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8/5/2013 Understanding the DSM-5 General Themes and Criteria for the New Diagnostics Brandy Hall, MA, LPC S. David Hall, PsyD, LMFT, LPC www.narrativeinstitute.org Who We Are • S. David Hall, PsyD, LMFT, LPC • Dr. David Hall the director of the Narrative Institute and is a licensed marital and family therapist and a licensed professional counselor in practice with Ebenezer Counseling Services in Knoxville, TN. Who We Are • Brandy Hall, MA, LPC/MHSP • Licensed professional counselor in Tennessee, practicing with Ebenezer Counseling Services in Knoxville, TN. She also serves as one of the teaching faculty with the Narrative Institute. Brandy’s clinical and teaching interests include anxiety, addiction, and the clinical diagnostic process. The Narrative Institutewwww.narrativeinstitute.org 1 8/5/2013 The Narrative Institute • Is an educational and training group that is devoted to the study and application of narrative theory and the craft of story in the fields of psychotherapy, medicine, spiritual care, education, entertainment, creative expression, business, and personal enrichment. What we will not be spending time on • The history of DSM • Minor controversies • We are not going to review all DSM-5 diagnoses, only those with significant changes between the DSM-IV-TR and the DSM-5 Important Dates • Now Available: DSM-5 Diagnostic Criteria Mobile App (came out July 22, 2013 for $70) • December 31, 2013: Insurance companies are expected to have transitioned • April 2014: Examinations given by NBCC will reflect changes • October 1, 2014: Everyone is required to start using the ICD-10-CM codes (the codes in parentheses) The Narrative Institutewwww.narrativeinstitute.org 2 8/5/2013 The Importance of Language • Language shapes the world (for good and ill) – The language we use to describe our clients shapes how we think of them – The language the client uses to describe themselves shapes how they think of themselves – The language the client uses to describe the problems they face shapes how they think of their problems The Importance of Language • The language others use to describe the client and their problems affects how they see the client • The labels, or diagnoses, we apply, therefore, will mold how we think of our clients, how they think of themselves, how they think of their problems, and how the world will see them as well. The Importance of Language • Potential clients who are afraid of certain diagnoses, or more correctly, of seeing themselves or being seen in a certain way, will often avoid seeking help whether by avoiding coming in altogether or by masking their true concerns even when they do come in. • This is one of the main reasons behind many of the name changes and new diagnostic names. – Mental Retardation --> Intellectual Disorder – Hypochondriasis --> Illness Anxiety Disorder The Narrative Institutewwww.narrativeinstitute.org 3 8/5/2013 The Purposes of the DSM-5 For Clinicians & Researchers • The idea that diagnosis means to “know thoroughly” – To allow professionals to have an agreed upon basis of knowledge and understanding between each other – “Primarily designed to assist clinicians in conducting clinical assessment, case formulation, and treatment planning” (pg. 25, DSM-5). – To help professionals conceptualize the client - to understand the problem(s) and know how to treat For Clinicians & Researchers • Does the DSM help in “knowing thoroughly” the disorders that we work with? • The DSM does not provide treatment guidelines for any disorder, only the diagnostic criteria. • The diagnostic guidelines set in the DSM are also given to provide criteria for improved research in mental disorders The Narrative Institutewwww.narrativeinstitute.org 4 8/5/2013 Insurance Reimbursement • The APA expects that the insurance industry will transition to the DSM-5 by December 31, 2013. • Insurance utilizes the codes from DSM/ICD to determine reimbursement • In the past many insurance companies used the mutliaxial format, while some did not, and only used the codes. Insurance Reimbursement • The DSM Task Force has to take into consideration that insurance companies will not reimburse for conditions not included in the DSM/ICD. – Discussed dropping Gender Identity Disorder, but there was outcry from those who seek assistance from insurance, so instead they changed the criteria some and renamed it Gender Dysphoria – The addition of Gambling Disorder under addictions Judicial Proceedings • Criminal responsibility - Use of the insanity plea • Involuntary commitment • Competence to stand trial • For more see page 25 of DSM-5 The Narrative Institutewwww.narrativeinstitute.org 5 8/5/2013 Pharmaceutical Implications • Ability to research, produce meds for classified disorders only per FDA • Controversy – More on this later Disability • Workplaces are not allowed to discriminate • Workplaces and schools have to allow for and provide for certain accommodations • The possibility to file for disability pay – Regarding disability, “additional information is usually required beyond that contained in the DSM-5 diagnosis, which might include information about the individual’s functional impairments and how these impairments affect the particular abilities in question. It is precisely because impairments, abilities, and disabilities vary widely within each diagnostic category that assignment of a particular diagnosis does not imply a specific level of impairment or disability” (pg. 25, DSM-5). Why the Update? The Narrative Institutewwww.narrativeinstitute.org 6 8/5/2013 To Stay Relevant with Current Research • Validity and Reliability • The APA recognizes, “that past science was not mature enough to yield fully validated diagnoses - that is, to provide consistent, strong, and objective scientific validators of individual DSM disorders” (pg 5, DSM-5). • This is still a concern. Research continues. To Stay Relevant with Current Research • Even though reliability is generally viewed as strong, diagnostic disagreement between clinicians on a given case still is common due to the overlap in symptoms between various diagnoses. • High comorbidity rates & high rates of using NOS categories are evidence of this. • More on this later. To Stay Relevant Socially, Culturally, and with Age and Gender • Developmental age versus chronological age, gender differences, and cultural variabilities of norms • Use of social media, online resources, and mobile apps The Narrative Institutewwww.narrativeinstitute.org 7 8/5/2013 To Stay Relevant Socially, Culturally, and with Age and Gender • A variety of assessment measures for various disorders, as well as the Cultural Formulation Interview, that were used in the field trials are available online at www.psychiatry.org/dsm5 • The DSM-5 is available as an online subscription at www.psychiatryonline.org • E-book • DSM-5 Diagnostic Criteria Mobile App To Make Money • In order to meet the first point of staying relevant with research, they really needed more time. However, it is estimated that the APA spent $20-$25 million on developing the DSM-5, and they could not afford to delay any longer as there are rumors that the APA was already in debt millions of dollars, and they needed to start generating more income. (hence the higher price tag). To Make Money • APA intends, “to make future revision processes more responsive to breakthroughs in research with incremental updates until a new edition is required. Since the research base of mental disorders is evolving at different rates for different disorders, diagnostic guidelines will not be tied to a static publication date but rather to scientific advances. These incremental updates will be identified with decimals, i.e. DSM-5.1, DSM-5.2, etc., until a new edition is required” (http://www.dsm5.org/about/Pages/faq.aspx). The Narrative Institutewwww.narrativeinstitute.org 8 8/5/2013 To Make Money • It is not clear at this point in what form the updates will come or how often. It is likely these updates will be released online, though they will probably also have hard copies for sale as well as they did for the previous Text Revisions. • As you can imagine, this could possibly lead to much confusion, and possibly more expense to professionals. To work better with the ICD System • The ICD is the official system for the US, and all World Health Organization Member States (over 100 countries) use it to report mortality and many for morbidity rates. • The ICD-9 codes are to be used until September 2014. The ICD-10 codes must be used starting October 1, 2014. To work better with the ICD System • The DSM-5 contains both sets of codes. The numerical codes we are already familiar with are the ICD-9-CM codes. The codes in parentheses, typically starting with an F or G in Section II of the DSM-5 and typically starting with a T or Z in Section III, are the ICD-10-CM codes that we will all be implementing on October 1, 2014. The Narrative Institutewwww.narrativeinstitute.org 9 8/5/2013 To work better with the ICD System • The ICD-11 is currently being revised and is set to be released in 2015. It will be used with electronic health applications and information systems. • See www.who.int/classifications/icd/en/ for more information. • The ICD and the DSM has sought over time to become more congruent and use the same codes and diagnostic criteria. They are currently classified as, “compatible”, and able to be used as companions to one another. Controversies & Criticisms Relationships with pharmaceutical companies • To what extent has this impacted the formulation of the DSM? Does