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Overview of Changes from DSM IVTR to DSM 5 and Their Implications
for the GAIN-I
Barbara Estrada, MS
GAIN Senior Clinical and Evaluation
Consultant
GAIN Coordinating Center
Purpose
This webinar will provide attendees a
description of the substantive changes from
DSM IV-TR to DSM-5 and how the GAIN
Coordinating Center plans
to address them in the
GAIN-I and clinical reports.
Your feedback is
important!
Overview
• The DSM IV diagnostic codes were replaced
with a new set of codes that map onto ICD-9.
• The GAIN is being updated to allow clinicians
to switch back and forth between DSM-IV and
DSM-5 at will.
Multi-Axial System
• The multi-axial system was removed in DSM-5 in
favor of collapsing Axis I and II into just diagnosis
and the remaining axis’s into other conditions.
– In the GRRS and ICP the heading "DSM-IV/ICD-9
Diagnosis" and "Axis I-V" headings are replaced by
"DSM-5/ICD-9 (ICD-10) Diagnosis" (formerly Axis I and
II), "DSM-5/ICD-9 (ICD-10) Other Conditions That May
Be a Focus of Clinical Attention" (formerly Axis III
through IV).
– DSM-5 eliminated the old Axis V, but did recommend
a new optional scale discussed further below.
DSM 5 pp. xxxiv, 16
Abuse and Dependence
• Within “Substance Use Disorders”, the
“Substance Abuse” and “Substance
Dependence” diagnoses were replaced with
"Substance Use Disorder -mild (2-3
symptoms), -moderate (4-5 symptoms), or –
severe (6-11 symptoms)." These changes were
made throughout the clinical reports.
DSM 5 pp. 484, 482-577
Substance Use Disorders
• DSM-5 includes a new substance use disorder
criterion regarding craving. We add two new
items. S9ua "When was the last time that you
had such strong urges to use alcohol or other
drugs you could not think of anything else?"
and S9ua1-99 in the S9 matrix "you had such
strong urges to use you could not think of
anything else?"
DSM 5 pp. 483, 482-577
Substance Use Disorders
• DSM-5 dropped the substance use criterion
"recurrent substance-related legal problems (e.g.,
arrests for substance-related disorderly conduct)"
because it was associated with social injustice as
much as individual severity. For scoring purposes
in DSM-5, this criterion was dropped for all
substances in S9 matrix (S9k, S9k1-99).
• The item, however, was retained to allow
clinicians to switch between DSM-IV (which
requires it) and DSM-5.
DSM 5 pp. 483, 482-577
Cannabis Withdrawal
• DSM-5 added cannabis withdrawal symptoms as
endorsing 3 or more of 1) Irritability, anger, or
aggression, 2) Nervousness or anxiety, 3) Sleep
difficulty, 4) Decreased appetite or weight loss, 5)
Restlessness, 6) Depressed mood , and 7) Physical
discomfort.
• We added two new withdrawal symptoms to for
cannabis withdrawal: Irritability, anger, or
aggression (new item S3c20), and depressed
mood (S3c21). The other symptoms were already
in the GAIN.
DSM 5 pp. 484, 482-577
Tobacco Use Disorder
• DSM-5 replaced “Tobacco dependence” with tobacco use
disorder (mild, moderate, severe).
• These new questions match the criteria for other drugs
currently in the GAIN and the exact wording of the new
craving item.
• We add four items for tobacco use. R1ch: repeatedly
caused you not to meet your responsibilities, R1cj: you
repeatedly used in unsafe situations, R1cm: did you keep
using even though it was leading to fights or getting you
into trouble with other people, R1ua: When was the last
time that you had such strong urges to take the drug that
you could not think of anything else.
DSM 5 pp. 571
Specifiers
Changes to specifiers were made throughout the
clinical reports to account for DSM-5 changes:
• Removal of specifiers "with physiological
symptoms” and "without physiological
symptoms." The remission specifiers were
deleted.
• Remission specifiers "Sustained Partial
Remission" and "Sustained Full Remission"
replaced with "In Sustained Remission". The
remission specifiers were changed.
DSM 5 pp. 484, 482-577
Specifiers
Changes to specifiers were made throughout the clinical
reports to account for DSM-5 changes:
• Remission specifiers "Early Partial Remission" and
"Early Full Remission" replaced with "In Early
Remission,” the timeframe for early remission was
changed to from 1 month to 3 months and added the
exception for craving. The remission specifiers were
changed. To allow for either the DSM-IV or 5
timeframes for early remission, we changed the S9
response set to Past Month, 2 to 3 Months Ago, 4 to 12
Months Ago, 1-3 Years Ago, More than 3 Years Ago,
and Never.
