and www.rolandwilliamsconsulting.com Dissociative Disorders (Cont.) • 3) the criteria for dissociative identity disorder have been changed to indicate that symptoms of disruption of identity may be reported as well as observed, and that gaps in the recall of events may occur for everyday and not just traumatic events. • Also, experiences of pathological possession in some cultures are included in the description of identity disruption. www.rolandwilliamsconsulting.com Dissociative Identity Disorder • Several changes to the criteria for dissociative identity disorder have been made in DSM-5. • Criterion A has been expanded to include certain possession-form phenomena and functional neurological symptoms to account for more diverse presentations of the disorder. www.rolandwilliamsconsulting.com Dissociative Identity Disorder (Cont.) • Criterion A now specifically states that transitions in identity may be observable by others or self-reported. Third, according to Criterion B, individuals with dissociative identity disorder may have recurrent gaps in recall for everyday events, not just for traumatic experiences. Other text modifications clarify the nature and course of identity disruptions. www.rolandwilliamsconsulting.com Somatic Symptom and Related Disorders • Somatic Symptom Disorder • DSM-5 better recognizes the complexity of the interface between psychiatry and medicine. Individuals with somatic symptoms plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed medical condition. • Individuals previously diagnosed with somatization disorder will usually meet DSM-5 criteria for somatic symptom disorder, but only if they have the maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to their somatic symptoms. www.rolandwilliamsconsulting.com • In DSM-IV, the diagnosis undifferentiated somatoform disorder had been created in recognition that somatization disorder would only describe a small minority of “somatizing” individuals, but this disorder did not prove to be a useful clinical diagnosis. Because the distinction between somatization disorder and undifferentiated somatoform disorder was arbitrary, they are merged in DSM-5 under somatic symptom disorder, and no specific number of somatic symptoms is required. www.rolandwilliamsconsulting.com Medically Unexplained Symptoms • DSM-IV criteria overemphasized the importance of an absence of a medical explanation for the somatic symptoms. Unexplained symptoms are present to various degrees, particularly in conversion disorder, but somatic symptom disorders can also accompany diagnosed medical disorders. The reliability of medically unexplained symptoms is limited, and grounding a diagnosis on the absence of an explanation is problematic and reinforces mind -body dualism. • The DSM-5 classification defines disorders on the basis of positive symptoms (i.e., distressing somatic symptoms plus abnormal thoughts, feelings, and www.rolandwilliamsconsulting.com behaviors in response to these symptoms). Hypochondriasis and Illness Anxiety Disorder • Hypochondriasis has been eliminated as a disorder, in part because the name was perceived as pejorative and not conducive to an effective therapeutic relationship. Most individuals who would previously have been diagnosed with hypochondriasis have significant somatic symptoms in addition to their high health anxiety, and would now receive a DSM-5 diagnosis of somatic symptom disorder. www.rolandwilliamsconsulting.com Hypochondriasis and Illness Anxiety Disorder (Cont.) • In DSM-5, individuals with high health anxiety without somatic symptoms would receive a diagnosis of illness anxiety disorder (unless their health anxiety was better explained by a primary anxiety disorder, such as generalized anxiety disorder). www.rolandwilliamsconsulting.com Pain Disorder • DSM-5 takes a different approach to the important clinical realm of individuals with pain. In DSM-IV, the pain disorder diagnoses assume that some pains are associated solely with psychological factors, some with medical diseases or injuries, and some with both. There is a lack of evidence that such distinctions can be made with reliability and validity, and a large body of research has demonstrated that psychological factors influence all forms of pain. Most individuals with chronic pain attribute their pain to a combination of factors, including somatic, psychological, and environmental influences. www.rolandwilliamsconsulting.com Pain Disorder (Cont.) • In DSM-5, some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an adjustment disorder would be more appropriate. www.rolandwilliamsconsulting.com Psychological Factors Affecting Other Medical Conditions and Factitious Disorder • Psychological factors affecting other medical conditions is a new mental disorder in DSM-5, having formerly been included in the DSM-IV chapter “Other Conditions That May Be a Focus of Clinical Attention.” • This disorder and factitious disorder are placed among the somatic symptom and related disorders because somatic symptoms are predominant in both disorders, and both are most often encountered in medical settings. The variants of psychological factors affecting other medical conditions are removed in favor of the stem diagnosis. www.rolandwilliamsconsulting.com Feeding and Eating Disorders • In DSM-5, the feeding and eating disorders include several disorders included in DSM-IV as feeding and eating disorders of infancy or early childhood in the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” www.rolandwilliamsconsulting.com • Pica and Rumination Disorder • The DSM-IV criteria for pic (eating clay, paper, sand, etc.) and for rumination disorder, (bringing up and re-chews food) have been revised for clarity and to indicate that the diagnoses can be made for individuals of any age. www.rolandwilliamsconsulting.com Avoidant/Restrictive Food Intake Disorder • DSM-IV feeding disorder of infancy or early childhood has been renamed avoidant/restrictive food intake disorder, and the criteria have been significantly expanded. • The DSM-IV disorder was rarely used, and limited information is available on the characteristics, course, and outcome of children with this disorder. Additionally, a large number of individuals, primarily but not exclusively children and adolescents, www.rolandwilliamsconsulting.com Avoidant/Restrictive Food Intake Disorder (Cont.) substantially restrict their food intake and experience significant and experience significant associated physiological or psychosocial problems but do not meet criteria for any DSM-IV eating disorder. • Avoidant/restrictive food intake disorder is a broad category intended to capture this range of presentations. www.rolandwilliamsconsulting.com Binge-Eating Disorder • Extensive research followed the promulgation of preliminary criteria for binge eating disorder in Appendix B of DSM-IV, and findings supported the clinical utility and validity of binge-eating disorder. • The only significant difference from the preliminary DSM-IV criteria is that the minimum average frequency of binge eating required for diagnosis has been changed from at least twice weekly for 6 months to at least once weekly over the last 3 months, which is identical to the DSM-5 frequency criterion for bulimia nervosa. www.rolandwilliamsconsulting.com Sexual Dysfunctions • In DSM-IV, sexual dysfunctions referred to sexual pain or to a disturbance in one or more phases of the sexual response cycle. Research suggests that sexual response is not always a linear, uniform process and that the distinction between certain phases (e.g., desire and arousal) may be artificial. In DSM-5, gender-specific sexual dysfunctions have been added, and, for females, sexual desire and arousal disorders have been combined into one disorder: female sexual interest/arousal disorder. www.rolandwilliamsconsulting.com Sexual Dysfunctions (Cont.) • To improve precision regarding duration and severity criteria and to reduce the likelihood of overdiagnosis, all of the DSM-5 sexual dysfunctions (except substance-/medicationinduced sexual dysfunction) now require a minimum duration of approximately 6 months and more precise severity criteria. These changes provide useful thresholds for making a diagnosis and distinguish transient sexual difficulties from more persistent sexual dysfunction. www.rolandwilliamsconsulting.com Subtypes • DSM-IV included the following subtypes for all sexual disorders: lifelong versus acquired, generalized versus situational, and due to psychological factors versus due to combined factors. • DSM-5 includes only lifelong versus acquired and generalized versus situational subtypes. • Sexual dysfunction due to a general medical condition and the subtype due to psychological versus combined factors have been deleted due www.rolandwilliamsconsulting.com Subtypes (Cont.) to findings that the most frequent clinical presentation is one in which both psychological and biological factors contribute. • To indicate the presence and degree of medical and other nonmedical correlates, the following associated features are described in the accompanying text: partner factors, relationship factors, individual vulnerability factors, cultural or religious factors, and medical factors. www.rolandwilliamsconsulting.com Gender Dysphoria • Gender dysphoria is a new diagnostic class in DSM-5 and reflects a change in conceptualization of the disorder’s defining features by emphasizing the phenomenon of “gender incongruence” rather than cross-gender identification per se, as was the case in DSM-IV gender identity disorder. • In DSM-IV, the chapter “Sexual and Gender Identity Disorders” included three relatively disparate diagnostic classes: gender identity disorders, sexual dysfunctions, and paraphilias. Gender identity disorder, however, is neither a sexual dysfunction nor a paraphilia. www.rolandwilliamsconsulting.com Gender Dysphoria (Cont.) • Gender dysphoria is a unique condition in that it is a diagnosis made by mental health care providers, although a large proportion of the treatment is endocrinological and surgical (at least for some adolescents and most adults). In contrast to the dichotomized DSM-IV gender identity disorder diagnosis, the type and severity of gender dysphoria can be inferred from the number and type of indicators and from the severity measures. www.rolandwilliamsconsulting.com Subtypes and Specifiers • The subtyping on the basis of sexual orientation has been removed because the distinction is not considered clinically useful. A posttransition specifier has been added because many individuals, after transition, no longer meet criteria for gender dysphoria; however, they continue to undergo various treatments to facilitate life in the desired gender. • Although the concept of posttransition is modeled on the concept of full or partial remission, the term remission has implications in terms of symptom reduction that do not apply directly to gender dysphoria. www.rolandwilliamsconsulting.com Disruptive, Impulse-Control, and Conduct Disorders • The chapter on disruptive, impulse-control, and conduct disorders is new to DSM-5. It brings together disorders that were previously included in the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” (i.e., oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified, now categorized as other specified and unspecified disruptive, impulse-control, and conduct disorders) and the chapter “ImpulseControl Disorders Not Otherwise Specified” (i.e., intermittent explosive disorder, pyromania, and kleptomania). www.rolandwilliamsconsulting.com Disruptive, Impulse-Control, and Conduct Disorders (Cont.) • These disorders are all characterized by problems in emotional and behavioral self-control. Because of its close