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The Making of the DSM-5 Presented by David J. Kupfer, MD Chair of the DSM-5 Task Force CARNEGIE LIBRARY OF PITTSBURGH SATURDAY, OCTOBER 26, 2013 Why we need DSM 2 Provides a common language to use to understand and communicate about mental disorders Goal of DSM-5 Revisions 3 A clinical guidebook that more precisely defines disorders and better characterizes groups of people who are seeking treatment, ultimately improving care patients and families receive • Diagnostic criteria were revised and new diagnoses were added in light of scientific and clinical advances • In the process we reduced the number of mental disorders from DSM-IV DSM-5 Key Dates 4 DSM-5’s 14-year revision process involved more than 1,500 mental health and medical experts from around the world 1999-2007 PrePlanning White Papers and Conferences 20082010 Review of DSM criteria 20062008 DSM-5 Task Force Work Group members appointed May 18, 2013 DSM-5 published 2011 Second comment period 2010 Launch DSM5.org/ first comment period; Field Trials 2012 Third comment period; Review; DSM-5 criteria approved Overarching Changes 6 Used the strongest scientific evidence to support changes to diagnostic criteria Revised chapter order based on underlying vulnerabilities and symptom characteristics Organized manual in sequence with developmental lifespan Decreased the number of “Not Otherwise Specified” diagnoses through greater criteria specificity Aligned manual with international classifications Disorder Specific Changes 7 Autism Spectrum Disorder AttentionDeficit/Hyperactivity Disorder Disruptive Mood Dysregulation Disorder Major Depressive Disorder / Bereavement Exclusion Mild Neurocognitive Disorder Substance Use Disorders Autism Spectrum Disorder 8 Revised diagnosis represents more medically and scientifically accurate and useful way of diagnosing individuals with autism-related disorders Single umbrella disorder will improve diagnosis of ASD without limiting the sensitivity of criteria or changing number of children being diagnosed Individuals with ASD must show symptoms from early childhood, even if those symptoms are not recognized until later Attention-Deficit/Hyperactivity Disorder 9 Several of the individual’s ADHD symptoms must be present prior to age 12 years (compared to 7 in DSM-IV) New criteria addresses adults affected by ADHD to ensure they get the care they need No exclusion criteria for people with autism spectrum disorder Disruptive Mood Dysregulation Disorder 10 DMDD is characterized by severe and recurrent temper outbursts that are grossly out of proportion in intensity or duration of the situation - Occur three more times each week for one year or more (on average) Children with DMDD display persistently irritable or angry mood, most of the day and nearly every day Onset of symptoms must be before age 10 - Diagnosis should not be made for the first time before age 6 or after age 18 Major Depressive Disorder / Bereavement Exclusion 11 Exclusion is replaced by notes in the criteria and text that caution clinicians to differentiate between normal grieving associated with a significant loss and a diagnosis of a mental disorder - Removing exclusion helps prevent major depression from being overlooked - Criteria for major depressive disorder now clarifies that the normal and expected response to a significant loss may resemble a depressive episode Bereavement exclusion in DSM-IV suggested that grief somehow protected someone from major depression or only lasted two months Hoarding 12 Listed as a distinct disorder within the Obsessive- Compulsive and Related Disorders chapter Many severe cases of hoarding are not accompanied by obsessive or compulsive behavior, warranting listing as a distinct disorder Mild Neurocognitive Disorder 13 Mild neurocognitive disorder goes beyond normal issues of aging - Describes level of cognitive decline, including changes that impact cognitive functioning Early identification of neurocognitive decline may enable use of treatments not effective at more severe levels of impairment and may prevent or slow progression Substance Use Disorders 14 Combines DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe Each specific substance is addressed as a separate disorder (same overarching criteria) Mild substance use disorder in DSM-5 requires two to three symptoms from list of 11, as opposed to one in DSMIV Section III 15 Section III introduces emerging measures and models to assist clinicians in their evaluation of patients Outlines conditions in need further study before inclusion in Section II of the manual Addresses how cultural influences can impact diagnosis and treatment Includes assessment tools and crosscutting symptom measures Future Forward 16 The best clinical tool available for diagnosing mental disorders Clinical utility of the manual is unparalleled DSM-5 was revised to be a “living document” Manual will continue to update its criteria to reflect the most up to date science