this effect its credibility? • Much has been made of the ties that some of the people on the DSM Task Force have with pharmaceutical companies as 69% of the Task Force members had direct industry ties. It should be noted that 57% of DSM-IV Task Force members had ties to pharmaceutical companies (Cosgrove & Krimsky, 2012). The Narrative Institutewwww.narrativeinstitute.org 10 8/5/2013 Relationships with pharmaceutical companies • The first drafts of the DSM-5 under-emphasized the biopsychosocial model in favor of the “bio-biobio model”, as former APA President Steven Sharfstein, MD called it, which leads to an increasing, “pill and an appointment”, mentality. – (http://psychnews.psychiatryonline.org/newsarticle.asp x?articleid=109213) • This over-emphasis has decreased some in the final product, but notably more evident than in DSM-IV-TR. ICD vs DSM • The difficulty and questionable necessity of maintaining both classification systems of the International Classification of Diseases (ICD) and the DSM. – The rest of the world uses the ICD system and it is the officially sanctioned system by the US government as well. – The DSM has to line up with the ICD codes for insurance purposes. – The ICD system contains the codes, but it does not contain detailed diagnostic descriptions. – The ICD is available online for free, whereas the DSM-5 costs $199 The Narrative Institutewwww.narrativeinstitute.org 11 8/5/2013 ICD vs DSM • Is it justifiable? Will the DSM be superseded by the ICD? • According to Dr. Geoffrey Reed, a WHO psychologist, “There would still be a role for the DSM, because it contains a lot of additional information that will never be a part of the ICD. In the future, it may be viewed as an important textbook of psychiatric diagnosis rather than as the diagnostic ‘Bible’”. (www.apa.org/monitor/2009/10/icd-dsm.aspx) National Institute of Mental Health (NIMH) • Three weeks before the DSM-5 was released, Thomas Insel, MD, Director of the NIMH, questioned the DSM’s validity as it continues to focus on symptomology, and he announced the launching of the Research Domain Criteria (RDoC) project, “to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system” (http://www.nimh.nih.gov/about/director/2013/transformingdiagnosis.shtml) National Institute of Mental Health (NIMH) • Insel has since confirmed that the NIMH, “has not changed it’s position on DSM-5”, and states that, “DSM-5 and RDoC represent complementary, not competing, frameworks”, and even says that findings from RDoC’s research may even be incorporated into future revisions of the DSM. (http://www.nimh.nih.gov/news/science-news/2013/dsm-5and-rdoc-shared-interests.shtml) The Narrative Institutewwww.narrativeinstitute.org 12 8/5/2013 Other Concerns • Open Letter to the DSM-5: – Published in October 2011, after the first draft of the DSM5 was released for public feedback. – The authors raises numerous concerns over some of the proposed changes. The concerns focused on adding disorders with little to no empirical evidence, the substantial emphasis on biological theory, the lowering of diagnostic thresholds, and deemphasizing sociocultural variation. http://www.ipetitions.com/petition/dsm5/ – Many of these critiques have impacted the DSM-5 greatly. Summary • Basically, NIMH and others criticizes DSM for not being neuro-biologically based enough and calls for more research to be done, while others criticize the DSM for focusing too much on medico-physiological theory without enough research to back it up while decreasing focus on other types of empirical knowledge such as psychological, social, cultural, etc. • The DSM-5 Task Force has since sought to find a balance between these two extremes while not jumping ahead of validated research. Changes To Know About The Narrative Institutewwww.narrativeinstitute.org 13 8/5/2013 Structural Changes to the Layout (Metastructure) • The DSM Task Force has attempted to balance between various critiques, which has lead to both many of the structural changes that we do see in the DSM-5 as well as the lack of some of the changes we expected to see. The Discontinuation of Using Multiaxial Diagnosis • The DSM-5 combines the first three axes into Section II. All mental disorders, personality disorders, intellectual disabilities, and other medical diagnoses are seen as the primary diagnoses. When making diagnoses, all disorders should be listed together. • Part of why Axis II existed was to call attention to disorders that needed more of a clinical and research focus. However, the APA states that, “there is no fundamental difference between disorders described on DSM-IV’s Axis I and Axis II” (APA, Personality Disorders Fact Sheet). The Discontinuation of Using Multiaxial Diagnosis • Axis IV is replaced with the last chapter in Section II: Other Conditions That May Be a Focus of Clinical Attention, which includes an expanded list of V-codes (and ICD-10, Z-codes) psychosocial and environmental factors and other conditions or problems that would affect treatment. These can be reported to insurance or just noted in the client’s file. The Narrative Institutewwww.narrativeinstitute.org 14 8/5/2013 The Discontinuation of Using Multiaxial Diagnosis • Axis V, the Global Assessment of Functioning, or GAF score was dropped. The GAF score was being used as a standard to determine the need for treatment, and the APA believes it does not convey adequate information to that end. • Instead of the single score, the APA recommends, “that clinicians continue to assess the risk of suicidal and homicidal behavior...and use available standardized assessments for symptom severity, diagnostic severity, and disability such as the measures in Section III of DSM-5”, including the WHO’s Disability Assessment Schedule (APA, Insurance Implications of DSM-5). Moving Toward a Dimensional Approach • Categorical approach is dichotomous. • “Because the previous DSM approach considered each diagnosis as categorically separate from health and other diagnoses, it did not capture the widespread sharing of symptoms and risk factors across many disorders that is apparent in studies of comorbidity” (pg. 12, DSM-5). • This led to high comorbidity rates and the heavy reliance on NOS diagnoses. Moving Toward a Dimensional Approach • The dimensional approach refers to a set of continuums on which an individual can have various levels of characteristics. • All of the diagnoses listed in Section II are still categorical. • In Section III, we see how the DSM is headed toward a dimensional approach in both the dimensional assessments offered as well as the alternate model for personality disorders. The Narrative Institutewwww.narrativeinstitute.org 15 8/5/2013 Moving Toward a Dimensional Approach • While the diagnoses in Section II are still categorical, “the revised chapter organization signals how disorders may relate to each other based on underlying vulnerabilities or symptom characteristics. It also breaks out some disorders because of greater understanding of their basic causes. As an example, the previous single chapter on ‘Anxiety disorders, including obsessive compulsive disorder and posttraumatic stress disorder’ now is three sequential chapters detailing Anxiety Disorders, Obsessive-Compulsive and Related Disorders, and Trauma- and Stressor-Related Disorders. This move both emphasizes the distinctiveness of the categories covered while signaling their interconnectedness.” (www.psychiatry.org/dsm5, American Psychiatric Association Releases DSM-5) Moving Toward a Dimensional Approach • These chapters are arranged in clusters which groups disorders together that relate to each other the most in overlapping symptoms and potential risk factors but divergent expressions Clusters – Neurodevelopmental Disorders – Internalizing Disorders – Somatic Disorders – Externalizing Disorders – Neurocognitive Disorders – Personality Disorders Full List of Clusters • Neurodevelopmental Cluster – Neurodevelopmental Disorders – Schizophrenia Spectrum & Other Psychotic Disorders • Internalizing Cluster – – – – – – Bipolar & Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive & Related Disorders Trauma- & Stressor-Related Disorders Dissociative Disorders The Narrative Institutewwww.narrativeinstitute.org 16 8/5/2013 Full List of Clusters • Somatic Cluster – – – – – – Somatic Symptom & Related Disorders Feeding & Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria • Externalizing Cluster – Disruptive, Impulse-Control, & Conduct Disorders – Substance-Related & Addictive Disorders Full List of Clusters • Neurocognitive Cluster – Neurocognitive Disorders • Personality Cluster – Personality Disorders • Other Cluster – Paraphilia Disorders – Other Mental Disorders – Medication-Induced Movement Disorders and Other Adverse Effects of Medication – Other Conditions That May Be a Focus of Clinical Attention Conditions for Further Study Lifespan Approach • The chapter in DSM-IV-TR, Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence has been eliminated in favor of placing these disorders in the chapters that they relate to most in symptomology. • Research showed that some of these disorders last into adulthood, but were being missed due to the assumption that they were childhood disorders. (e.g., ADHD, Pica) The Narrative Institutewwww.narrativeinstitute.org 17 8/5/2013 Lifespan Approach • Some disorders can be precursors for other related disorders. – e.g., Individuals with Separation Anxiety Disorder tend to develop other anxiety disorders later in life if left untreated • Many of the chapters are internally, “arranged developmentally, with