DSM – 5: A Brief Overview Chuck Pistorio, Ph.D. Laura Tejada, Ph.D. Shedeh Tavakoli, Ph.D. Overview Outline significant changes Chapter organizations New categories New Diagnoses Eliminated diagnoses Review specific changes for some of the most commonly diagnosed disorders Changes in Philosophy Greater emphasis on culture Cultural Formulation Inventory (CFI) Awareness of international use ICD, WHO Validity rather than reliability More emphasis on client’s experiences and reported symptoms/needs Changes to Chapters Chapters reorganized Organized by common etiologies More dimensional approach Diagnosis is ongoing Reflects developmental lifespan Removed Disorders Usually Diagnosed in Infancy, Childhood & Adolescence Individual chapters organized developmentally Changes to Five-Axis System DSM-IV Five-Axis System DSM-5 Equivalent Axis I: Mental Health Disorders Record on diagnosis line List primary reason for visit first Axis II: Personality Disorders & Mental Record on diagnosis line Retardation List primary reason for visit first Axis III: General Medical Conditions Record on diagnosis line List those most important to understanding mental health first Axis IV: Psychosocial & Environmental Problems Record on diagnosis line V, Z, or T codes from chapter “Other Conditions that May be of Clinical Attention” (p. 715) Axis V: Global Assessment of Functioning [GAF] Optional use of World Health Organization Disability Schedule [WHODAS] (p. 745) Changes to Five-Axis System DSM-IV Five-Axis System DSM-5 Equivalent Axis I: 309.81 PTSD, with delayed onset; 296.32 Major Depressive Disorder, recurrent, moderate, with mild anxious distress 1. 309.81 PTSD, with delayed onset 2. 296.32 Major Depressive Disorder, recurrent, moderate, with mild anxious distress 3. V15.41 Personal history of spouse or partner violence, physical 4. V60.1 Inadequate housing 5. V60.2 Extreme poverty Axis II: No diagnosis Axis III: No diagnosis Axis IV: V.15.41 Personal history of spouse or partner violence, physical V60.1 Inadequate housing; V60.2 Extreme poverty Axis V: GAF score Changes to NOS Not Elsewhere Classified [NEC] Specific symptoms with code Other Specified Allows documentation of why client does not meet specific diagnostic criteria Unspecified Significant distress but does not meet criteria Insufficient information (crisis, ER) Organization & Content Section I Orientation Historical back ground Development of DSM-5 How to use it Section II Diagnostic Criteria and codes “Medication-induced Movement Disorders” “Other Conditions That May be a Focus of Clinical Attention.” Organization & Content Section III Emerging Measures and Models Assessment measures http://www.psychiatry.org/practice/dsm/dsm5/onlineassessment-measures Cultural formulation Alternative DSM-5 model for personality disorders “Criteria Sets for Conditions for Further Study” Appendix Highlights of changes from DSM-IV to DSM-5 Glossary of technical terms Glossary of cultural terms Alpha & numeric listings of diagnoses and codes List of advisors and contributors Structure for Each Diagnosis Diagnostic Criteria Subtypes and/or specifiers Severity Codes and recording procedures Explanatory text (new or expanded) Structure for Each Diagnosis Diagnostic and associated features Prevalence Development and course Risk and prognosis Culture- and gender-related factors Diagnostic markers Functional consequences Differential diagnosis Comorbidity New Disorders Social (Pragmatic) Communication Disorder Disruptive Mood Dysregulation Disorder Premenstrual Dysphoric Disorder Hoarding Disorder Excoriation (Skin‐Picking) Disorder Disinhibited Social Engagement Disorder (split from Reactive Attachment Disorder) Binge Eating Disorder New Disorders Central Sleep Apnea Sleep-Related Hypoventilation Rapid Eye Movement Sleep Behavior Disorder Restless Legs Syndrome Caffeine Withdrawal Cannabis Withdrawal Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other Medical Conditions) Mild Neurocognitive Disorder Eliminated Sexual Aversion Disorder Polysubstance-Related Disorder Diagnostic Changes New categories: Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Transformed: Neurodevelopmental Disorders (Infancy, adolescence, childhood) Somatic Symptom and Related Disorders Combined: Language disorders Insomnia Disorder Autism spectrum Alcohol use disorder Specific Learning Disorder Cannabis use disorder Delusional disorder Stimulant Intoxication Panic Disorder Stimulant withdrawal Dissociative Amnesia Substance/medicationinduced disorders Somatic Symptom Examples of Changes Trauma and Stress-Related Disorders New chapter in DSM-5 brings together anxiety disorders that are preceded by a distressing or traumatic event Reactive Attachment Disorder Disinhibited Social Engagement Disorder (new) PTSD (includes PTSD for children 6 years and younger) Acute Stress Disorder Adjustment Disorders Posttraumatic Stress Disorder (PTSD) There are 8 criterion Criteria (A)- Exposure to actual or threatened death, serious injury, or sexual violence Four symptom