association with conduct disorder, antisocial personality disorder has dual listing in this chapter and in the chapter on personality disorders. Of note, ADHD is frequently comorbid with the disorders in this chapter but is listed with the neurodevelopmental disorders. www.rolandwilliamsconsulting.com Oppositional Defiant Disorder • Four refinements have been made to the criteria for oppositional defiant disorder. • First, symptoms are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. This change highlights that the disorder reflects both emotional and behavioral symptomatology. • Second, the exclusion criterion for conduct disorder has been removed. www.rolandwilliamsconsulting.com Oppositional Defiant Disorder (Cont.) • Third, given that many behaviors associated with symptoms of oppositional defiant disorder occur commonly in normally developing children and adolescents, a note has been added to the criteria to provide guidance on the frequency typically needed for a behavior to be considered symptomatic of the disorder. • Fourth, a severity rating has been added to the criteria to reflect research showing that the degree of pervasiveness of symptoms across settings is an important indicator of severity. www.rolandwilliamsconsulting.com Conduct Disorder • The criteria for conduct disorder are largely unchanged from DSM-IV. A descriptive features specifier has been added for individuals who meet full criteria for the disorder but also present with limited pro-social emotions. This specifier applies to those with conduct disorder who show a callous and unemotional interpersonal style across multiple settings and relationships. The specifier is based on research showing that individuals with conduct disorder who meet criteria for the specifier tend to have a relatively more severe form of the disorder and a different treatment response. www.rolandwilliamsconsulting.com Intermittent Explosive Disorder • The primary change in DSM-5 intermittent explosive disorder is the type of aggressive outbursts that should be considered: physical aggression was required in DSM-IV, whereas verbal aggression and non- destructive/noninjurious physical aggression also meet criteria in DSM-5. • DSM-5 also provides more specific criteria defining frequency needed to meet criteria and specifies that the aggressive outbursts are impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences. www.rolandwilliamsconsulting.com Intermittent Explosive Disorder (Cont.) • Furthermore, because of the paucity of research on this disorder in young children and the potential difficulty of distinguishing these outbursts from normal temper tantrums in young children, a minimum age of 6 years (or equivalent developmental level) is now required. • Finally, especially for youth, the relationship of this disorder to other disorders (e.g., ADHD, disruptive mood dysregulation disorder) has been further clarified. www.rolandwilliamsconsulting.com Substance-Related and Addictive Disorders Gambling Disorder • An important departure from past diagnostic manuals is that the substance-related disorders chapter has been expanded to include gambling disorder. This change reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance use disorders to a certain extent. www.rolandwilliamsconsulting.com Personality Disorders • The criteria for personality disorders in Section II of DSM-5 have not changed from those in DSM-IV. An alternative approach to the diagnosis of personality disorders was developed for DSM5 for further study and can be found in Section III. www.rolandwilliamsconsulting.com Paraphilic Disorders Specifiers • An overarching change from DSM-IV is the addition of the course specifiers “in a controlled environment” and “in remission” to the diagnostic criteria sets for all the paraphilic disorders. • These specifiers are added to indicate important changes in an individual’s status. There is no expert consensus about whether a long-standing paraphilia can entirely remit, but there is less argument that consequent psychological distress, psychosocial impairment, or the propensity to do harm to others can be reduced to acceptable levels. Therefore, the www.rolandwilliamsconsulting.com Paraphilic Disorders Specifiers (Cont.) specifier has been added to indicate remission from a paraphilic disorder. • The specifier is silent with regard to changes in the presence of the paraphilic interest per se. The other course specifier, “in a controlled environment,” is included because the propensity of an individual to act on paraphilic urges may be more difficult to assess objectively when the individual has no opportunity to act on such urges. www.rolandwilliamsconsulting.com Also Eliminated – Somatization Disorder (gone) – Amnestic Disorders (amnesia now a feature of neurocognitive disorders) – Dissociative Fugue (now a subtype of dissociative amnesia) – Pain Disorder (gone) – Hypochondriasis (cases now divided between Somatic Symptom Disorder and Illness Anxiety Disorder depending on severity of physical symptoms) – Asperger’s Disorder (may now be diagnosed as ASD) www.rolandwilliamsconsulting.com Also Eliminated (Cont.) – Childhood Disintegrative Disorder (may now be diagnosed as ASD) – Pervasive Developmental Disorder NOS (may now be diagnosed as ASD) – Vaginismus and Dyspareunia (now GenitoPelvic Pain/Penetration Disorder) – Gender Identity Disorder (now Gender Dysphoria) – Sexual Aversion Disorder (dropped, most cases reclassifiable as specific phobia) – Substance Dependence/Abuse Disorders, (now SUD with specifiers) www.rolandwilliamsconsulting.com Notable Mentions • The proliferation of medical marijuana has led to a clinical diagnosis of “cannabis withdrawal,” for example. • With the significant increase in caffeine consumption via coffee shops and energy drinks there is the clinical diagnosis of caffeine withdrawal www.rolandwilliamsconsulting.com Notable Mentions • Removal of bereavement exclusion: the exclusion criterion in DSM-IV applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one has been removed and replaced by several notes within the text delineating the differences between grief and depression. This reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one. www.rolandwilliamsconsulting.com Notable Mentions • Personality disorders: DSM-5 will maintain the categorical model and criteria for the 10 personality disorders included in DSM-IV and will include the new trait-specific methodology in a separate area of Section 3 to encourage further study how this could be used to diagnose personality disorders in clinical practice. www.rolandwilliamsconsulting.com Notable Mentions • Disruptive mood dysregulation disorder will be included in DSM-5 to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year. The diagnosis is intended to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children. www.rolandwilliamsconsulting.com Notable Mentions • Autism spectrum disorder: The criteria will incorporate several diagnoses from DSM-IV including autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified), into the diagnosis of autism spectrum disorder for DSM-5 to help more accurately and consistently diagnose children with autism. www.rolandwilliamsconsulting.com Conditions for Further Study • Proposed criterion sets have been described for the following conditions in which further research is encouraged: – – – – – Attenuated Psychosis Syndrome Depressive episodes with short duration hypomania Persistent complex bereavement disorder Internet gaming disorder Neurobehavioral disorder associated with prenatal alcohol exposure – Suicidal behavior disorder – Non-suicidal self injury www.rolandwilliamsconsulting.com Combined Language Disorder (Expressive Language Disorder & Mixed Receptive Expressive Language Disorder) Autism Spectrum Disorder (Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder, Rhett's disorder Pervasive Developmental Disorder-NOS) www.rolandwilliamsconsulting.com Combined • Specific Learning Disorder (Reading Disorder, Math Disorder, Disorder of Written Expression) • Delusional Disorder (Shared Psychotic Disorder, Delusional Disorder) www.rolandwilliamsconsulting.com Combined • Panic Disorder (Panic Disorder Without Agoraphobia Panic Disorder With Agoraphobia) • Dissociative Amnesia (Dissociative Fugue Dissociative Amnesia) www.rolandwilliamsconsulting.com Combined • Somatic Symptom Disorder (Somatization Disorder Undifferentiated Somatoform Disorder Pain Disorder) • Insomnia Disorder (Primary Insomnia Insomnia Related to Another Mental Disorder) www.rolandwilliamsconsulting.com Combined • Hypersomnolence Disorder (Primary Hypersomnia Hypersomnia Related to Another Mental Disorder) • Non-Rapid Eye Movement Sleep Arousal Disorders (Sleepwalking Disorder Sleep Terror Disorder) www.rolandwilliamsconsulting.com Combined • Genito‐Pelvic Pain/Penetration Disorder (Vaginismus Dyspareunia) • Alcohol Use Disorder (Alcohol Abuse Alcohol Dependence) • Cannabis Use Disorder (Cannabis Abuse Cannabis Dependence) www.rolandwilliamsconsulting.com Combined • Phencyclidine Use Disorder (Phencyclidine Abuse Phencyclidine Dependence) • Other Hallucinogen Use Disorder (Hallucinogen Abuse Hallucinogen Dependence) • Inhalant Use Disorder (Inhalant Abuse Inhalant Dependence) www.rolandwilliamsconsulting.com Combined • Opioid Use Disorder (Opioid Abuse Opioid Dependence) • Sedative, Hypnotic, or Anxiolytic Use Disorder (Sedative, Hypnotic Anxiolytic Abuse Sedative, Hypnotic, or Anxiolytic Dependence) • Stimulant Use Disorder (Amphetamine Abuse Amphetamine Dependence; Cocaine Abuse Cocaine Dependence) www.rolandwilliamsconsulting.com Combined • Stimulant Intoxication (Amphetamine Intoxication Cocaine Intoxication) • Stimulant Withdrawal (Amphetamine Withdrawal Cocaine Withdrawal) • Substance/Medication-Induced Disorders (aggregated categories: Mood , Anxiety ,and Neurocognitive ) www.rolandwilliamsconsulting.com • NOS DSM IV = 41 • Other/Unspecified DSM-5 =65 (To match ICD-10) www.rolandwilliamsconsulting.com 15 New Diagnosis www.rolandwilliamsconsulting.com Social (Pragmatic) Communication Disorder • With this addition to the manual, psychiatrists can now more precisely diagnose speech and written language problems that are unrelated to autism or diminished cognitive ability, according to an American Psychiatric Association fact sheet about the disorder. Indeed, while symptoms of this disorder, which must date back to childhood, include “inappropriate responses in conversation” and www.rolandwilliamsconsulting.com Social (Pragmatic) Communication Disorder (Cont.) difficulty communicating, the diagnosis can only be made after autism spectrum disorders have been ruled out, according to the APA. These problems often hamper people’s social lives, academic careers and job performance, and the diagnosis, known as SCD for short, is intended to bring their issues “out of the shadows” and help them get appropriate treatment, according to the fact sheet. www.rolandwilliamsconsulting.com Disruptive Mood Dysregulation Disorder • While this diagnosis, limited to children under 18, could be interpreted by some parents as applicable "anytime you have a temper tantrum,” says McHugh, the tendency to dismiss kids’ outbursts often leads to misdiagnoses, at the expense of the children and their families, when the disorder goes untreated. The new diagnosis is designed to help families and children who “have never been successfully treated www.rolandwilliamsconsulting.com Disruptive Mood Dysregulation Disorder (Cont.) for extreme, explosive rages,” says David Kupfer, chairman of the DSM-5 task force and a professor of psychiatry at the University of Pittsburgh “Too many severely impaired children like this have fallen through the cracks because