disorders sequenced according to the typical age of onset.” (DSM-5, pg. 189) Diagnostic Changes Definition of Mental Disorder: DSM-IV • DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR all used the same definition: “A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever the original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction. Neither deviant behavior (e.g. political, religious, or sexual) and conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.” The Narrative Institutewwww.narrativeinstitute.org 18 8/5/2013 Definition of Mental Disorder: DSM-5 • DSM-5: “A syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behaviors (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.” General Changes • The DSM-5 replaces the NOS categories with two options: other specified disorder and unspecified disorder to enhance diagnostic specificity to the clinician. • 799.9 Diagnosis or Condition Deferred has been dropped, though the provisional specifier is still available. General Changes • Some cultural concepts have been integrated into various “Other Specified” diagnoses. – e.g.,- Shubo-kyofu, Koro, & Jikoshu-kyofo are some of the options listed under Other Specified Obsessive-Compulsive and Related Disorder. • Some of the disorders and subtypes share the same diagnostic code because DSM codes are now completely compatible with ICD codes, and therefore new codes could not be created for billing purposes. – e.g., Hoarding Disorder and Obsessive-Compulsive Disorder share 300.3 (F42). However, the name of the diagnosis should always be recorded in the medical record, not only the code. • Some of the names of DSM-5 disorders are different than names used in the ICD system. Again, this is due to the necessity of lining up the codes with the ICD system. The Narrative Institutewwww.narrativeinstitute.org 19 8/5/2013 DSM-5 Disorder DSM5/ICD-9CM Code ICD-9-CM Title DSM5/ICD-10CM Code ICD-10-CM Title Social (pragmatic) communication disorder 315.39 Other developmental speech or language disorder F80.89 Other developmental disorders of speech and language Disruptive mood dysregulation disorder 296.99 Other specified episodic mood disorder F34.8 Other persistent mood [affective] disorders Premenstrual dysphoric disorder 625.4 Premenstrual tension syndromes N94.3 Premenstrual tension syndrome Hoarding disorder 300.3 Obsessive- compulsive disorders F42 Obsessive- compulsive disorder Other specified obsessive 300.3 compulsive and related disorder Obsessive- compulsive disorders F42 Obsessive- compulsive disorder Unspecified obsessive compulsive and related disorder Obsessive- compulsive disorders F42 Obsessive- compulsive disorder Excoriation (skin picking) 698.4 disorder Dermatitis factitia [artefacta] L98.1 Factitial dermatitis Binge eating disorder Bulimia nervosa F50.8 Other eating disorders 300.3 307.51 Coding Mistakes in DSM-5 • In their rush in getting the DSM-5 released, the APA had several coding mistakes. Code mistakes and corrections can be found at http://www.dsm5.org/Documents/IMPORTANT%20CODI NG%20CORRECTIONS%20FOR%20DSM-5%207-1513.pdf Coding Corrections for DSM-5 and DSM-5 Desk Reference – Updated 6/20/13 Name of Disorder Incorrectly Listed As Corrected Code IN DSM-5: Corrections should be made on the following pages: IN DSM-5 DESK REFERENCE: Corrections should be made on the following pages: Intellectual Disability (Intellectual Developmental Disorder) 319 (70) Mild 319 (71) Moderate 319 (72) Severe 319 (73) Profound 317 (70) Mild 318.0 (71) Moderate 318.1 (72) Severe 318.2 (73) Profound xiii, 33, 848, 872 (also delete coding note on page 33) ix, 18 (also delete coding note on page 18) Selective Mutism 312.23 (F94.0) 313.23 (F94.0) xviii, 195, 859, 871 xvii, 116 Trichotillomania (Hair-Pulling Disorder) 312.39 (F63.2) 312.39 (F63.3) xix, 251, 861, 890 xviii, 133 Conduct Disorder, Adolescent Onset Type 312.32 (F91.2) 312.82 (F91.2) xxiv, 846, 871 xxv Kleptomania 312.32 (F63.3) 312.32 (F63.2) xxiv, 478, 848, 890 xxvi, 225 The Narrative Institutewwww.narrativeinstitute.org 20 8/5/2013 DSM-5 Disorders Clusters/Groups • Neurodevelopmental Cluster – Neurodevelopmental Disorders – Schizophrenia Spectrum & Other Psychotic Disorders • • • • • • Internalizing Cluster Somatic Cluster Externalizing Cluster Neurocognitive Cluster Personality Cluster Other Cluster Neurodevelopmental Disorders • Intellectual Disabilities –Intellectual Disability (Intellectual Developmental Disorder) –Global Developmental Delay –Unspecified Intellectual Disability (Intellectual Developmental Disorder) The Narrative Institutewwww.narrativeinstitute.org 21 8/5/2013 Neurodevelopmental Disorders • Intellectual Disability (Intellectual Developmental Disorder) • A federal statute (Public Law 111-256, Rosa’s Law) replaces the term “mental retardation” with “intellectual disability”, which is reflected in the DSM-5. • The term Intellectual Developmental Disorder will be used in the ICD-11 Neurodevelopmental Disorders • Intellectual Disability (Intellectual Developmental Disorder) – Emphasis is placed in the wording on intellectual and adaptive functioning deficits, and changes the severity specifiers to the basis of adaptive functioning rather than IQ scores since adaptive functioning determines the level of support required. See pages 34-36 for information to determine severity level. – The ICD-9 coding is inaccurate in both the DSM-5 and the Desk Reference. Coding is done by specifier: 317 Mild, 318.0 Moderate, 318.1 Severe, 318.2 Profound Neurodevelopmental Disorders • Communication Disorders – Language Disorder • A combination of DSM-IV’s Expressive and Mixed Receptive-Expressive Language Disorders – Speech Sound Disorder • Previously Phonological Disorder, changed to reflect the understanding that the etiology of the disorder may be from difficulty with phonological knowledge or with the ability to coordinate movements for speech. The Narrative Institutewwww.narrativeinstitute.org 22 8/5/2013 Neurodevelopmental Disorders • Communication Disorders • Childhood-Onset Fluency Disorder (Stuttering) – Criteria are mostly unchanged except: • Criteria A deletes interjections as an option • Criteria B adds anxiety about the disturbance as an option if other limitations are not present • There is an additional criteria that the onset be in childhood as Adult-Onset Fluency Disorder has a separate diagnosis code. Neurodevelopmental Disorders • Social (Pragmatic) Communication Disorder • New diagnosis • SCD is characterized by a persistent difficulty in the social use of verbal and nonverbal communication that cannot be explained by low cognitive ability. • Symptoms include difficulty in the acquisition and use of spoken and written language as well as problems with inappropriate responses in conversation that result in functional limitations. Neurodevelopmental Disorders • Autism Spectrum Disorder – Research supports the combination of four separate disorders from the DSM-IV, Autistic Disorder (Autism), Asperger’s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder NOS, into a continuum of symptom severity. – ASD requires both deficits in social communication and social interaction and restricted repetitive behaviors, interests, and activities (RRBs) The Narrative Institutewwww.narrativeinstitute.org 23 8/5/2013 Neurodevelopmental Disorders • Autism Spectrum Disorder – 3 Levels of Severity: (see table on pg. 52) • Level 1: Requiring support • Level 2: Requiring substantial support • Level 3: Requiring very substantial support – Note: Anyone with an established DSM-IV diagnosis of Autism, Asperger’s, or PDD NOS should be given the diagnosis of ASD for continuity of care. • Rett’s Disorder has been dropped as it is now understood to be a neurogenetic disorder with specific etiology. Neurodevelopmental Disorders • Attention Deficit Hyperactivity Disorder (ADHD) – Research has shown that ADHD symptoms can often hold steady through adulthood, and so DSM-5 seeks to enable adults to receive care. – The symptoms have not changed, but they have included examples to help clinicians identify the symptoms in clients of all ages. – Children still need to exhibit at least 6 symptoms, but older adolescents and adults only need 5. – Also, several symptoms must have been present before age 12, which was changed from age 7 in DSM-IV. Neurodevelopmental Disorders • Specific Learning Disorder • Because various learning deficits commonly cooccur, the DSM-5 has combined Reading Disorder, Disorder of Written Expression, and Mathematics Disorder, though they still have separate diagnosis codes. The Narrative Institutewwww.narrativeinstitute.org 24 8/5/2013 Neurodevelopmental Disorders • Motor Disorders • No substantial changes in this category, though criteria in stereotypic movement disorder differentiates from body-focused repetitive behavior disorders in the chapter on obsessivecompulsive and related disorders. Schizophrenia Spectrum & Other Psychotic Disorders • Schizophrenia – Regarding symptomatic changes to schizophrenia, the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (multiple voices conversing with one another) was eliminated. The special attribution of these two symptoms in the DSM-IV meant that the manifestation of only one of the symptoms was sufficient in and diagnosis of schizophrenia. – The symptom threshold has been raised from 1 to 2 specific symptoms exhibited to qualify for diagnosis, including the requirement of the symptom of delusions, hallucinations, or disorganized speech Schizophrenia Spectrum & Other Psychotic Disorders • Schizophrenia – The DSM-5 has also done away with the subtypes