clusters, rather than three Re-experiencing (B) Avoidance (C) Persistent negative alterations in mood and cognition (D) Arousal- describes behavioral symptoms (E) Duration of B, C, D, and E is more than 1 month Causes clinically significant distress Not attributed to substance use or medical condition PTSD DSM 5 more clearly defines what constitutes traumatic event Sexual assault is specifically included Recurring exposure, that could apply to first responders Recognition of PTSD in young children Developmentally sensitive: Criteria have been modified for children 6 and younger Thresholds- number of symptoms in each cluster have been lowered Risk and Prognostic actors: Pretraumatic factors Per traumatic factors Posttraumatic factors Substance-Related and Addictive Disorders DSM-5 consolidates substance abuse and dependence into one disorder: substance use disorder accompanied by criteria for: intoxication, withdrawal, substance-induced disorders, and unspecified related disorders. Criteria are nearly identical to DSM-IV w/ exception of: -Recurrent substance-related legal problems criterion has been deleted from DSM-5. -And new criterion: craving, or a strong desire or urge to use a substance added. The threshold is set at 2 or more criteria vs. 1 or more for abuse and 3 or more for dependence in the DSM-IV. Substance-Related and Addictive Disorders New disorders in substance-related & addictive disorders chapter of DSM-5: Gambling Disorder (non-substance related disorder) Cannabis Withdrawal Caffeine Withdrawal * The dx of polysubstance dependence has been eliminated. Substance-Related and Addictive Disorders Specifiers: In DSM-5 severity for substance use disorders is based on the number of criteria endorsed: -mild= 2-3 criteria -moderate = 4-5 criteria -Severe= 6 or more criteria The DSM-IV specifier for psychological subtype has been eliminated. Substance-Related and Addictive Disorders In DSM-5 early remission is defined as at least 3 but less then 12 months without substance use disorder criteria (except craving). Sustained remission is defined as at least 12 months without criteria (except craving). New specifiers include: -in a controlled environment -on maintenance therapy Neurodevelopmental Disorders DSM-IV TR – “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” Intellectual Disability (vs mental retardation) – Rosa’s Law Assess cognitive capacity (IQ) and adaptive functioning (the primary determinant of severity). Autism Spectrum Disorder (gone – Asperger’s, childhood disintegrative disorder, pervasive developmental disorder) Addition – Social (Pragmatic) Communication Disorder Neurodevelopmental Disorders Attention-Deficit/Hyperactive Disorder (prior to age 12 vs age 7, less symptoms for adults, option for comorbid with ASD) Specific Learning Disorder (DSM-IV TR = Academic Skills Disorders; greater detail in diagnosis, e.g., word reading, fluency, comprehension; clarify requirements for Low Achievement criterion) Specifiers – greater detail on severity (e.g., ID – mild, moderate, severe, profound; ASD – Levels 1, 2, 3) Removed – Separation Anxiety Disorder, Pica and Rumination Disorder, Feeding Disorder of Infancy or Early Childhood, Oppositional Defiant Disorder, Conduct Disorder Personality Disorders Criteria for PD’s in Section II of DSM-5 not changed from DSM-IV No longer exist as an Axis II disorder (i.e., dropped multiaxial evaluation system) PD now coded at same level as other mental disorders No longer marginalized and treated differently Personality Disorders NOS dropped in favor of: (1) Other specified PD and (2) Unspecified PD New, alternative approach to diagnosing PD developed for further study and included in separate section (Section III) Personality Change Due to Another Medical Condition included in PD chapter (vs. DSM-IV’s Mental Disorders Due to a General Medical Condition) Alternative DSM-5 Model for Personality Disorders New model for assessment of personality disorders and traits Includes Categorical and Dimensional approaches Model not accepted by APA for inclusion in Section II Decision –include in Section III as the “Alternative DSM-5 Model for Personality Disorders” Rationale: the model “preserve(s) continuity with current clinical practice, while also introducing a new approach that aims to address numerous shortcomings of the current approach to personality disorders.” Six PDs (vs. ten) – antisocial, avoidant, borderline, narcissistic, obsessivecompulsive, and schizotypal) Alternative DSM-5 Model for Personality Disorders Based on Five Factor model of personality (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness) PD Model (Negative affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism) Negative Affectivity Neuroticism Detachment Introversion Antagonism Antagonism Disinhibition Low Conscientiousness Psychoticism Openness 25 Facets (traits): e.g., Anxiousness, Attention Seeking, Depressivity, Emotional Lability, Hostility, Impulsivity, Separation Insecurity, Withdrawal QUESTIONS? ? QUESTIONS? ? QUESTIONS?