LIFE’S ALL ABOUT CHANGE
DSM 5,
ICD-10 Codes, and
ASAM Levels Of Care
OVERVIEW
 Introduction
 DSM Revision Process
 General Changes to DSM-5
 New and Revised Disorders
 ICD 10 and the DSM-5
 Implications
BEFORE THE DSM
 1917- APA had a diagnostic system with 59 mental disorders
 1934 – APA made revisions to classifications
 1940’s – Following WWII, military clinicians found little practical
use for the APA’s diagnostic system
 1948 – 6th edition of International Classification of Diseases
published
 1948 – APA began development on the DSM 1st Edition
1952
 Queen Elizabeth II
succeeded King George VI
to the English throne
 DSM – 1 published with
106 Diagnosis
1968
 U.S. President Lyndon B.
 DSM – 2 published with
Johnson signs the Civil
Rights Act of 1968
182 Diagnosis
 Conformed to the ICD
system
 Green Bay Packers win
Super Bowl II
 Hey Jude is #1 on
Billboard
1980
 Ronald Regan is elected
President
 Bjorn Borg defeated John
McEnroe in Wimbledon
 Georgia is NCAA Football
Champions
 Ted Turner launches CNN
 Another One Bites The Dust
by Queen #1 Billboard
 DSM – III published with
265 Diagnosis
 Retained conformity to the
ICD system
 More emphasis on “medical
model”
 Multi-axial system that
focused on symptoms
rather than causes.
1987
 Dow Jones closes above 2000
for the first time
 DSM – III R published
 Increased reliability and
validity
 First Anti-Smoking campaign
airs with Yul Brynner
 Living on a Prayer is #1 on the
Billboard
 Increased diagnosis to 292
1994
 Nancy Kerrigan is attacked by
Tonya Harding’s bodyguard
 Lorena Bobbitt went to trial
 6.6 Earthquake hit LA
 Bill Clinton becomes the 42nd
President
 Forrest Gump is released
 DSM – IV published
 Goal to retain conformity
with ICD 9
 Changes included a detailed
system of diagnostic
criteria
 Diagnoses increased to 365
2000
 The Millennium/Y2K
 DSM – IV R published
 No change in number of
 Air France Flight 4590
Concorde crashes after
takeoff killing all 109
passengers
 NY Yankees wins 3rd
straight World Series
Championship
diagnoses
 Increase of 800% from 182
to 365 from 1952 to 2000
DSM-5 REVISION TIMELINE
Year
Activity
1999
Pre-Planning
2006
Task force formed
2008-2010
Literature review and data Analysis
April 2010-December 2011
Field trials in large, academic medical
centers
October 2010 – February 2012
Field trials in routine clinical practices
July 2012
Final draft of DSM 5 for APA review
December 2012
Draft finalized
May 20, 2013
Publication date
PRINCIPLES TO GUIDE DSM-5 REVISION
PROCESS
1) Highest priority is “clinical utility”
2) Recommendations should be based on research evidence
3) When possible, continuity with the DSM – IV should be
maintained
4) There should be no pre-determined constraints on
changes from DSM-IV in areas where the manual’s
organization and criteria were problematic
CONCERNS WITH THE REVISION PROCESS
Empirical support
Field trials
Dimensional assessments
Low reliabilities
Possible boundary issues with pharmaceutical
companies
Kappa Values
(Target >= 0.6 for diagnostic reliability )
DSM-5
DSM-IV
DSM-III
ADHD
0.61
0.59
0.50
Alcohol use disorder
0.40
0.80
Antisocial PD
Attenuated psychosis syndrome
<0.01
Autism spectrum disorder
0.69
Binge eating disorder
0.56
Bipolar I disorder
0.54
Bipolar II disorder
0.40
Borderline PD
0.55
Conduct DO
0.48
Disruptive mood dysregulation disorder (DMDD)
0.50
Generalized anxiety disorder
0.85
0.01
0.57
0.61
0.20
0.65
0.72
Major depressive disorder
0.32
0.59
0.80
Major neurocognitive disorder
0.50
Mild neurocognitive disorder
0.50
Mixed anxiety depression (not in DSM 5)
0.06
Obsessive-compulsive PD
0.31
Oppositional defiant disorder (OD)
0.41
0.55
0.66
PTSD
0.67
0.59
0.55
Schizophrenia
0.46
0.76
0.81
Suicidal self-injury (not in DSM 5)
-0.03
GENERAL CLASSIFICATION CHANGES
REMOVAL OF MULTIAXIAL SYSTEM
New non-axial documentation of diagnosis
Combines the former Axes I, II, III
Separate “notations” for psychosocial and
contextual factors (formerly Axis IV)
Separate “notations” for disability (formerly Axis V)
No more GAF score
NEW DIAGNOSTIC CODES
Diagnostic codes changed from numeric to
alphanumeric
October 1, 2015 all insurance companies will
require the reporting of ICD 10 codes
No longer numeric codes; alphanumeric
 OCD was 300.3 now it is F42
REMOVED NOS
Replaced NOS with:
“Other specified _____________ disorder”
“Unspecified ________________ disorder
DSM-5 ORGANIZATIONAL STRUCTURE
 Section I: DSM-5 Basics
 Introduction & information on how to use the updated manual
 Section II: Essential Elements: Diagnostic Criteria & Codes
 Outlines the categorical diagnosis
 Section III: Emerging Measures and Models
 Include conditions requiring further research along with cultural
formulations, glossary, and names of individuals involved in
developing DSM-5
 Appendix
DSM-5 TABLE OF CONTENTS
1.