of schizophrenia as research showed that these were too labile and/or too commonly overlapped with other subtypes. Certain subtypes are now descriptive specifiers and can be applied to other disorders such as schizoaffective disorder, major depressive disorder, and bipolar disorder. The Narrative Institutewwww.narrativeinstitute.org 25 8/5/2013 Schizophrenia Spectrum & Other Psychotic Disorders • Schizoaffective Disorder • The changes regarding schizoaffective disorder involve a more stringent criterion that a major mood episode needs to be present for the majority of the time that schizophrenic symptoms are also being exhibited. • The desire was to make schizoaffective disorder more of a longitudinal diagnosis rather than an episodic one. Schizophrenia Spectrum & Other Psychotic Disorders • Delusional Disorder • The criterion that delusions be “non-bizarre” has been removed with the updates to the DSM-5, with an added specifier for bizarre type delusions. • Explicit demarcation has also been added to exclude overlap with psychotic variants of obsessive-compulsive disorder and/or body dysmorphic disorder. If symptoms are better explained by either OCD or BDD then those diagnoses are to be used. Schizophrenia Spectrum & Other Psychotic Disorders • Delusional Disorder • Shared delusional disorder is no longer separated from delusional disorder in DSM-5, if shared delusions are present but the criteria for delusional disorder is not, the diagnosis should be “other specified schizophrenia spectrum and other psychotic disorder.” The Narrative Institutewwww.narrativeinstitute.org 26 8/5/2013 Schizophrenia Spectrum & Other Psychotic Disorders • Catatonia • Criteria for this diagnosis is standardized across all disorders; whether it be depressive, bipolar, psychotic, medical, or unidentified. All contexts require three symptoms (up from the one or two symptoms) out of 12 in order to meet diagnosis for catatonia. • Catatonia may be used as a separate diagnosis or as a specifier within psychotic, bipolar, or depressive disorders. Clusters/Groups • Neurodevelopmental Cluster • Internalizing Cluster • • • • • – Bipolar & Related Disorders – Depressive Disorders – Anxiety Disorders – Obsessive-Compulsive & Related Disorders – Trauma- & Stressor-Related Disorders – Dissociative Disorders Somatic Cluster Externalizing Cluster Neurocognitive Cluster Personality Cluster Other Cluster Bipolar & Related Disorders • Bipolar Disorders – The criteria for bipolar episodes, whether manic or hypomanic, now focus on changes in both activity and energy level as opposed to just mood. – The diagnosis of bipolar I disorder, mixed episode, has been removed from the DSM-5 and replaced with the specifier “with mixed features.” This new specifier may be used with either bipolar I or bipolar II. – A new specifier of “anxiety distress” has been added to delineate anxiety symptoms manifested along with the bipolar symptoms. The Narrative Institutewwww.narrativeinstitute.org 27 8/5/2013 Depressive Disorders • New depressive disorders such as “disruptive mood dysregulation disorder” and “premenstrual dysphoric disorder” have been added to the DSM-5. Disruptive mood dysregulation disorder is intended for children up to the age of 18 years who exhibit many symptoms that were previously categorized as bipolar disorder. The results of significant research has led to “premenstrual dysphoric disorder” being classified in the main body of the DSM-5 (whereas in the DSM-IV it was included in appendix B as a diagnosis for “further study”) Depressive Disorders • Major Depressive Disorder – The main diagnostic criterion for major depressive disorder remains unchanged in the DSM-5. The cooccurrence of manic symptoms which are insufficient for a diagnosis of a manic episode now fall under the specifier of “with mixed features.” – The exclusion of bereavement has been removed from the DSM-5. This was done as research showed that the loss of a loved one often precipitated a major depressive episode and because bereavement related depression symptoms responded the same to medication and psychological treatments which are shown to be efficacious in the treatment of non-bereavement related depression. – See section 3 for persistent complex bereavement disorder Depressive Disorders • Persistent Depressive Disorder • This is disorder is a merger of both chronic major depressive disorder and dysthymic disorder. • The merger came out of the lack of scientifically significant findings regarding differences between the two previously separate diagnoses. • You would not give a the diagnoses of major depressive disorder and persistent depressive disorder at the same time. The Narrative Institutewwww.narrativeinstitute.org 28 8/5/2013 Anxiety Disorders • Changes to the anxiety disorders chapter of the DSM-5 include the removal of obsessivecompulsive disorder, posttraumatic stress disorder, and acute stress disorder; which of all been placed in different chapters related specifically to obsessive-compulsive and trauma-stressor disorders. Anxiety Disorders • Agoraphobia, Specific Phobia, Social Anxiety Disorder • Changes to the phobic disorders include the removal of the requirement that an individual over 18 recognizes that their anxiety is excessive or unreasonable, and instead simply qualifies that the anxiety is out of proportion to the actual threat or danger of the situation. Also, the requirement that the phobic features be present for six months duration now applied to individuals all ages as opposed to simply individuals under the age of 18 Anxiety Disorders • Panic attack • The main diagnostic structure of panic attacks remains the same. However, the descriptions of the different types of panic attacks have been simplified to “unexpected” or “expected” panic attacks. As panic attacks were seen as an indicator for the severity of many diagnoses, “with panic attacks” can be listed as a specifier with all DSM-5 diagnosis. The Narrative Institutewwww.narrativeinstitute.org 29 8/5/2013 Anxiety Disorders • Panic Disorder and Agoraphobia • The previous connection of panic disorder and agoraphobia from the DSM-IV is done away with in the DSM-5, with panic disorder and agoraphobia being two completely separate diagnoses. • In instances where there is cooccurrence of panic disorder and agoraphobia they are coded as two separate diagnoses. • Agoraphobia now requires the presence of two or more situations causing fear, this to help distinguish agoraphobia from other specific phobias. Anxiety Disorders • Specific Phobias • The only change to the diagnostic criteria for specific phobias is that insight and/or belief in the excessiveness or unreasonableness of the phobic fear is no longer required for individuals over 18 years old to receive the diagnosis. Anxiety Disorders • Social anxiety disorder (social phobia) • Like specific phobias, individuals over the age of 18 are not now required to recognize the excessiveness or unreasonableness of their fear in order to be diagnosed. 2 diagnostic specifiers added to social anxiety disorder are “generalized” and “performance only.” This change was done as research had shown that those who experience social anxiety only in the context of performance situations, such as public speaking, represented a distinct subgroup in terms of both etiology and treatment. The Narrative Institutewwww.narrativeinstitute.org 30 8/5/2013 Anxiety Disorders • Separation Anxiety Disorder • This disorder has been moved from the section of “disorders usually first diagnosed in infancy, childhood, or adolescence” and is now classified in the “anxiety disorder” section. • The disorder may now be diagnosed even if the onset has been shown after the age of 18. • An addition to the criterion is that the anxiety must be present for 6 months or more. Anxiety Disorders • Selective Mutism • Like separation anxiety disorder, this disorder has been moved from the section of “disorders usually first diagnosed in infancy, childhood, or adolescence” and is now classified in the “anxiety disorder” section as research has shown that anxiety is a major feature of individuals with selective mutism. Obsessive-Compulsive & Related Disorders • This chapter on obsessive-compulsive and related disorders is new to the DSM-5. “Because recent studies have shown that obsessive-compulsive disorder involves distinct neurocircuits, it and several related disorders constitute their own chapter instead of being addressed in the chapter on anxiety disorders” (The Organization of DSM-5). • Disorders in this section include the DSM-IV diagnoses of obsessive-compulsive disorder, body dysmorphic disorder, and trichotillomania (hair-pulling disorder); as well as new disorders including excoriation (skin-picking) disorder, hoarding disorder, substance-/medication-induced obsessive-compulsive and related disorder and obsessive-compulsive and related disorder due to another medical condition. The Narrative Institutewwww.narrativeinstitute.org 31 8/5/2013 Obsessive-Compulsive & Related Disorders • New specifiers for obsessive-compulsive and related disorders • The three specifiers of “good or fair insight,” “poor insight, “ and “absent insight/delusional” are given for use in obsessivecompulsive disorder with analogous specifiers also added to body dysmorphic disorder and hoarding disorder. The “absent insight/delusional” specifier now allows individuals who meet the criteria to be diagnosed with a obsessive-compulsive or related disorder rather than a schizophrenia spectrum disorder. • An added “tic-related” specifier for obsessive-compulsive disorder has also