DSM 5 pp. 484, 482-577
Substance Class Changes
Substance/Class Changes were made throughout
the clinical reports to account for new DSM-5
classification:
• Amphetamine and Cocaine were collapsed into
Stimulant Use Disorder
• PCP was collapsed into Hallucinogen Use
Disorder.
• All substance use disorders allow specification of
primary form of a drug used within a class (e.g.,
Amphetamine, Methamphetamine, Cocaine,
Crack, PCP, OxyContin)
DSM 5 pp. 520, 561
Major Depressive Disorder
• According to DSM-5 Major Depressive Disorder
includes a new symptom, "Feelings of
worthlessness or excessive or inappropriate guilt
(which may be delusional) nearly every day (not
merely self-reproach or guilt about being sick).”
We added a new item (M1b13) "Feeling
worthless or that the bad things that have
happened in your life are your fault.”
• The item was simplified from the DSM-5
symptom for ease of administration.
DSM 5 pp. 160
Gambling Disorder
• DSM-5 has renamed "Pathological Gambling" to
"Gambling Disorder".
• The criterion “paid for your gambling with bad
checks, someone else's money, or with
something that didn't belong to you” no longer
included in diagnostic criteria for DSM-5 and we
changed the terminology throughout the reports.
• Item V9h was kept to allow clinicians to switch
between DSM-IV and DSM-5.
DSM 5 pp. 585
ADHD
DSM-5 included several changes to ADHD which we
have made:
• "Attention Deficit Hyperactive Disorder Combined Type" changed to "AttentionDeficit/Hyperactivity Disorder - Combined
presentation". Criterion changed to up to age 16
requires 6 or more inattention symptoms and 6
or more hyperactivity/ impulsivity symptoms; age
17 and older requires 5 or more inattention
symptoms and 5 or more
hyperactivity/impulsivity symptoms.
DSM 5 pp. 59-66
ADHD
• “Attention Deficit Hyperactive Disorder Inattentive Type" changed to "AttentionDeficit/Hyperactivity Disorder - Predominantly
inattentive presentation". Criterion changed
to up to age 16 requires 6 or more inattention
symptoms; age 17 and older requires 5 or
more inattention symptoms.
DSM 5 pp. 59-66
ADHD
• "Attention Deficit Hyperactive Disorder Hyperactive Type" changed to "AttentionDeficit/Hyperactivity Disorder - Predominantly
Hyperactive/Impulsive Presentation”. Criterion
changed to up to age 16 requires 6 or more
hyperactivity/impulsivity symptoms; age 17 and
older requires 5 or more hyperactivity/impulsivity
symptoms.
• ADHD age of on-set criteria raised form age 7 to
15. The higher ages of onset is still allowed as
provisional.
DSM 5 pp. 59-66
NOS/Rule Outs
• DSM-5 Replaced "Not Otherwise Specified" to
"Unspecified”, and "Rule Out" to
"Provisional". These changes were made
throughout the clinical reports.
DSM 5 pp. 15
Axis III and IV
• DSM-5 recommends the use of V Codes from
ICD-9-CM or Z codes from ICD-10-CM for
previous sections for Axis III and IV. We have
included appropriate V codes and Z codes to
describe client self-report where possible.
However, the previous list of psychosocial
problems will also print in the clinical reports.
DSM 5 pp. 16
Axis V
• DSM-5 dropped Axis V GAF .
• DSM-5 recommends use of WHODAS 7 General Disability
Score in order to provide a global measure of disability. We
have added 8 items (XDSM5g-q) at the end of the GAIN and
in the GRRS and ICP section “Other Conditions that May be
a Focus of Clinical Attention.”
• The items correspond to the 7 subscale and total score for
the WHODAS 7 General Disability Scores (Understanding
and communicating, Getting around, Self-care, Setting
along with people, Life activities-Household, Life activitiesschool/work, Participating in society, and Total).
DSM 5 pp. 16, 734, 745-748
Arabic Numerals
• Roman numerals (V) were replaced by Arabic
numerals (5) in DSM-5.
Timeline
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GAIN User input: NOW
GAIN-I DSM 5 Instrument Development
Clinical Reports Development
Training materials (Administration, GAIN
Clinical Interpretation, Manual, website, etc.)
• Launch
We are all ears!
Discussion and questions