they suffer from a disorder that had not yet been defined.” www.rolandwilliamsconsulting.com Premenstrual Dysphoric Disorder • In classifying symptoms preceding women’s monthly cycle as a mental disorder, the DSM-5 has provoked outrage from those who worry that people will use the official illness to discriminate against women, like they have with PMS, the milder sister to PMDD. (The new disorder was mentioned in an appendix of the DSM-4 as a condition needing further study.) Other critics worry that the diagnosis could allow people to use common and mundane problems like minor menstrual cramps as medical excuses. But www.rolandwilliamsconsulting.com Premenstrual Dysphoric Disorder (Cont.) researchers for the DSM-5 found justification for listing the disorder, which affects 2% to 5% of premenopausal women, according to an article published in the American Journal of Psychiatry in May 2012. Symptoms include depression, “feelings of hopelessness” and bloating sensations at specific times during a woman’s menstrual cycle—severe enough to interfere with people’s ability to function at work or school. www.rolandwilliamsconsulting.com Hoarding Disorder • The television remedy for hoarding on shows such as A&E”s “Hoarders” usually involves a heavy-duty house cleaning by a team of professionals and many garbage bags or dumpsters. But thanks to the DSM5’s inclusion of “hoarding disorder” as a standalone diagnosis, doctors may be able to treat the condition with a pill. There is now adequate evidence to confirm the “diagnostic validity” of hoarding, which is characterized by “persistent difficulty discarding or parting with possessions due to a perceived need to save the items and distress associated with discarding them,” according to an APA guide to the changes in DSM-5. The newly added diagnosis is listed under www.rolandwilliamsconsulting.com Hoarding Disorder (Cont.) obsessive-compulsive disorders, though the APA admits that that there is not enough data to say whether hoarding is truly related to OCD or another mental illness. Still, hoarding may have underlying neurobiological causes, which may mean that it can be treated with medication. Indeed, some DSM critics believe the creation of hoarding disorder could be driven by pharmaceutical interests: “All they are saying is, we think hoarding should be made an illness that we can get paid for,” says McHugh, who believes psychiatrists should investigate the root causes of the hoarding in order to formulate a treatment plan that could involve behavior therapy instead of drugs. www.rolandwilliamsconsulting.com Caffeine Withdrawal • People who are grumpy before they’ve had their morning coffee may welcome caffeine withdrawal to the DSM-5 as a legitimate mental affliction. A controversial addition, the new diagnosis directly reflects our increasing dependence on caffeine, from the proliferation of Starbucks outlets to the growing array of non-coffee energy drinks and caffeineinjected alcoholic beverages: “Caffeine is invading our society more and more,” Alan Budney, a psychiatrist who helped develop the DSM-5, said at a 2011 industry symposium, according to reports. (Caffeine withdrawal was included in an appendix of the DSM-4 as a condition needing further study.) www.rolandwilliamsconsulting.com Caffeine Withdrawal (Cont.) But some psychiatrists worry that caffeine withdrawal may be an easy way to clinically label symptoms such as headaches, sleep disturbances and moodiness, at the cost of missing a serious pathological disorder. “The real problem for [psychiatrists] is, Will they be able to have time with the patient to distinguish between caffeine withdrawal and the kind of uneasiness and headaches that come from an encounter they might have had in life experiences?” says McHugh. www.rolandwilliamsconsulting.com Cannabis Withdrawal • Included in the DSM-5 in tandem with caffeine withdrawal, experts say the increasing prevalence of another substance besides coffee merited the new “cannabis withdrawal” diagnosis. As marijuana has become available to buy legally and for medical purposes in more states, psychiatrists have also noted withdrawal symptoms in people who frequently smoke marijuana and then quit. A study of 384 lifetime cannabis smokers, conducted in partnership with the National Institutes of Health and published in 2012, found that more than 40% of participants met the withdrawal criteria in the www.rolandwilliamsconsulting.com Cannabis Withdrawal (Cont.) DSM-5. Only in recent years have medical experts recognized that marijuana can be associated with drug withdrawal, so the DSM until now excluded the condition “due to debate about the clinical significance of the cannabis withdrawal syndrome,” according to researchers who helped develop the DSM-5. But the researchers identified several cannabis withdrawal symptoms that interfered with people’s ability to function normally, including loss of appetite, nightmares and “imagining being stoned (cravings).” www.rolandwilliamsconsulting.com Excoriation (Skin-Picking) Disorder • Under the awning of obsessive-compulsive disorders, this condition is characterized by chronic picking and scratching of the skin that can cause wounds and scabs, and diagnosed when the behaviors are not associated with another disorder. The disorder can be triggered by other skin irregularities like acne or bug bites, according to a 2011 paper from the University of Cincinnati College of Medicine that proposed including the disorder in the DSM. The condition can be www.rolandwilliamsconsulting.com Excoriation (Skin-Picking) Disorder (Cont.) associated with other disorders involving compulsive eating, buying and stealing, the researchers wrote. The DSM-5 added “excoriation disorder” in light of “strong evidence for its diagnostic validity and clinical utility,” according to the APA, and the problem is often treated with antidepressants, anti-anxiety drugs or other medications. www.rolandwilliamsconsulting.com Binge Eating Disorder • In the context of an increasing national obesity epidemic, psychiatrists made a statement by adding this diagnosis: “This change is intended to increase awareness of the substantial differences between binge eating disorder and the common phenomenon of overeating,” according to an APA fact sheet. With nearly 70% of Americans overweight or obese according to the Centers for Disease Control and Prevention, the manual distinguishes between problems with weight versus mental health, noting that “while overeating is a challenge for many Americans, recurrent binge eating is much less common, far more severe, and is associated with significant www.rolandwilliamsconsulting.com Binge Eating Disorder (Cont.) physical and psychological problems.” (The new disorder was included in an appendix of the DSM-4 as a condition needing further study.) People with this disorder frequently eat a large amount of food very quickly, even when they’re not hungry, and often when they are alone to avoid embarrassment, according to the APA. • Binge Eating Disorder is not to be confused with bulimia nervosa, which involves, in addition to binge eating, purging behaviors like vomiting. The revised manual stipulates that binging or purging just once a week qualifies for the diagnosis, rather than biweekly. www.rolandwilliamsconsulting.com Rapid Eye Movement Sleep Behavior Disorder • In his 2012 autobiographical film “Sleepwalk With Me,” the comedian Mike Birbiglia brought attention to this disorder, often called REM behavior disorder, which causes him to act out his dreams in real life. The phenomenon became particularly problematic for Birbiglia after he jumped through a second-story hotel window in a dream about escaping a missile, landing him in the emergency room with glass wounds. (The disorder differs from typical sleepwalking in that people with REM behavior disorder usually remember what they were doing in the dream.) www.rolandwilliamsconsulting.com Rapid Eye Movement Sleep Behavior Disorder (Cont.) • Now, the disorder, which the DSM previously included ambiguously under parasomnia, gains official recognition by the clinical psychiatry community in addition to Hollywood. The diagnosis, which the APA says is fully supported by research evidence, is often preceded by dream enactment episodes resulting in injury to the person or the partner with whom they share a bed. In treating the condition, doctors may recommend removing sharp and dangerous objects from the bedroom and cushioning the area around the bed. www.rolandwilliamsconsulting.com Restless Legs Syndrome • Given its solid neurological basis, some psychiatrists, including McHugh at Johns Hopkins, wonder why the disease, characterized by uncomfortable urges to move the legs when lying down, wasn’t given full DSM status long ago. But scientific and genetic research have advanced the medical knowledge of the disorder, which is now also identified as Willis-Ekbom disease, since the previous version of the DSM. www.rolandwilliamsconsulting.com Restless Legs Syndrome (Cont.) While about 2% to 3% of adults are severely affected by it, up to 10% of people in the U.S. may have it, according to the Willis-Ekbom Disease Foundation (formerly the Restless Legs Syndrome Foundation). By giving official diagnostic status to the disorder, which was previously classified as a “not otherwise specified” form of dyssomnia, the DSM-5 may promote more precise diagnoses and treatment of restless legs syndrome, psychiatrists say. www.rolandwilliamsconsulting.com Major Neurocognitive Disorder and Mild Neurocognitive Disorder • With these additions, the DSM-5 expands the category of dementia, the memory and cognitive impairment increasingly afflicting the aged: About 14% of Americans age 71 and older have dementia, and the number is expected to double by 2050 because of the wave of baby boomers hitting 65, according to a new report by the Alzheimer’s Association. The new diagnoses also allow psychiatrists to distinguish between different levels of dementia’s severity. “The psychiatry group is waking up to what the neurologists have been classifying and recognizing for a long time,” says McHugh, the Johns Hopkins psychiatrist. Still, the “threshold” between mild and major neurocognitive disorder “is inherently arbitrary,” the APA admits. (The newly added mild version was mentioned in an appendix of the DSM-4 for conditions needing further study.) But by differentiating between them, the DSM-5 could pave the way for the diagnosis and treatment of “less disabling” cognitive impairment that could be nonetheless problematic for people and their families, according to the APA. www.rolandwilliamsconsulting.com Disinhibited Social Engagement Disorder • This disorder can often be mistaken for ADHD, attention deficit/hyperactivity disorder, but the DSM-5 may reduce the confusion by adding it to the list of official diagnoses. While children with disinhibited social engagement disorder can be inattentive and impulsive, the disorder may stem from inadequate caregiving and neglect. This disorder was previously grouped with reactive attachment disorder, children who have it may not actually lack attachments, according to the APA. The separate classification allows for different clinical interventions and treatment plans. www.rolandwilliamsconsulting.com Central Sleep Apnea and Sleep-Related Hypoventilation • The DSM has long struggled to classify sleep disorders, especially those that related to problems with breathing while sleeping. The growing share of the population with diabetes and cardiovascular disease, which studies have shown to increase the risk of central sleep apnea and other breathing-related sleep disorders, may make it more important to precisely identify the problems. But the