been added due to growing research showing the comorbidity between obsessive-compulsive disorder and a tic disorder and how this might have relevance in the clinical situation. Obsessive-Compulsive & Related Disorders • Body Dysmorphic Disorder • Relevant to the reclassification of body dysmorphic disorder from a somatic disorder into the new section of obsessivecompulsive and related disorders, the new criterion for body dysmorphic disorder involves the patient engaging in repetitive behaviors or mental acts in response to their preoccupation with perceived defects or flaws in their physical appearance. • A new specifier of “with muscle dysmorphia” has also been added to reflect growing research regarding the particulars of those whose fixation is related to their muscles. • The specifier of “absent insight/delusional” with body dysmorphic disorder is now to be utilize with those presenting with the delusional variant of body dysmorphic disorder as opposed to the DSM-IV duel-diagnosis of delusional disorder, somatic type, and body dysmorphic disorder. Obsessive-Compulsive & Related Disorders • Hoarding Disorder • This represents a new diagnosis for the DSM-5 that is seen as related to obsessive-compulsive disorder but has been shown by the available data not to be a variant of OCD or any other mental disorder. • This diagnosis involves the patient presenting with persistent difficulty discarding or parting with possessions and noted distress associated in discarding them. The Narrative Institutewwww.narrativeinstitute.org 32 8/5/2013 Obsessive-Compulsive & Related Disorders • Trichotillomania (hair-pulling disorder) • The parenthetical “hair-pulling disorder” is the only noted change to trichotillomania beyond the categorization shift from the DSM-IV to the DSM-5. • Excoriation (skin-picking) Disorder • Excoriation represents a new disorder in the DSM-5. It is characterized by the recurrent urge to pick at one's own skin, often to the point of causing dermatological damage. Obsessive-Compulsive & Related Disorders • Substance/medication-induced obsessive-compulsive and related disorder and obsessive-compulsive and related disorder due to another medical condition • This new diagnosis replaces the DSM-IV diagnosis of “anxiety disorder due to a general medical condition with obsessivecompulsive symptoms.” The diagnosis also replaces the DSMIV diagnosis of “substance-induced anxiety disorder” with the “obsessive-compulsive symptoms” specifier. Obsessive-Compulsive & Related Disorders • Other specified and unspecified obsessive-compulsive and related disorders • Conditions under this category include “body-focused repetitive behavior disorder,” “obsessional jealousy,” and “unspecified obsessive-compulsive and related disorder.” • Body-focused repetitive behavior disorder involves recurrent body focused behaviors, other than hair pulling and skin picking, (i.e., nail biting, etc.). • Obsessional jealousy involves a preoccupation with perceived infidelity of one's partner that does not qualify as delusional. The Narrative Institutewwww.narrativeinstitute.org 33 8/5/2013 Trauma- & Stressor-Related Disorders • This new category allows for broader qualification in traumatic experience in many of the trauma-based diagnoses, with vicarious experiences of stress and trauma now seen as legitimate underlying causes for many of the Trauma-& Stressor-Related Disorders. Trauma- & Stressor-Related Disorders • Posttraumatic Stress Disorder • “Compared to DSM-IV, the diagnostic criteria for DSM-5 draw a clearer line when detailing what constitutes a traumatic event. Sexual assault is specifically included, for example, as is a recurring exposure that could apply to police officers or first responders. Language stipulating an individual’s response to the event—intense fear, helplessness or horror, according to DSM-IV—has been deleted because that criterion proved to have no utility in predicting the onset of PTSD” (http://www.dsm5.org/Documents/PTSD%20Fact%20Sheet.pdf) • The DSM-5 attempts take into account behavioral symptoms that manifest with PTSD. To this end, 4 diagnostic clusters of re-experiencing, avoidance, negative cognitions and mood, and arousal. Trauma- & Stressor-Related Disorders • Acute Stress Disorder • An explicit qualification of the traumatic event experienced is now required for the diagnosis of acute stress disorder; with the qualifiers being that the event was experienced directly, was witnessed, or was experienced indirectly. • The DSM-IV criteria that “the person’s response involved intense fear, helplessness, or horror” has been removed due to the lack of supporting research in the diagnostic validity of that requirement. The Narrative Institutewwww.narrativeinstitute.org 34 8/5/2013 Trauma- & Stressor-Related Disorders • Adjustment Disorders • The DSM-5 reclassified as just disorders in the context of stress-response conditions occurring in reaction to distressing events. This is a reconceptualization of the adjustment disorders, which in the DSM-IV were used to diagnose individuals exhibiting clinically significant symptoms without meeting the criteria for a range of other disorders. The DSM-IV subtypes of “depressed mood,” “anxiety,” and “disturbance in conduct” have been retained in the DSM-5 without changes. Trauma- & Stressor-Related Disorders • Reactive attachment disorder • The two subtypes of reactive attachment disorder, “emotionally withdrawn/inhibited” and “indiscriminately social/disinhibited,” that were found in the DSM-IV have been redefined as distinct disorders in the DSM-5. • Reactive attachment disorder now entails only the “emotionally withdrawn/inhibited” subtype whereas the “indiscriminately social/disinhibited” subtype fits into the new diagnosis of “Disinhibited Social Engagement Disorder.” • Both disorders are seeing as an outcome of social neglect and healthy attachment. • Yet reactive attachment disorder is seen as more closely related to internalizing disorders, while disinhibited social engagement disorder is more closely linked with ADHD and the Neurodevelopmental cluster. Dissociative Disorders • Dissociative Identity Disorder • The criteria for diagnosis of dissociative identity disorder now allows for self-report, as well as observance by others, as meeting criterion A for diagnosis. • Criterion B now allows for recurrent gaps in recall for events that are not necessarily consider traumatic. • There is also now a greater willingness to consider certain possession-form phenomenon and neurological symptoms in accounting for the diversity of presentation in this disorder. The Narrative Institutewwww.narrativeinstitute.org 35 8/5/2013 Clusters/Groups • • Neurodevelopmental Cluster Internalizing Cluster • Somatic Cluster – Somatic Symptom & Related Disorders – Feeding & Eating Disorders – Elimination Disorders – Sleep-Wake Disorders – Sexual Dysfunctions – Gender Dysphoria • • • • Externalizing Cluster Neurocognitive Cluster Personality Cluster Other Cluster Somatic Symptom & Related Disorders • What was known in the DSM-IV as somatoform disorders are now called “somatic symptom and related disorders” in the DSM-5. There is a reduction of number and subcategories of these disorders in the DSM-5 in order to decrease diagnostic overlap. Somatic Symptom & Related Disorders • Somatic Symptom Disorder • This new disorder is designed to replace the DSM-IV diagnosis of somatization disorder and undifferentiated somatoform disorder, which is problematic due to its high symptom count required for diagnosis and its preclusion against the diagnosis of another medical condition. The new diagnosis of somatic symptom disorder is designed to diagnose individuals maladaptive thoughts, feelings, and behaviors with somatic symptoms that may or may not be related to a known medical condition. The Narrative Institutewwww.narrativeinstitute.org 36 8/5/2013 Somatic Symptom & Related Disorders • Somatic Symptom Disorder • The significance placed on the requirement of medically unexplained symptoms for many of the somatoform disorders in the DSM-IV has been lessened in the DSM-5 with the recognition that the establishment of a diagnosis because of the absence of an explanation was problematic and did not recognize the reciprocal affects between psychological and physiological stress that current research has validated. Somatic Symptom & Related Disorders • Somatic Symptom Disorder • The DSM-5 therefore focuses on diagnosis on the basis of positive symptoms, whether somatic or psychological in nature, and diminishes the importance of positively proving the absence of a medical explanation for the symptoms. The exception to this is in conversion disorder or pseydocyesis (phantom pregnancy) because in these cases it is possible to demonstrate the lack of medical causation. Somatic Symptom & Related Disorders • Hypochondriasis and illness anxiety disorder • The DSM-5 has removed hypochondriasis from its list of disorders as connotation of the diagnosis was perceived as pejorative. For individuals who would have previously met diagnostic criteria for hypochondriasis who experience both high health anxiety and significant somatic symptoms, the diagnosis should be somatic symptom disorder. • For those individuals with high health anxiety without somatic symptoms, the new diagnosis of “illness anxiety disorder” is most appropriate when a primary anxiety disorder does not provide better explanation. The Narrative Institutewwww.narrativeinstitute.org 37 8/5/2013 Somatic Symptom & Related Disorders • Pain Disorder • The growing body of research which has demonstrated major psychological factors in all experienced forms of pain has influenced the restructuring of pain disorder in the DSM-5. The DSMIV subcategories of pain associated solely with psychological factors, pain associated with medical diseases or injuries, and pain associated with both has been eliminated due to the poor reliability and validity between these subcategories. Somatic Symptom & Related Disorders • Psychological Factors Affecting Other Medical Conditions • This was included in the DSM-IV under Other Conditions That May Be a Focus of Clinical Attention, but was made a mental disorder in the DSM-5 in part because of its common utilization in insurance billing Somatic Symptom & Related Disorders • Factitious Disorder & Factitious Disorder Imposed on Another • Previously had their own chapter, but subsumed under this chapter as they commonly occur in medical settings. • Factitious Disorder Imposed on Another has been taken out of the NOS shadow, and the name clarified (from Factitious Disorder By Proxy). • Criteria for both are slightly altered (see pgs. 324325). The Narrative Institutewwww.narrativeinstitute.org 38 8/5/2013 Somatic Symptom & Related Disorders • Conversion Disorder (functional neurological symptom disorder) • Criteria for conversion disorder has changed to emphasize the lack of evidence of psychologically causal factors at the time of diagnosis and reemphasizes the importance of neurological examination in excluding diagnosable neurological impairment as causal for the dysfunction. Feeding & Eating Disorders • Pica and Rumination Disorder • the age restrictions found in the DSM-IV for both Pica and Rumination disorder have been removed so now the diagnosis may be made for individuals regardless of age. • Avoidant/Restrictive Food Intake Disorder • The diagnosis was previously known as feeding disorder of infancy or early childhood. Along with the name change, the DSM-5 expands the diagnostic field for this disorder to include adult individuals as well as children and adolescents. Feeding & Eating Disorders • Anorexia Nervosa • Most of the diagnostic criteria for anorexia nervosa remains unchanged, though the requirement of amenorrhea (absence of menstrual period) has been completely eliminated as a requirement for the disorder. • Criterion B of the diagnosis is been expanded to include persistent behavior that interferes with weight gain as opposed to only overtly expressed fear of weight gain. The Narrative Institutewwww.narrativeinstitute.org 39 8/5/2013 Feeding & Eating Disorders • Bulimia Nervosa • DSM-5 criteria for bulimia nervosa reduces the required minimum of frequency of binge eating and inappropriate compensatory behavior from the DSMIV requirement twice a week to only once a week. Feeding & Eating Disorders • Binge Eating Disorder • As with bulimia nervosa, the diagnostic threshold for binge eating disorder has been lowered from the DSM-IV standard of binge eating twice weekly for 6 months to the new standard of once weekly over the last 3 months. The major diagnostic difference between bulimia nervosa and binge eating is that binge eating does not involve the inappropriate compensatory behavior in response to the binge eating. Elimination Disorders • No major changes have been made to elimination disorders in the DSM-5, except for their reclassification into their own chapter instead of being classified under disorders usually first diagnosed in infancy, childhood, or adolescence as was the case in the DSM-IV. The Narrative Institutewwww.narrativeinstitute.org 40 8/5/2013 Sleep-Wake Disorders • Due to the research which has demonstrated the interactive, and not necessarily causal, effects between sleep disorders and comorbid medical and mental disorders, the DSM-5 has removed the previous diagnoses of “sleep disorders related to another mental disorder” and “sleep disorder related to general medical condition.” • The differentiation between primary and secondary insomnia is also reduced with both DSM-IV disorders now falling under the new diagnosis of “insomnia disorder.” • Hypersomnolence is now distinguished from narcolepsy, as narcolepsy has been shown to be associated with hypocretin deficiency. Sexual Dysfunctions • Genito-Pelvic Pain/Penetration Disorder • This new disorder replaces the previous DSM-IV diagnoses of vaginismus and dyspareunia, which had high symptom overlap and comorbidity. • Sexual Aversion Disorder • This diagnosis is been removed from the DSM-5 due to the lack of supporting research and underuse diagnostically by clinicians. Gender Dysphoria • Gender dysphoria represents a new section in the DSM-5 and reflects the different conceptualization of “gender congruence” as not helpfully related to sexual dysfunctions and paraphilias, which was were the DSM-IV’s diagnosis of gender identity disorder was categorized. • The new diagnostic conceptualization focuses more on the wording of “gender incongruence” rather than cross-gender identification. This is an acknowledgment of the wide variety of gender incongruent variances individuals may have. The Narrative Institutewwww.narrativeinstitute.org 41 8/5/2013 Gender Dysphoria • In children, the criteria of a “strong desire to be the other gender” replaces “repeatedly stated desire to be the other gender” which recognizes that in certain environments children may not verbalize their desire to be a different gender. • A specifier of “posttransition” has been added to gender dysphoria those individuals who are still pursuing various treatments related to living as their desired gender, though they may not still need the initial diagnostic criteria for gender dysphoria. Clusters/Groups • Neurodevelopmental Cluster • Internalizing Cluster • Somatic Cluster • Externalizing Cluster – Disruptive, Impulse-Control, & Conduct Disorders – Substance-Related & Addictive Disorders • Neurocognitive Cluster • Personality Cluster • Other Cluster Disruptive, Impulse-Control, & Conduct Disorders • This is a new chapter in the DSM-5 incorporates disorders that were previously found in the chapter “disorders usually first diagnosed in infancy, childhood, or adolescence.” The main distinction of these disorders is that they are characterized by difficulties in behavioral and emotional self-control. Because of its comorbidity with some of these disorders in later development, antisocial personality disorder is listed both in this chapter as well as in the chapter on personality disorders. The Narrative Institutewwww.narrativeinstitute.org 42 8/5/2013 Disruptive, Impulse-Control, & Conduct Disorders • Oppositional Defiant Disorder • 4 modifications of note have been made to oppositional defiant disorder. Firstly, symptoms are now grouped around the three types of “angry/irritable mood,” “argumentative/defiant behavior,” and “vindictiveness.” This refinement has been done to better encapsulate what is seen as both the emotional and behavioral elements of this disorder. Secondly, the exclusion criterion related to conduct disorder has been eliminated. Thirdly, a guide regarding frequency has been added in order to avoid overdiagnosis for defiant behavior that is considered developmentally normative in children and adolescents. And finally a severity rating has been added related to the pervasiveness of the contexts of symptoms. Disruptive, Impulse-Control, & Conduct Disorders • Conduct Disorder • Mostly unchanged from the DSM-IV, though the specifier has been added for individuals who also display with “limited pro-social emotions” as this has been shown as an indicator of severity in the disorder. Disruptive, Impulse-Control, & Conduct Disorders • Intermittent Explosive Disorder • The DSM-5 has expanded to include verbal and nondestructive aggression as meeting diagnostic criteria, whereas the DSM-IV required physical aggression. In order to avoid overdiagnosis for temper tantrums immune children which are considered developmentally normative, a minimum of six years of age, or the developmental equivalent, is now required. The outbursts also have to be deemed to be driven by impulsivity and/or anger, and cause marked distress and impairment, in order to qualify for diagnosis. The Narrative Institutewwww.narrativeinstitute.org 43 8/5/2013 Substance-Related & Addictive Disorders • Gambling Disorder • In including gambling disorder, the DSM-5 incorporated, for the first time, a process/behavioral addiction which is not directly related to substance use. Though other process/behavioral addictions were considered for inclusion in the DSM-5 (notably sex addiction), gambling disorder was the only nonsubstance addiction considered to be empirically supported enough for inclusion at this point. Substance-Related & Addictive Disorders • Substance Use Disorder – The previously independent diagnoses of substance abuse and substance dependence have been merged in the DSM5 into substance use disorder. Previous DSM-IV diagnostic requirements for recurrent legal problems have been eliminated out of the DSM-5 requirements. Added have been criterion for “creating or a strong desire were urged to use the substance.” The combination of the two previous disorders the diagnostic threshold has been increased to meeting two or more criteria rather than one or more as was the case in the DSM-IV. • Cannabis Withdrawal and Caffeine Withdrawal are new diagnoses in the DSM-5. Clusters/Groups • • • • Neurodevelopmental Cluster Internalizing Cluster Somatic Cluster Externalizing Cluster • Neurocognitive Cluster • Neurocognitive Disorders • Personality Cluster • Other Cluster The Narrative Institutewwww.narrativeinstitute.org 