www.rolandwilliamsconsulting.com Central Sleep Apnea and Sleep-Related Hypoventilation (Cont.) medical community has also learned much more about these conditions since the previous DSM edition, enabling the new diagnoses: “This change reflects the growing understanding of pathophysiology in the genesis of these disorders and, furthermore, has relevance to treatment planning,” according to the APA’s guide to the changes in the DSM-5. www.rolandwilliamsconsulting.com Other Conditions that may be a Focus of Clinical Attention Commonly referred to as “the V codes” Child Maltreatment and Neglect Adult Maltreatment and Neglect Relational Problems Educational Problems Occupational Problems Housing Problems Economic Problems www.rolandwilliamsconsulting.com Z Codes in ICD 10 • Z00-Z13 Persons encountering health services for examinations • Z14-Z15 Genetic carrier and genetic susceptibility to disease • Z16-Z16 Resistance to antimicrobial drugs • Z17-Z17 Estrogen receptor status • Z18-Z18 Retained foreign body fragments • Z20-Z28 Persons with potential health hazards related to communicable diseases • Z30-Z39 Persons encountering health services in circumstances related to reproduction • Z40-Z53 Encounters for other specific health care www.rolandwilliamsconsulting.com Z Codes in ICD 10 (Cont.) • Z40-Z53 Encounters for other specific health care • Z55-Z65 Persons with potential health hazards related to socioeconomic and psychosocial circumstances • Z66-Z66 Do not resuscitate status • Z67-Z67 Blood type • Z68-Z68 Body mass index (BMI) • Z69-Z76 Persons encountering health services in other circumstances • Z77-Z99 Persons with potential health hazards related to family and personal history and certain conditions influencing health status www.rolandwilliamsconsulting.com Mental Health Issues Expanded www.rolandwilliamsconsulting.com No More Axis I-V • With the advent of the DSM-5 in 2013, the APA eliminated the longstanding multiaxial system for mental disorders. • Previously, the DSM-IV organized each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability: • Axis I = clinical psychiatric disorders (ex. depression, schizophrenia) • Axis II = Personality disorders (ex. bipolar, conduct disorder, borderline) www.rolandwilliamsconsulting.com No More Axis I-V (Cont.) • Axis III= General medical conditions (ex. Diabetes, Hypertension, Stroke) • Axis IV= Psychosocial and environmental problems (ex. Death of loved one, Divorce, Jobloss, Bankruptcy) • Axis V= Global assessment function (ex. scale of 1-100) 1 is low level of function and 100 being superior function. www.rolandwilliamsconsulting.com This is Not New • What many professionals do not realize is that this new coding system presented in DSM-5 is not completely new. Both DSM-IV and DSM-IV-TR offered two ways of coding: the multiaxial system and simply listing the diagnosis, similar to what is now required in DSM-5. In DSM-5, listing the mental disorders and the relevant medical conditions are combined, thereby avoiding the artificial distinction suggested by listing them on separate axes. The diagnostic assessment starts with identifying either the principal or the provisional diagnosis www.rolandwilliamsconsulting.com Making and Reporting Diagnosis • • • • How to order the diagnoses; The use of subtypes, specifiers, and severity; Making a provisional diagnosis Use of “other specified” or “unspecified” disorders. www.rolandwilliamsconsulting.com The Diagnostic Impression • With the elimination of Axis I, II, and III that were used in earlier versions of the DSM, the replacement requires all three of these axis to be combined by simply listing the relevant diagnosis as either the principal diagnosis or in some cases adding a provisional diagnosis. Listing the principal diagnosis eliminates the need for Axes I and II. www.rolandwilliamsconsulting.com The Diagnostic Impression (Cont.) • Also, combining any medical conditions and listing them with the principal diagnosis eliminates the need for Axis III, which included any related medical conditions. Eliminating Axis I, II, and III helped to clarify that Axis II specifically was never meant to be a separate set of diagnoses, nor was it the intent of the multiaxial system to separate medical and mental health conditions in assessment or treatment. www.rolandwilliamsconsulting.com The Diagnostic Assessment • Biomedical Factors – medical conditions, perceived overall health status, maintenance and continued health and wellness. • Psychological Factors – Mental functioning, cognitive functioning, assessment of danger to self/others • Social and Environmental Factors – social societal help seeking, occupational participation, social support, family support, ethnic or religious affiliation www.rolandwilliamsconsulting.com Ordering the Diagnosis • Individuals will often have more than one diagnosis, so it is important to consider their ordering. The first diagnosis is called the principal diagnosis. In an inpatient setting, this would be the most salient factor that resulted in the admission. • In an outpatient environment, this would be the reason for the visit or the main focus of treatment. The secondary and tertiary diagnosis should be listed in order of need for clinical attention. • If a mental health diagnosis is due to a general medical condition, the ICD coding rules require listing the medical condition first, followed by the psychiatric diagnosis, due to the general medical condition. www.rolandwilliamsconsulting.com Principal and Provisional Diagnosis • The Practitioner can Use Either of These Terms When the Diagnostic Criteria are Met: – Principal diagnosis: • Symptoms related to the disorder are the primary reason for the diagnostic assessment and often denotes the request for treatment/ intervention. When the principal diagnosis is listed according to DSM-5, it is listed first, but there can be more than one diagnosis as long as each meets the criteria. If there is more than one diagnosis, they should be listed in terms of severity. www.rolandwilliamsconsulting.com – Provisional diagnosis: • Many times when a client is interviewed and the initial diagnostic assessment is completed, a principal diagnosis cannot be determined. In these cases, a provisional diagnosis can be assigned. A provisional diagnosis (often referred to in the field as the best-educated clinical guess) is based on clinical judgment and reflects a strong suspicion that an individual suffers from a type of disorder that, for some reason or another, either the actual criteria are not met or the practitioner does not have information available to make a more informed diagnostic. www.rolandwilliamsconsulting.com Subtypes and Specifiers • Subtypes “Specify whether” – Mutually exclusive and exhaustive – Homogeneous subgroupings within a diagnosis • Specifiers: – – – – – course, ( in partial remission) severity, ( mild, moderate, severe) frequency, ( two times per week) duration, ( minimum duration of six months) descriptive features, ( with poor insight) www.rolandwilliamsconsulting.com Subtypes • Subtypes for a diagnosis can be used to help communicate greater clarity. They can be identified in the DSM-5 by the instruction “Specify whether” and represent mutually exclusive groupings of symptoms (i.e., the clinician can only pick one). For example, the ADHD has three different subtypes to choose from: • predominantly inattentive, • predominantly hyperactive/impulsive, or • a combined presentation. www.rolandwilliamsconsulting.com Specifiers • Specifiers, on the other hand, are not mutually exclusive, so more than one can be used. The clinician chooses which specifiers apply, if any, and they are listed in the manual as “Specify if.” Some diagnoses will offer an opportunity to rate the severity of the symptoms. These are identified in the DSM as “Specify current severity.” Referencing the ADHD diagnosis, there are three options of severity: mild, moderate, or severe. • Severity levels of autism spectrum disorder”, which classifies autism on three levels of severity “requiring support,” “requiring substantial support,” and “requiring very substantial support.” www.rolandwilliamsconsulting.com • Subtype: “Specify whether”—only choose one, • Specifier: “Specify if”—pick as many as apply, and • Severity: “Specify current severity”—choose the most accurate level of symptomology. www.rolandwilliamsconsulting.com Informal Diagnostic Labels • Rule-out—the client meets many of the symptoms but not enough to make a diagnosis at this time; it should be considered further (e.g., rule-out major depressive disorder). • Traits—this person does not meet criteria, however, he or she presents with many of the features of the diagnosis (e.g., borderline traits or cluster B traits). www.rolandwilliamsconsulting.com Informal Diagnostic Labels (Cont.) • By history—previous records (another provider or hospital) indicate this diagnosis; records can be inaccurate or outdated (e.g., alcohol dependence by history). • By self-report—the client claims this as a diagnosis; it is currently unsubstantiated; these can be inaccurate (e.g., bipolar by selfreport). www.rolandwilliamsconsulting.com Other/Unspecified Disorders • The DSM-IV had a diagnosis of not otherwise specified (NOS) to capture symptomology that did not fit well into a structured category. In lieu of the NOS diagnosis, the DSM-5 offers two options when these situations arise. The other specified and unspecified disorders should be used when a provider believes an individual’s impairment to functioning or distress is clinically significant, however, it does not meet the specific diagnostic criteria in that category. • The “other specified” should be used when the clinician wants to communicate specifically why the criteria do not fit. www.rolandwilliamsconsulting.com Other/Unspecified Disorders (Cont.) • The “unspecified disorder” should be used when he or she does not wish, or is unable to, communicate specifics. • For example, if someone appeared to have significant panic attacks but only had three of the four required criteria, the diagnosis could be “Other Specified Panic Disorder—due to insufficient symptoms.” Otherwise, the clinician would report “Unspecified Panic Disorder.” www.rolandwilliamsconsulting.com WHODAS 2.0 Replaces GAF • World Health Organization Disability Assessment Schedule • This 36-item, self-administered questionnaire assesses a client’s functioning in six domains: understanding and communicating, getting around, self-care, getting along with people, life activities, and participation in society www.rolandwilliamsconsulting.com WHODAS 2.0 • Generic assessment instrument for health and disability • Used across all diseases, including mental, neurological and addictive disorders • short, simple and easy to administer ( 5 to 20 minutes) • applicable in both clinical and general populations settings • a tool to produce standardized disability levels and profiles • applicable across cultures, and all adult populations • directly linked at the level of concepts to the international classification of functioning, disability and health, (ICF) www.rolandwilliamsconsulting.com • The WHODAS 2.0 looks at functioning across six specific domains: • Functioning is not assumed to be static, rather it is expected to change, and therefore it can be measured. The WHODAS will not tell you “why” someone is having problems functioning, but it will tell you which areas, if any, pose problems for the client. www.rolandwilliamsconsulting.com WHODAS Covers 6 Domains of Functioning • Cognition – understanding and communicating • Mobility – moving and getting around • Self-care – hygiene, dressing, eating and staying alone • Getting along – interacting with other people • Life activities – domestic responsibilities, leisure, work and school • Participation – joining in community activities www.rolandwilliamsconsulting.com • Cognition comprises questions about communication and thinking activities. Specific areas assessed include concentrating, remembering, problem solving, learning and communication. • Mobility questions explore the client’s ability to stand, move around inside the home, get out of the home and walk a long distance. The latter uses the term “kilometer”, since the rest of the world uses the metric system. • Self-care looks at the client’s ability to manage bathing, dressing, eating, and staying alone. www.rolandwilliamsconsulting.com Treatment Planning using the WHODAS 2.0 • Writing a treatment plan using WHODAS 2.0 results is fairly straightforward. You can incorporate the results domain by domain, and/ or you can summarize the results giving a general disability score. This is a far more psychometrically sound method of evaluating global assessment of functioning than the GAF. www.rolandwilliamsconsulting.com • These first three areas are typically considered by most clinicians in evaluating how well a client functions. The addition of three other domains makes the WHODAS especially useful in assessing individuals with behavioral health issues. www.rolandwilliamsconsulting.com • Getting along assesses the client’s ability to relate to other people, and explores difficulties that might be encountered with this due to a health condition. This may include intimates (e.g. spouse or partner, family members or close friends), or strangers. • Life activities includes activities that people do on most days such as household tasks, and attendance at work and school. The questions explore the client’s difficulty in engaging in these activities on a day-to-day basis. Definitions for what each of these activities include are provided on a flashcard. www.rolandwilliamsconsulting.com • Participation asks clients to consider how other people and the world around them make it difficult for them to take part in society. The focus of these questions is on how the environment (external factors) as opposed to their own difficulties (internal factors) impacts their ability to function. This domain also includes questions about the impact of their health condition. “Here, they are reporting not on their activity limitations but rather on the restrictions they experience from people, laws and other features of the world in which they find themselves. www.rolandwilliamsconsulting.com PLEASE"NOTE:"When"scoring"WHODAS,"the"following"numbers"are"assigned"to"responses: 0"="No"Difficulty 1"="Mild"Difficulty 2"="Moderate"Difficulty 3"="Severe"Difficulty 4"="Extreme"Difficulty"or"Cannot"Do Score Understanding and communicating D1.1 Concentrating on doing something for ten minutes? 0 D1.2 Remembering to do important things? 0 D1.3 Analysing and finding solutions to problems in day-to-day life? 0 D1.4 Learning a new task, for example, learning how to get to a new place? 0 D1.5 Generally understanding what people say? 0 D1.6 Starting and maintaining a conversation? 0 Getting around D2.1 Standing for long periods such as 30 minutes? 0 D2.2 Standing up from sitting down? 0 D2.3 Moving around inside your home? 0 D2.4 Getting out of your home? 0 D2.5 Walking a long distance such as a kilometre [or equivalent]? 0 Self-care D3.1 Washing your whole body? 0 D3.2 Getting dressed? 0 D3.3 Eating? 0 D3.4 Staying by yourself for a few days? 0 Getting along with people D4.1 Dealing with people you do not know? 0 D4.2 Maintaining a friendship? 0 D4.3 Getting along with people who are close to you? 0 D4.4 Making new friends? 0 www.rolandwilliamsconsulting.com WHODAS Client Results Understanding and Communicatin g Getting Around Self-Care Getting Along w/Others Extreme 5.00 Severe 4.00 Moderate 3.00 Mild 2.00 None 1.00 Domain Averages www.rolandwilliamsconsulting.com Life Activities, School/Work Life Activities, Household Participation in Society Cultural Formulation • One of the improved elements of the DSM-5 is the updating of the Cultural Formulation Interview. In addition to acknowledging the impact culture has on behavior, this edition of the DSM calls for systematic assessment of the cultural identity of the individual, how that individual and his/ her family conceptualizes distress, the key stressors experienced, the cultural features of vulnerability and resilience for the individual, how culture informs or interferes with the therapeutic relationship, and an overall cultural assessment (APA, 2013). www.rolandwilliamsconsulting.com Identifying Cultural Aspects • Practitioners Need to Help the Client: – Identify and discuss the impact of current life circumstances that can affect daily functioning. – Self-report race and ethnicity, respecting the selfidentification of multiracial individuals, in a manner consistent with how the client thinks of himself or herself. – Identify and acknowledge any psychological problems stemming from adaptation to a new environment. www.rolandwilliamsconsulting.com Identifying Cultural Aspects (Cont.) – Identify and explore the degree to which the client has positive and supportive peer relationships contributing to or reducing feelings of isolation and facilitating transition. – Identify social variables for which race or ethnicity serves as a proxy (e.g., social status, neighborhood context, perceived discrimination, social cohesion, social capital, social support, types of occupation, employment, emotional well-being, and perceived life opportunities. – Identify willingness to explore new coping skills to help negotiate his or her environment. www.rolandwilliamsconsulting.com Cultural Formulation Interview • The Cultural Formulation Interview (CFI) is a brief (16question), semi-structured interview used to elicit the individual’s experience, as well as inviting informants from that individual’s social and cultural networks to contribute their observations. Four areas are explored using person-centered and problem-centered language. A script is provided to guide the interviewer in eliciting the client’s cultural definition of the problem, his or her cultural perceptions as to the cause and context of the problem, as well as what support exists, what cultural factors affect the client’s self-coping abilities and past help-seeking strategies, and what problems exist in terms of current helpwww.rolandwilliamsconsulting.com seeking. The CFI • Semi-structured interviews • No right or wrong answers • Gather demographic information first as it can help to select questions • Can use entire instrument or just what is needed to supplement the interview • Supplementary modules are available online for children and adolescents, elderly individuals, immigrants, and www.rolandwilliamsconsulting.com CFI Examines Four Domains • Cultural Definition of the Problem • Cultural Perceptions Cause, Contexts, and Support • Cultural Factors Affecting Self Coping, and Pass Help Seeking • Cultural Factors Affecting Current Help Seeking www.rolandwilliamsconsulting.com Selected Cultural Concepts of Distress • Ataque de nervios (anxiety often related to a trauma [Latino]) • Nervios (similar to ataque de nervios but chronic in nature [Latino]) Dhat syndrome (discharge and impotence [Southeast Asia]) • Khyai cap (windlike attacks [Cambodian]) • Kufungisisa (similar to brain fog [Nigeria] anxiety attacks, brain-tiredness [Zimbabwean]) • Maladi moun (humanly caused illness, sent sickness, jealous [Haitian]) www.rolandwilliamsconsulting.com Selected Cultural Concepts of Distress (Cont.) • Shenjing shuairuo (stress related, imbalances [Chinese]) • Susto (stress-related frightening traumatic event [Latino, Mexico, Central or South America) • Taijin kyofusho (unrealistic fears, body odor [Japan]) • Source: Abbreviated definitions summarized from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013 by the American Psychiatric Association. www.rolandwilliamsconsulting.com Supplemental Modules • • • • • • • • • • • • Explanatory Model Level of Functioning Social Network Psychosocial Stressors Spirituality, Religion And Moral Traditions Cultural Identity Coping and Help Seeking Client Patient Relationship School-Age Children and Adolescents Older Adults Immigrants and Refugees Caregivers www.rolandwilliamsconsulting.com Assessment Measures • For further clinical evaluation and research, the APA is offering a number of “emerging measures” in Section III of DSM-5. These patient assessment measures were developed to be administered at the initial patient interview and to monitor treatment progress, thus serving to advance the use of initial symptomatic status and patient reported outcome (PRO) information, as well as the use of “anchored” severity assessment instruments. Instructions, scoring information, and interpretation guidelines are included. www.rolandwilliamsconsulting.com • These measures should be used to enhance clinical decision-making and not as the sole basis for making a clinical diagnosis. Further information on these measures can be found in DSM-5. www.rolandwilliamsconsulting.com Cross-Cutting • Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses. They are intended to help identify additional areas of inquiry that may guide treatment and prognosis. The cross-cutting measures have two levels: Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients, and Level 2 questions provide a more in-depth assessment of certain domains. www.rolandwilliamsconsulting.com Crosscutting of Symptoms • Acknowledging the diagnostic criteria, while documenting the crosscutting or overlapping symptoms, allows explication of the relationship between symptoms characteristic of more than one disorder to be documented without the creation or addition of a second disorder. • For example, how many times have you worked with a depressed client who did not have sleep difficulties that could be confused with the diagnosis of insomnia? www.rolandwilliamsconsulting.com Crosscutting of Symptoms (Cont.) Documenting with the dimensional assessment and taking into account the crosscutting of symptoms, while clearly noting those related to depression and disturbed sleep, can make a stronger diagnostic assessment while avoiding an unnecessary label indicative of a second diagnosis. • Cross Cutting of Symptoms Measurement Scale www.rolandwilliamsconsulting.com Disorder Specific Severity Measures • Severity measures are disorder-specific, corresponding closely to criteria that constitute the disorder definition. They may be administered to individuals who have received a diagnosis or who have a clinically significant syndrome that falls short of meeting full criteria. Some of the assessments are self-completed, whereas others require a clinician to complete. www.rolandwilliamsconsulting.com WHODAS 2.0 • The World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0) assesses a patient’s ability to perform activities in six areas: understanding and communicating; getting around; self-care; getting along with people; life activities (e.g., household, work/school); and participation in society. The scale is self- or informant-administered and corresponds to concepts contained in the WHO International Classification of Functioning, Disability and Health. www.rolandwilliamsconsulting.com Personality Inventories • The Personality Inventories for DSM-5 measure maladaptive personality traits in five domains: negative affect, detachment, antagonism, disinhibition, and psychoticism. For adults and children ages 11 and older, there are brief forms with 25 items and full versions with 220 items. www.rolandwilliamsconsulting.com Alternative Model for Diagnosing Personality Disorders • The DSM-5 alternative model suggests that two