44 8/5/2013 Neurocognitive Disorders (NCDs) • The disorders listed in this chapter were previously under the DSM-IV chapter “Delirium, Dementia, and Amnestic and Other Cognitive Disorders” • Delirium • Previously Delirium was broken into 5 different diagnoses, but in the DSM-5 all of them are listed together with clarified criteria along with different specifiers and coding notes to identify the etiology of the condition. Neurocognitive Disorders (NCDs) • Major and Mild Neurocognitive Disorders – Combines DSM-IV diagnoses of Dementia and Amnestic Disorder. – The term “dementia” may still be used when appropriate and necessary, but not all Major and Mild NCDs will apply. – Mild NCDs are included to allow for early detection and treatment of the cognitive issues that go beyond normal aging in order to hopefully slow and possibly even halt progression. – Note: severity specifiers in Major NCD address difficulties with activities of daily living (ADL), not the level of cognitive deficits. Neurocognitive Disorders (NCDs) • Major and Mild Neurocognitive Disorders – A table is available on page 593 with updated cognitive domains with examples of symptoms, observations, and assessments. – In addition to the already established criteria sets for the etiological subtypes of alzheimer’s, vascular disease, and substance/medication use; there are new criteria sets for frontotemporal lobar degeneration, lewy body disease, traumatic brain injury, HIV infection, prion disease, parkinson’s disease, huntington’s disease. NCDs due to another medical condition, multiple etiologies, and unspecified are also included. The Narrative Institutewwww.narrativeinstitute.org 45 8/5/2013 Clusters/Groups • • • • • Neurodevelopmental Cluster Internalizing Cluster Somatic Cluster Externalizing Cluster Neurocognitive Cluster • Personality Cluster • Personality Disorders • Other Cluster Personality Disorders • Section II – They have retained the categorical approach with the same personality disorders with no change to criteria. (The reports of its demise have been greatly exaggerated). – The only changes are updates in terminology that reflects changes to other diagnoses. (e.g., Schizoid PD includes an exclusion that symptoms do not occur exclusively during Autism Spectrum Disorder, as opposed to Pervasive Developmental Disorder) – There is the addition of Personality Change Due to Another Medical Condition, and as it is throughout the DSM-5, Personality Disorder NOS has been broken apart into Other Specified and Unspecified Personality Disorder. Personality Disorders • Section II – Since the multi-axial format has been eliminated, these personality disorders are now to be listed alongside other mental disorder rather than listed separately. – There was much discussion about significantly changing the methodology of how we conceptualize and diagnose personality disorder, however, based on feedback, the APA decided it was premature to overhaul this section at this point. – There is an alternate model available for use in Section III which offers a hybrid methodology that incorporates both the categorical and dimensional approaches. The Narrative Institutewwww.narrativeinstitute.org 46 8/5/2013 Personality Disorders • Section III – The APA wanted to introduce the model they had developed in earlier drafts in order to allow professionals the ability to start using the model now with the hopes that they would become more familiar with the model (so there would be less push-back in the future), and also so clinicians and researchers can give feedback on its utility. – The hybrid model incorporates six of the familiar personality disorders (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal), though the criteria for there have been redesigned in a dimensional/trait approach. Personality Disorders • Section III • The hybrid model replaces the NOS designation with Personality Disorder-Trait Specified (PD-TS) which will provide a more informative diagnosis as it allows the clinician to identify trait domains and facets that are specific to the individual. Criteria for a Personality Disorder in the Hybrid Model- Section III • Criterion A: Level of personality functioning – Disturbances in self (identity and self-direction) and interpersonal (empathy and intimacy) functioning – Moderate or greater impairment The Narrative Institutewwww.narrativeinstitute.org 47 8/5/2013 Criteria for a Personality Disorder in the Hybrid Model- Section III • Criterion B: One or more pathological personality traits – Five broad domains (based on the Five Factor Model) 1. Negative Affectivity (vs. Emotional Stability): emotional lability, anxiousness, separation insecurity, submissiveness, hostility, perseveration, depressivity, suspiciousness, and restricted affectivity 2. Detachment (vs. Extraversion): withdrawal, intimacy avoidance, anhedonia, depressivity, suspiciousness, and restricted affectivity Criteria for a Personality Disorder in the Hybrid Model- Section III • Criterion B: One or more pathological personality traits – Five broad domains (based on the Five Factor Model) 3. Antagonism (vs. Agreeableness): manipulativeness, deceitfulness, grandiosity, attention seeking, callousness, and hostility 4. Disinhibition (vs. Conscientiousness): irresponsibility, impulsivity, distractibility, risk taking, and rigid perfectionism 5. Psychoticism (vs. Lucidity): unusual beliefs and experiences, eccentricity, cognitive and perceptual dysregulation. Criteria for a Personality Disorder in the Hybrid Model- Section III • Criteria C: – Inflexibility and pervasiveness of impairment and traits • Criteria D: – Stability of impairment and traits • Criteria E: – Not better accounted for by another mental disorder • Criteria F: – Not due to the effects of a substance or another medical condition • Criteria G: – Not normal for their developmental stage or sociocultural environment The Narrative Institutewwww.narrativeinstitute.org 48 8/5/2013 Level of Personality Functioning Scale (see pg. 775-778) • 0-4: 0 - Little or No Impairment, 1 - Some Impairment, 2 Moderate Impairment, 3 - Severe Impairment, 4 - Extreme Impairment • Must exhibit Moderate Impairment (Level 2) or above to qualify for a Personality Disorder. • This helps clinicians to be able to think about personality traits in a continuum, which not only prevents overdiagnosis, but also aids case conceptualization for clients who do not have a personality disorder. An example of proposed diagnostic criteria for Narcissistic PD A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following areas: 1. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal inflated or deflated, or vacillating between extremes; emotional regulation mirrors fluctuations in self-esteem. 2. Self-direction: Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations. An example of proposed diagnostic criteria for Narcissistic PD A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following areas: 3. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others. 4. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutually constrained by little genuine interest in others’ experiences and predominance of a need for personal gain. The Narrative Institutewwww.narrativeinstitute.org 49 8/5/2013 An example of proposed diagnostic criteria for Narcissistic PD B. Both of the following pathological personality traits 1. Grandiosity (an aspect of Antagonism): Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescension toward others. 2. Attention seeking (an aspect of Antagonism): Excessive attempts to attract and be the focus of the attention of others; admiration seeking. Criteria C - G are also met. An example of proposed diagnostic criteria for Narcissistic PD • Specifiers: Other traits and personality functioning specifiers may be used. For example, other traits of Antagonism can be specified when more pervasive antagonistic features (“malignant narcissism”) are present. Other traits of Negative Affectivity can be specified to record more “vulnerable” presentations. The level of personality functioning (Level 2-4) can also be specified. • Assessments for both adolescents and adults, as well as an informant version, are available online that help clinicians to identify specific traits in their clients. There are also brief versions that identify problems in the five domains. Clusters/Groups • • • • • • Neurodevelopmental Cluster Internalizing Cluster Somatic Cluster Externalizing Cluster Neurocognitive Cluster Personality Cluster • Other Cluster – Paraphilia Disorders – Other Mental Disorders – Medication-Induced Movement Disorders and Other Adverse Effects of Medication – Other Conditions That May Be a Focus of Clinical Attention Conditions for Further Study The Narrative Institutewwww.narrativeinstitute.org 50 8/5/2013 Paraphilia Disorders • A distinction is drawn in the DSM-5 between paraphilias and paraphilic disorders, with the requirement for paraphilic disorders being that the paraphilia causes “marked distress or impairment” or entails harm to self or others. These changes were done in order to avoid pathologizing consensual and non-distressing sexual activity which meets the criteria of paraphilia. Other Mental Disorders • This is the catch-all chapter that lists four diagnoses: – Other Specified Mental Disorder Due to Another Medical Condition – Unspecified Mental Disorder Due to Another Medical Condition – Other Specified Mental Disorder – Unspecified Mental Disorder Medication-Induced Movement Disorders and Other Adverse Effects of Medication • These disorders were previously included in the chapter for Other Conditions that May Be a Focus of Clinical Attention • Antidepressant Discontinuation Syndrome is a notable addition The Narrative Institutewwww.narrativeinstitute.org 51 8/5/2013 Other Conditions That May Be a Focus of Clinical Attention • These are not mental disorders. • These are conditions or problems that either are a reason for the visit or otherwise affect the diagnosis, course, prognosis, or treatment of the individual’s mental disorder. • These include codes from the ICD-9 (typically V codes) and ICD-10 (usually Z codes). • Some examples include Parent-Child Relational Problem, Child Sexual Abuse, Homelessness, Religious or Spiritual Problem, and Malingering. DSM-5: Section III A review what has not been looked at already Assessment Measures • Cross-Cutting Symptom Measures – “These 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.” – Only Level 1 is included in the DSM-5. Level 2 and disorderspecific severity measures are only available online. The Narrative Institutewwww.narrativeinstitute.org 52 8/5/2013 Assessment Measures • Clinician-Rated Dimensions of Psychosis Symptom Severity • This measures the presence and severity of 8 domains: hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms (restrictive emotional expression or avolition), impaired cognition, depression, and mania. Assessment Measures • World Health Organization Disability Assessment Schedule 2.0 (WHODAS 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.” – This is intended to replace the imprecise and uninformative GAF Score Assessment Measures • All of these assessments are available online http://www.psychiatry.org/practice/dsm/dsm5/onlineassessment-measures • Other clinician-rated severity measures are available online. These include: autism spectrum and social communication disorders, somatic symptom disorder, oppositional defiant disorder, conduct disorder, and nonsuicidal self-injury. • Also available online are personality inventories, early development and home background forms, and the cultural formulation interviews. The Narrative Institutewwww.narrativeinstitute.org 53 8/5/2013 Cultural Formulation Interview • In order to obtain the most useful clinical information, improve therapeutic rapport and efficacy, and to avoid problems with stereotyping and misdiagnosis, the CFI can be used with a client of any background. • “The CFI follows a person-centered approach to cultural assessment by eliciting information from the individual about his or her own views and those of others in his or her social network” (pg 751, DSM-5). • This can be used with any client, regardless of cultural background to aid the clinician in determining illness severity or impairment, agreement on course of care, and improving treatment compliance. Alternative DSM-5 Model for Personality Disorders Reviewed in Personality Disorder Section of this Seminar Conditions for Further Study • These conditions are not to be used for clinical use at this time. They are included to encourage further research. • As such, we will not be going into depth on these conditions. In earlier drafts of the DSM-5 some of these were included, which elicited a negative response from some. Because of this, there has been some confusion about their inclusion, so it is important to mention these. The Narrative Institutewwww.narrativeinstitute.org 54 8/5/2013 Conditions for Further Study • Attenuated Psychosis Syndrome – This is seen by some as a prodrome for other psychotic or mood disorders with psychotic features. – However, there lacks sufficient evidence for the condition developing into another disorder, and many feared that this would lead to the overuse of antipsychotics for individuals in whom they would do more harm than good. • Depressive Episodes With Short-Duration Hypomania – The main difference between this and Bipolar II is the hypomanic episode lasts 2-3 days as opposed to a minimum of 4 days in Bipolar II. Conditions for Further Study • Persistent Complex Bereavement Disorder – This is differentiated from normal grief by criteria that the death had to have occurred a minimum of 12 months prior, or 6 months for children, and by the presence of severe grief reactions that interfere with the person’s ability to function. • Caffeine Use Disorder – Substance dependence due to caffeine is included in the ICD-10 – One of the reasons it has not been included in Section II is that the diagnostic threshold needs to be higher than that of other substance use disorders to prevent overdiagnosis, and there needs to be further research to validate and potentially clarify proposed criteria. Conditions for Further Study • Internet Gaming Disorder – A potential addictive disorder, not including non-gaming forms of internet use (e.g., facebook, online shopping, pornography). • Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure (ND-PAE) – This is intended to encompass the full range of developmental disabilities associated with exposure to alcohol in utero. – The physical effects of Fetal Alcohol Syndrome are not necessary for diagnosis The Narrative Institutewwww.narrativeinstitute.org 55 8/5/2013 Conditions for Further Study • Suicidal Behavior Disorder – This involves a suicide attempt within the last 24 months. Suicidal ideation alone does not qualify • Nonsuicidal Self-Injury – Intentional self-inflicted damage to the surface of the body with the expectation that the injury will lead only to minor or moderate harm (there is no suicidal intent at the time of the behavior) – This is differentiated from Factitious Disorder, in which there may be injury done to self, though the person exaggerates the injury or otherwise seeks to deceive, in seeking care; whereas, with nonsuicidal self-injury, the individual uses the injury to reduce negative emotions, resolve interpersonal difficulty, or as a way to punish themselves, and often attempts to hide the injury from others. Summary Bibliography Clay, R. A. (2011). Revising the DSM. Monitor of Psychology, 42(1), 54. Retrieved July 22, 2013, from http://www.apa.org/monitor/2011/01/dsm.aspx Cosgrove, L., & Krimsky, S. (2012). A comparison of DSM-IV and DSM-5 panel members' financial associations with industry: a pernicious problem persists. PLoS Medicine, 9(3). Retrieved July 29, 2013, from http://www.plosmedicine.org/article/info%3Adoi%2F10.1 371%2Fjournal.pmed.1001190 DSM-5. (n.d.). psychiatry.org. Retrieved June 5, 2013, from www.psychiatry.org/dsm5 The Narrative Institutewwww.narrativeinstitute.org 56 8/5/2013 Bibliography DSM-5 development. (n.d.). APA DSM-5. Retrieved June 15, 2013, from http://www.dsm5.org DSM-5 press briefing. (2013, May 18). Psychiatry.org. Retrieved July 31, 2013, from http://www.psychiatry.org/advocacy-newsroom/newsroom/video-news/dsm-5-press-briefing Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington, D.C.: American Psychiatric Association. Bibliography Diagnostic and statistical manual of mental disorders: DSM-IVTR. (4th ed.). (2000). Washington, DC: American Psychiatric Association. Hyman, S. E. (2011). Grouping diagnoses of mental disorders by their common risk factors. The American Journal of Psychiatry, 168:1-3. Retrieved August 1, 2013, from ajp.psychiatryonline.org/article.aspx?articleID=102574 ICD vs. DSM. (2009, October). Monitor on Psychology, 40, No. 9, 63. Retrieved June 12, 2013, from http://www.apa.org/monitor/2009/10/icd-dsm.aspx Bibliography Insel, T. (2013, April 29). Director's blog: transforming diagnosis. NIMH. Retrieved July 16, 2013, from http://www.nimh.nih.gov/about/director/2013/transformin g-diagnosis.shtml Insel, T. R., & Lieberman, J. A. (2013, May 13). DSM-5 and RDoC: shared interests. NIMH. Retrieved July 16, 2013, from http://www.nimh.nih.gov/news/sciencenews/2013/dsm-5-and-rdoc-shared-interests.shtml International classification of diseases. (n.d.). Classifications. Retrieved June 11, 2013, from www.who.int/classifications/icd/en/ The Narrative Institutewwww.narrativeinstitute.org 57 8/5/2013 Bibliography Moran, M. (2013, May 3). DSM section contains alternative model for evaluation of PD . Psychiatric News, 10. Retrieved July 31, 2013, from http://psychnews.psychiatryonline.org/newsArticle.aspx? articleid=1685439 Moran, M. (2013, May 17). Section III of new manual looks to future. Psychiatric News, 10. Retrieved July 30, 2013, from http://psychnews.psychiatryonline.org/newsarticle. aspx?articleid=1688802 Online Assessment Measures. (n.d.). Psychiatry.org. Retrieved July 1, 2013, from http://www.psychiatry.org/practice/dsm /dsm5/online-assessment-measures Bibliography Psychiatry online. (n.d.). PsychiatryOnline. Retrieved July 2, 2013, from http://www.psychiatryonline.org Sharfstein, S. S. (2005, August 19). Big pharma and american psychiatry: the good, the bad, and the ugly. Psychiatric News. Retrieved August 2, 2013, from http://psychnews.psychiatryonline.org/newsarticle.aspx? articleid=109213 For humanistic psychology. (2011, October 22). Open letter to the DSM-5. iPetitions. Retrieved July 19, 2013, from http://www.ipetitions.com/petition/dsm5/ Fees Paid for Training Referrals If you know of an organization that could benefit from this training or others from the Narrative Institute, we like to pay a 5% referral fee if your lead results in a seminar being presented. Simply email us with your contact information and the information regarding the organization you are referring us to, along with a contact person for that organization. For a full list of our current trainings visit our website at www.narrativeinstitute.org Email us at [email protected] The Narrative Institutewwww.narrativeinstitute.org 58