determinations must be met when diagnosing a personality disorder: level of impairment and evaluation of which personality traits are pathological in nature. Disturbances in “self” and “interpersonal functioning” are hallmarks of personality disorders. The alternative model suggests that these disturbances are best evaluated on a continuum, rather than on a dichotomous, “present/ not present” www.rolandwilliamsconsulting.com • “Self” is further divided into elements of identity and self-direction. The DSM-5 provides definitions of both these. “Identity” consists of the individual’s experience of self and other, including self-esteem and capacity for and ability to regulate emotions. “Self-direction” includes the ability to have and pursue life goals, to have internalized standards of behavior that are constructive and pro-social, and to be able to be self-reflective. www.rolandwilliamsconsulting.com • Interpersonal functioning is also divided, specifically identifying empathy and intimacy as measurable elements. “Empathy” is defined as having both comprehension and appreciation of the experiences and motivations of others, as well as understanding the effects of behavior on others. “Intimacy” consists of connection, closeness, and regard, as evidenced by depth and duration of the connection, desire and capacity for closeness, and mutuality reflected in interpersonal behavior. www.rolandwilliamsconsulting.com Levels of Pathology • Drawing from the Five-Factor Model (FFM) of personality, the DSM-5 alternative model identifies the following pathological personality traits: detachment, antagonism, disinhibition, and psychoticism. Within these domains they identify 25 specific trait facets shown in the table below. www.rolandwilliamsconsulting.com Negative Affectivity Detachment Antagonism Dis-inhibition Pscychoticism Emotional Lability Withdrawal Manipulative Responsibility Unusual Beliefs and Experiences Anxiousness Intimacy Avoidance Deceitfulness Impulsivity Eccentricity Separation Insecurity Anhedonia Grandiosity Distractivity Cognitive and Perceptual Dysregulation Depressivity Attention Seeking Risk-Taking Hostility Restricted Affectivity Callousness Rigid Perfectionism Perseveration Suspiciousness Hostility Submissiveness Suspiciousness Restricted Affectivity www.rolandwilliamsconsulting.com Psychotic Disorders • When preparing for the diagnostic assessment and the appropriate diagnosis, the practitioner must first be aware of the key features prevalent in the psychotic disorders that are used to constitute the diagnosis. Starting this process requires familiarity with applying the five primary characteristics of each of the following disorders: delusions, hallucinations, disorganized thinking and speech, grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms. www.rolandwilliamsconsulting.com Diagnostic Criteria • Diagnostic criteria for the specific personality disorders consists of seven items: • 1) moderate or greater impairment in personality functioning, • 2) identification of the specific personality traits that are pathologic, • 3) demonstration that the impairments are relatively inflexible and pervasive across a broad range of personal and social situations, • 4) these impairments and trait expression are “relatively stable” and have an onset at least at www.rolandwilliamsconsulting.com Diagnostic Criteria (Cont.) adolescence or early adulthood, • 5) these impairments and traits can’t be explained by something else (e.g., culture, circumstance, illness), • 6) these can’t be attributed to the physiological effects of a substance or medical condition (e.g., head trauma), and • 7) these are not better understood as “normal” for the developmental stage or sociocultural environment. www.rolandwilliamsconsulting.com Categorical vs Dimensional Approach • Whereas a categorical approach to diagnosis classifies a diagnosis as either present or absent, a dimensional approach to diagnosis entails using measures to evaluate the extent to which symptoms exist. Hence, the dimensional approach provides a continuum to evaluate symptoms, whereas a categorical system does not. www.rolandwilliamsconsulting.com Yes/No Categorical Approach • The Categorical Approach is the approach to classifying mental disorders involving assessment of whether an individual has a disorder on the basis of symptoms and characteristics that is described as typical of the disorder. This approach also uses 2 classification strategies DSM and ICD. The DSM names the disorders and describes them in specific terms. The ICD identifies symptoms that indicate the presence of a disorder. Categorical approaches are based on a number of underlying principles and assumptions including: www.rolandwilliamsconsulting.com Score Based Dimensional Approach • The Dimensional approach is the approach to classifying mental disorders that quantifies a person’s symptoms or other characteristics of interest and represents them with numerical values on one or more scales or continuums, rather than assigning them to a mental disorder category. • Diagnosis then becomes not a process of deciding the presence of a symptom or disorder but rather the degree to which a particular characteristic is present. Instead of making judgements, the dimensional approach asks the question “how much?” Lower scores equate to lower impairment and higher scores equate to higher impairment. www.rolandwilliamsconsulting.com The End to NOS • To be replaced with: – Other Specified Disorder • this category enables the clinician to identify presentations in which the symptoms are clinically significant, but did not meet the full criteria for disorder, and to state the specific reason why the diagnostic criteria for any given disorder has not been met. (When this diagnosis is used documenting the reason for selecting it is required.) www.rolandwilliamsconsulting.com The End to NOS (Cont.) – Unspecified Disorder • If the presentation is clinically significant and does not meet the full criteria for disorder,” and the clinician chooses not to specify the reason the criteria have not been met, (e.g. insufficient information, emergency room setting, etc. ), that “unspecified diagnosis” would be given. www.rolandwilliamsconsulting.com Basic Definitions • Neurodevelopmental: Examines diagnoses across the life span. Disorders most frequently diagnosed in childhood. • Neurocognitive: Disorders most frequently diagnosed in adulthood www.rolandwilliamsconsulting.com • The DSM-5 has 20 chapters that are dedicated to each category of disorders listed. At the beginning of each chapter is an overview of the disorders outlined in that particular chapter, listing what they are and what they have in common. • For example, in the chapter on schizophrenia spectrum and other psychotic disorders, key features that define all of the psychotic disorders in the chapter are outlined, highlighting what they share, with each listed and organized along a gradient of psychopathology. www.rolandwilliamsconsulting.com Presentation of Disorders • Diagnostic Features (outlines specific criteria) • Associated Features Supporting the Diagnosis (characteristics) • Prevalence (adults, males, females, etc.) • Development and Course (signs and how long it lasts) • Risk and Prognostic Factors (temperamental, environmental, genetic, and physiological) • Course Modifiers www.rolandwilliamsconsulting.com Presentation of Disorders (Cont.) • Culture-Related Diagnostic Issues • Gender-Related Diagnostic Issues • Diagnostic Markers (sleep history and a sleep diary) • Suicide Risk • Functional Consequences • Differential Diagnosis • Comorbidity www.rolandwilliamsconsulting.com Bipolar Disorders: Episodes and Specifies www.rolandwilliamsconsulting.com Bipolar and Related Disorders • The diagnostic assessment of an individual suffering from any type of bipolar disorder shows the presence of two primary symptoms: • a depressed mood and • an elevated mood. • Displaying both symptoms can confuse both families and practitioners. When clients report the symptoms of depression, it may lack clarity, www.rolandwilliamsconsulting.com Bipolar and Related Disorders (Cont.) and there may be problems in semantics related to defining what is experienced. When they experience a bipolar episode and the energy returns, optimism may rise, only to have it extinguished as the lift in mood becomes uncontrollable and destructive to the expected purpose. www.rolandwilliamsconsulting.com Manic episode: • Present mood is persistently elevated, irritable, and expansive, with severe mood disturbance, and leading to impaired functioning. There must be at least three of these symptoms: pressured speech, increased psychomotor agitation, flight of ideas, decreased need for sleep, increased involvement in goal-oriented activities, distractibility, and inflated self-esteem or grandiosity. There is also excessive involvement in pleasurable activities, which have the potential for high risk and negative consequences. The time frame for the episode is at least 1 week. If hospitalization to control or address behaviors occurs, the 1-week time frame is not needed. www.rolandwilliamsconsulting.com Hypomanic episode: • Similar to manic, but all features and symptoms are less severe, although they still interfere with functioning. Criteria for hypomanic include a distinct period of persistently expansive, irritable, elevated mood that lasts at least 4 days but less than 1 week. There must be present at least three symptoms (whereas four symptoms are required if there is predominantly an irritable mood): pressured speech, increased involvement in goal-oriented activities, psychomotor agitation, distractibility, decreased need for sleep, and inflated self-esteem or grandiosity. There is also excessive involvement in pleasurable activities, which have the potential for high risk and negative consequences. www.rolandwilliamsconsulting.com Major depressive episode: • Depressed mood for at least 2 weeks or a loss of interest or pleasure in nearly all activities, plus at least five additional symptoms experienced by the client almost daily for the same 2-week period. Associated features include sleeping and appetite disturbances (very common symptoms); fatigue or decreased energy; changes in sleep; changes in psychomotor activity; reduced ability to think, concentrate, or make decisions; feelings of worthlessness or guilt; morbid ideation or suicidal ideation, plans, or attempts; and irritable mood. www.rolandwilliamsconsulting.com Description of Bipolar Mood Disorders • Bipolar I Disorder: This disorder is considered the most severe and is characterized by at least one manic episode and a history of hypomanic or a depressive episode. Specific criteria for the number of symptoms required for each manic, hypomanic, or depressive episode must be met. • Bipolar II Disorder: This disorder is characterized by one or more depressive episodes with at least one hypomanic episode: a period of elevated or irritable mood with increased activity, lasting at least 4 consecutive days and present throughout each day most of the time. www.rolandwilliamsconsulting.com • Cyclothymic Disorder: This disorder is characterized by a persistent mood disturbance lasting at least 2 years (1 year in children and adolescents), and the individual must not be without the symptoms for 2 months. This disorder, although considered more chronic because of the duration of the symptoms, is less severe because the symptoms experienced do not meet the criteria for either the full hypomanic or depressive episodes. www.rolandwilliamsconsulting.com • Substance/ Medication-Induced Bipolar and Related Disorder: This disorder is characterized by a disturbance in mood that clinically predominates and includes symptoms of elevated or irritable mood, with or without depressed mood, or diminished interest or pleasure in all or most activities. A physical exam and laboratory tests are needed to confirm that the symptoms developed during or soon after substance intoxication or withdrawal or after taking a medication as evidence that the substance/ medication produces the mood symptoms. The disorder is not better explained by a bipolar or related disorder that is not induced by substances/ medications, does not occur only during a delirium, and causes significant impairment in social, occupational, or other areas of functioning. Categories of the substances include alcohol, phencyclidine, other hallucinogen, sedative, hypnotic or anxiolytic, amphetamine or other stimulant, cocaine, other, or unknown substance. www.rolandwilliamsconsulting.com • Bipolar and Related Disorder Due to Another Medical Condition: This disorder is characterized by a period of elevated or irritable mood with abnormally increased activity or energy that is presented clinically. Results from laboratory tests and physical exams show evidence of another medical disorder. The disturbance is not explained by another mental disorder and does not occur exclusively during a delirium. The disorder must cause significant impairment in social, occupational, or other areas of functioning to meet this diagnosis. It is indicated to specify with manic features, with manic or hypomanic features, or with mixed features. www.rolandwilliamsconsulting.com • Other Specified Bipolar and Related Disorder: This disorder is characterized by impairment in social, occupational, or other significant areas of functioning but does not meet full criteria for any of the other categories of bipolar and related disorders. This diagnostic category can apply to the following four clinical presentations: short-duration hypomanic episodes (2– 3 days) and major episodes, hypomanic episodes with insufficient symptoms and major depressive episodes, hypomanic episode without prior major depressive episode, and short-duration cyclothymia (less than 24 months). www.rolandwilliamsconsulting.com • Unspecified Bipolar and Related Disorder: This disorder presents with symptoms characteristic of bipolar and related disorder but does not meet the full criteria for any of the bipolar and related disorder category. The unspecified bipolar disorder category used when there is insufficient information to place a more formal diagnosis and may be used in settings such as emergency rooms. www.rolandwilliamsconsulting.com Specifies for Bipolar and Related Disorders • • • • • • • • • • With anxious distress With mixed features With rapid cycling With melancholic features With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern www.rolandwilliamsconsulting.com Overview of Depressive Disorders • Somatic, cognitive, and emotional concerns identified in the DSM-5 are the predominant features linking the disorders. In addition, these disorders all share depressed mood with subsequent changes in eating, sleeping, and energy levels; impairments in executive function and attention; and changes in self-awareness and perception. When depressed clients experience a loss of interest or pleasure in activities and difficulty concentrating, these symptoms can lead to problems with performing activities of daily living (ADLs) and making decisions. www.rolandwilliamsconsulting.com • Although some types of mixed presentations in depression exist, the DSM-5 focuses primarily on the depressive ones. For a diagnosis, however, these problems must be severe enough to affect occupational and social functioning. • When suffering from depressive disorders, all individuals experience some degree of depressive symptoms, although the duration, time frame, and etiology may vary. www.rolandwilliamsconsulting.com Disruptive Mood Dysregulation Disorder (DMDD) • DMDD has 11 specific criteria (ranging from A to K) that must be met. The core feature is irritability that is persistent for at least a year and maintains a severe and continuous course that is not related to a developmental phase. The behaviors are not consistent with the precipitating event and involve either verbal or behavioral manifestations toward people or property. Temper outbursts must be continuous, occurring at least three or more times over a 7day period. Other criteria are documented in this text. www.rolandwilliamsconsulting.com Major Depressive Disorder • There are nine primary symptoms, and the individual must have at least five of them. In addition, the symptoms must all occur during the same 2-week period, and the individual who suffers from major depressive disorder must have either a depressed mood or a loss of interest or pleasure in daily activities consistently for the 2week period. Of the nine symptoms, at least one must be depressed mood or loss of interest or pleasure. www.rolandwilliamsconsulting.com Persistent Depressive Disorder (Dysthymia) • This is a milder yet more chronic form of the disorder, requiring a 2-year history of depressed mood. The individual suffering from this disorder is not without the symptoms for more than 2 months at a time. The disorder is considered less severe than major depressive disorder but is constant for a period of 2 years, during which the individual experiences some symptoms related to the disorder almost every day. www.rolandwilliamsconsulting.com Premenstrual Dysphoric Disorder (PMDD) • This new condition to the DSM-5 occurs in women who have severe depressive symptoms, irritability, and tension that occur before menstruation. www.rolandwilliamsconsulting.com Substance/ Medication-Induced Depressive Disorder • Meet the criteria for major depressive disorder and document the substance/ medication taken, confirmed by history, physical exam, or lab result. The individual needs to experience the symptoms soon after ingestion or with resultant intoxication or withdrawal from the substance. In addition, that the substance taken is capable of displaying the side effects that resulted has to be confirmed. www.rolandwilliamsconsulting.com Depressive Disorder Due to Another Medical Condition • Similar to the criteria for substance/ medication-induced disorder, the individual is expected to suffer from a persistent depressed mood, accompanied by diminished interest and pleasure in activities that once were pleasurable. There also needs to be direct evidence from an adequate history, physical exam, or lab result that makes the connection to the medical condition causing it. www.rolandwilliamsconsulting.com Other Specified Depressive Disorder or Unspecified Depressive Disorder • The diagnosis of either of these disorders requires the symptoms characteristic of the depressive disorders. The three specifiers are recurrent brief depression, short-duration depressive episode, and depressive episode with insufficient symptoms. The primary difference between the specified and the unspecified disorder is that in the specified disorder, the practitioner documents the reason that it does not meet the criteria. www.rolandwilliamsconsulting.com Presentation of Anxiety • Clients who are anxious often do not seek the help of a primary care physician unless urged by family members or support system influences, such as emergency responders. • Clients often cannot control the signs and symptoms experienced and try to address them with repetitive behaviors. • Clients present with both physical and mental symptoms (e.g., tremors, dyspnea, dizziness, sweating, irritability, restlessness, hyperventilation, pain, heartburn) and when confronted, may back away from help or attention to their concerns. www.rolandwilliamsconsulting.com Understanding OCD and Related Disorders • Obsessive-compulsive disorder (OCD) and the related disorders are characterized by “recurrent obsessions or compulsions that are severe enough to be time consuming or cause marked distress or significant impairment”. The significant impairment occurs in the person's normal routine, occupational functioning, academic functioning, social activities, or relationships. Obsessions can be www.rolandwilliamsconsulting.com Understanding OCD and Related Disorders (Cont.) defined as recurring and distressing thoughts, images, and urges. These factors are beyond the control of the individual and are perceived as inappropriate and anxiety provoking. Some of the most common obsessions are a fear of contamination, a fear of being harmed or harming others, disturbing visions of a sexual or aggressive content, doubting, and unacceptable impulses. www.rolandwilliamsconsulting.com • Obsessive-compulsive disorder (OCD): – OCD has four specific criteria (ranging from A to D) that must be met. The core criterion is the presence of obsessions and/ or compulsions. • Body dysmorphic disorder (BDD): – BDD has four specific criteria (ranging from A to D) that must be met. Individuals with this disorder exhibit a “preoccupation with one or more perceived defects or flaws in physical appearance” that may or may not be visible to others. • Hoarding disorder (HD): – HD has six specific criteria (ranging from A to F) that must be met. Individuals with hoarding disorder suffer from an inability to discard possessions that may have significant financial value, emotional value, or no value at all. www.rolandwilliamsconsulting.com • Trichotillomania (hair pulling disorder): – Five specific criteria (ranging from A to E) must be met. This disorder consists of hair loss associated with recurrent hair pulling when the individual has tried unsuccessfully to decrease or stop the hair pulling. • Excoriation (skin picking) disorder: – Five specific criteria (ranging from A to E) must be met. The recurrent skin picking results in skin lesions and/or skin infections; there are unsuccessful attempts to stop or decrease the skin picking. www.rolandwilliamsconsulting.com • Substance/medication induced obsessivecompulsive and related disorder: – Five specific criteria (ranging from A to E) must be met, along with two components that can be documented based on history and medical examinations (physical exams and laboratory finds). www.rolandwilliamsconsulting.com Overview of the 9 Disorders • Obsessive-compulsive and related disorder due to another medical condition: – Five specific criteria (ranging from A to E) must be met. The behaviors related to the disorder dominate the individual's situation. There is evidence based on history and medical tests that the disorder results from another medical condition. • Other specified obsessive-compulsive and related disorder: – The designation of this category requires that the symptoms are characteristic of an obsessivecompulsive and related disorder. This category can www.rolandwilliamsconsulting.com Overview of the 9 Disorders (Cont.) be used when there is not enough information to make a full diagnosis or when the symptoms do not fully reach the criteria of the obsessive-compulsive and related disorder. • Unspecified obsessive-compulsive and related disorder: – This diagnosis is used when the symptoms do not fully meet the obsessive-compulsive and related disorder categories and the cause for not meeting the disorder is not listed. www.rolandwilliamsconsulting.com Obsessions and Compulsions • Obsessions: Persistent, recurring, and distressing intrusive thoughts, images, and urges inappropriate, anxiety provoking, and contrary to the individual's free will. • Compulsions: Persistent repetitive behaviors (e.g., checking and rechecking, collecting, skin picking) or mental acts (e.g., counting) in response to an obsession or to applied rigid rules, and not performed for pleasure or gratification. www.rolandwilliamsconsulting.com Trauma and Stressor Related Disorders • Trauma can be defined as the occurrence of emotionally traumatic events that overwhelm an individual. All of the disorders presented in this chapter require identification of a triggering event. This triggering event does not have to be isolated; it can be a multitude of events that are repeated and ongoing. Although much of the current research has focused on major catastrophes and people's reactions to them, each individual may respond to trauma differently. www.rolandwilliamsconsulting.com Trauma and Stressor Related Disorders (Cont.) • For some, the event teaches resilience and to push forward beyond what is generally expected. In normative stress reactions the aftermath of the trauma may last two to three days. Yet, when the reaction becomes too extensive and the individual cannot function or regroup, a disorder may result. What all of the disorders listed in this chapter of the DSM share is exposure to a traumatic event. For reactive attachment disorder and disinhibited social engagement disorder, this early trauma can include social neglect. www.rolandwilliamsconsulting.com • Trauma and stress can affect people differently. When most people experience anxiety, they have an adequate set of background capacities and can attribute meaning, motivation, and intention. Extreme circumstances, especially over a period of time or in the formative years, including repeated social and emotional neglect or situational factors such as acts of betrayal, malevolence, and deceit (e.g., war, torture), can be especially difficult to process. www.rolandwilliamsconsulting.com DSM-5 Categorizes the Following under Trauma and Stressor Related Disorders • • • • • • Reactive attachment disorder (RAD) Disinhibited social engagement disorder (DSED) Posttraumatic stress disorder (PTSD) Acute stress disorder (ASD) Adjustment disorders Other specified trauma- and stressor-related disorders • Unspecified trauma- and stressor-related disorder. www.rolandwilliamsconsulting.com Primary Spectrums of Mental Illness • The Depression Spectrum: Sadness versus Despair • The Mania Spectrum: Moody versus Bipolar • The Anxiety Spectrum: Carelessness versus Anxiousness • The Psychosis Spectrum: Eccentric versus Psychotic • The Focusing Spectrum: Attentive versus Obsessive Compulsive Disorders • The Substance Abuse Spectrum: Social Use versus Addicted • The Autism Spectrum: Withdrawn versus Autistic • The Personality Spectrum: Obnoxious versus Neurotic www.rolandwilliamsconsulting.com Substance Use Disorders Expanded www.rolandwilliamsconsulting.com • Changes in Substance Related Disorders from the DSM-IV – Removal of Substance Abuse and Dependence – Severity of disorder (mild to severe) based on the number of symptom criteria met: • Mild: • Moderate: • Severe: 2-3 symptoms 4-5 symptoms 6 or more symptoms www.rolandwilliamsconsulting.com • DSM-IV-TR – 305.00 Alcohol Abuse – 303.90 Alcohol Dependence • DSM-5 – (F10.10) Mild Alcohol Use Disorder – (F10.20) Moderate Alcohol Use Disorder – (F10.20) Severe Alcohol Use Disorder www.rolandwilliamsconsulting.com • The word “addiction” is omitted due to it’s uncertain definition and it’s potentially negative connotation • Craving or strong desire replaces preoccupation • Items deleted: “recurrent legal problems” and the polysubstance category www.rolandwilliamsconsulting.com 10 Separate Classes of Drug • • • • • • • • • • Alcohol Caffeine Cannabis Hallucinogens Inhalants Opioids Sedatives, hypnotics and anxiolytics Stimulants Tobacco Other (or unknown) substances www.rolandwilliamsconsulting.com Addictive Disorders • Includes Gambling Disorder • Other potential behavioral addictions, (internet addiction, sex addiction, exercise addiction, shopping addiction, etc.) not included due to, “insufficient peer-reviewed evidence to establish the diagnostic criteria and course description” www.rolandwilliamsconsulting.com Substance Use Disorders • The Essential Feature – continued use despite significant substance-related problems • Changes in brain circuits may persist, exhibited in repeated relapses & intense drug cravings • Criteria include impaired control, social impairment, risky use, and pharmacological symptoms (withdrawal/tolerance) www.rolandwilliamsconsulting.com Substance Use Disorders • 11 diagnostic criteria (some classes of substances have 10 criteria) • 2 or more within a 12-month period • Must include a pattern of use leading to clinically significant impairment or distress www.rolandwilliamsconsulting.com Substance Use Disorders: Diagnostic Criteria 1. Substance often taken in larger amounts or over a longer period of time than intended (impaired control) 2. A persistent desire or unsuccessful efforts to cut down or control use (impaired control) 3. A great deal of time spent in activities necessary to obtain the substance, use it, or recover from its effects (impaired control) 4. Craving, or strong desire or urge to use (impaired control) (New criteria) www.rolandwilliamsconsulting.com Substance Use Disorders: Diagnostic Criteria 5. Recurrent use resulting in failure to fulfill major role obligations at work, school, or home (social impairment) 6. Continued use despite having persistent or recurrent social/interpersonal problems caused or exacerbated by use (social impairment) 7. Important social, occupational, or recreational activities given up or reduced because of use (social impairment) www.rolandwilliamsconsulting.com Substance Use Disorders: Diagnostic Criteria 8. Recurrent use in situations which is physically hazardous (risky use) 9. Use is continued despite knowledge of having a persistent or recurrent physical/psychological problem likely to have been caused or exacerbated by use (risky use) www.rolandwilliamsconsulting.com Substance Use Disorders: Diagnostic Criteria 10. Tolerance: the need for markedly increased amounts of substance to achieve intoxication or desired effect, or a markedly diminished effect with continued use of same amount (pharmacological) 11. Withdrawal: a characteristic syndrome, or use to relieve or avoid withdrawal (pharmacological) www.rolandwilliamsconsulting.com • Criteria 1-4 relate to use • Criteria 5-8 relate to behavioral issues associated with use • Criteria 9-11 relate to physical/emotional issues www.rolandwilliamsconsulting.com The Big Five • • • • • Criteria 2: Wanting to cut down/setting rules Criteria 4: Craving and/or compulsion to use Criteria 5: Failure at role fulfillment due to use Criteria 7: Sacrifice activities to use Criteria 11: Withdrawal symptoms www.rolandwilliamsconsulting.com Sustained Remission • No positive diagnostic findings (other than craving) for 12 consecutive months • Substance use is NOT part of the remission definition • This remission definition is appropriate for both misuse and chronic addiction • Possible levels of outcome: 1) abstinence without problems; 2) some use without problems; 3) use with sub-diagnostic problems; 4) meets current diagnosis www.rolandwilliamsconsulting.com ICD-10 Diagnostic Criteria for Alcohol Dependence • A craving or feeling of compulsion to use the alcohol. • Evident impairment of the ability to control use of alcohol. This can be related to difficulties in avoiding initial use, difficulties in discontinuing use, difficulties in controlling the level of use. • Withdrawal state, or use of the substance to mitigate or avoid withdrawal symptoms, and subjective awareness of the efficacy of this behavior. www.rolandwilliamsconsulting.com ICD-10 Diagnostic Criteria for Alcohol Dependence (Cont.) • Presence of tolerance to the alcohol’s effects. • Progressive neglect of pleasures, behaviors or interests in favor of using alcohol. • Persistent use of alcohol despite evident presence of harmful consequences. www.rolandwilliamsconsulting.com Compatibility DSM5-ICD-10 • Use any positive finding on the DSM-5 criteria to match on the basis of where each criterion loads on the ICD-10 • Likely to over diagnosis as some components of the DSM-5 category are not part of ICD-10 • Example: Job problems (DSM Criterion 5) or interpersonal conflicts (DSM Criterion 6) due to use do not neglect of interests for the dependence criteria nor necessarily a “dysfunctional behavior” for harmful use • Global match based on DSM-5 criteria most likely to produce a good fit. www.rolandwilliamsconsulting.com Recording Procedures for Substance Related Disorders • New recording procedures to occur by 10/14 • Use the code for the class of substances, but record the specific substance • Severity determined by # of symptom criteria • Mild (2-3); Moderate (4-5); Severe (6 or more) • Severity can change over the course of time by reductions or increases • Record for each individual substance disorder www.rolandwilliamsconsulting.com Recording Procedures for Substance Related Disorders Course Specifies • “in early remission” (3-11 months) • “in sustained remission” (12 mos. or longer) • None of the criteria met for that duration with exception of craving • “on maintenance therapy” (for opioids, tobacco) • “in a controlled environment” (access to substance is restricted) www.rolandwilliamsconsulting.com Substance Related Disorders • Divided into two groups: – Substance induced disorders: includes conditions of intoxication or withdrawal and other induced mental disorders – Substance use disorders: relates to pathological patterns of behaviors related to the use of a substance www.rolandwilliamsconsulting.com Tobacco Use Disorder • Problematic pattern of use leading to significant impairment or distress as manifested by 2 or more of the 11 symptom criteria • Includes the specifier “on maintenance therapy” for those taking a nicotine replacement aid or a tobacco cessation medication www.rolandwilliamsconsulting.com Gambling Disorder • Previously known as “Pathological Gambling” and was in category of Impulse Control Disorders • Problematic gambling leading to significant impairment or distress • Leading to four or more of the following symptoms over a 12-month period www.rolandwilliamsconsulting.com Gambling Disorder Diagnostic Criteria 1. Needs to gamble with increasing amounts of money for desired excitement 2. Is restless or irritable when attempting to cut down or stop gambling 3. Repeated unsuccessful efforts to control, cut back, or stop gambling 4. Often preoccupied with gambling 5. Gambles when feeling distressed (helpless, guilty, anxious, depressed) www.rolandwilliamsconsulting.com Gambling Disorder Diagnostic Criteria 6. After losing money gambling, often returns another day to get even 7. Lies to conceal the extent of involvement with gambling 8. Jeopardized or lost a significant relationship, job, or career opportunity due to gambling 9. Relies on others to provide money to relieve financial situations caused by gambling www.rolandwilliamsconsulting.com Gambling Disorder Diagnostic Criteria • Removal of the criteria “has committed acts of forgery, fraud, theft, or embezzlement to finance gambling” • Can be specified as either “Episodic” or “Persistent” and “In early remission” or “In sustained remission” www.rolandwilliamsconsulting.com Gambling Disorder Severity Rating • Mild: 4-5 criteria • Moderate: 6-7 criteria • Severe: 8-9 criteria www.rolandwilliamsconsulting.com Gambling Disorder • About 0.2%-0.3% of general population • 3x more likely in males • Highest in African Americans (0.9%), whites (0.4%), Hispanics (0.3%) • For females, the progression is more rapid • About 17% commit suicide • Often associated with SUDs and impulse –control disorders (males) & mood/ anxiety D/O (females) www.rolandwilliamsconsulting.com Closure • Sources: – American Psychiatric Association (APA) www.DSM5.org. – www.APA,org – DSM-5 Essentials, Wiley – DSM-5 in Action, Wiley www.rolandwilliamsconsulting.com