Neurodevelopment D/Os
2.
Schizophrenia Spectrum & Other Psychotic Disorders
3.
Bipolar & Related Disorders
4.
Depressive D/Os
5.
Anxiety D/Os
6.
Obsessive-Compulsive & Related D/Os
7.
Trauma & Stressor-Related D/Os
8.
Dissociative D/Os
9.
Somatic Symptom & Related D/Os
10.
Feeding & Eating D/O
11.
Elimination D/O
12.
Sleep-Wake D/O
DSM-5 TABLE OF CONTENTS
13. Sexual Dysfunctions
14. Gender Dysphoria
15. Disruptive, Impulse-Control, & Conduct D/Os
16. Substance-Related & Addictive D/Os
17. Neurocognitive D/Os
18. Personality D/Os
19. Paraphilia D/Os
20. Other Mental D/Os
21. Medication-Induced Movement D/Os & Other Adverse Effects of
Medication
22. Other Conditions That May Be a Focus of Clinical Attention
NEW AND REVISED DISORDERS
NEURODEVELOPMENTAL DISORDERS
 Intellectual Disability
(Intellectual
Developmental Disorder)
 Name change
 Severity determined by adaptive
functioning rather than IQ
score
 Communication D/O
 Include language disorder
 Speech sound disorder
 Childhood-onset fluency
disorder
 Social pragmatic
communication disorder
NEURODEVELOPMENTAL DISORDERS
 Autism Spectrum Disorder (F84.0)
 Encompasses autistic disorder, Asperger’s disorder, childhood
disintegrative disorder, and pervasive developmental disorder NOS
 Symptoms in two core areas:
1. Deficits in social communication & social interaction
2. Restricted repetitive behaviors, interests, & activities
NEURODEVELOPMENTAL DISORDERS
 Attention-Deficit/Hyperactivity Disorder (F90._)
 Two symptom domains: inattention & hyperactivity/impulsivity
 Onset prior to age 12
 Adults lower symptom threshold
 Specific Learning Disorders (F81.__)
 Motor Disorders
SCHIZOPHRENIA SPECTRUM AND OTHER
PSYCHOTIC DISORDERS
 SCHIZOPHRENIA (F20.9):
 2 criterion A symptoms (one must include 1-3)
1.
Delusions
2.
Hallucinations
3.
Disorganized speech
4.
Grossly abnormal psychomotor behavior
5.
Negative symptoms
 Eliminated schizophrenia subtypes
 Recommended use of dimensional assessment in Section III
SCHIZOPHRENIA SPECTRUM AND OTHER
PSYCHOTIC DISORDERS
 SCHIZOAFFECTIVE DISORDER (F25._)
 A mood episode is present for majority of the disorder’s duration
 DELUSIONAL DISORDER (F22)
 No longer requires that delusions be “non-bizarre”
 A specifier for bizarre delusions has been added
 CATATONIA (F06.1)
 A specifier that can be added
BIPOLAR AND RELATED DISORDERS
 BIPOLAR I and BIPOLAR II DISORDERS (F31.__)
 Criterion A emphasizes changes in activity and energy, as well as
mood.
 Removed “Mixed Episode” and added “With Mixed Features”
 OTHER SPECIFIED BIPOLAR AND RELATED
DISORDERS (F31.89)
 Anxious Distress Specifier
DEPRESSIVE DISORDERS
 DISRUPTIVE MOOD DYSREGULATION
DISORDER (DMDD) (F34.8)
 Temper outbursts involving yelling, rages, or physical aggression
 Overreacting to common stressors
 Temper outbursts occurring on average 3 or more times a week for
at least 12 months (not symptom-free for more than 3 months at a
time)
 Children age 6 to 18
DEPRESSIVE DISORDERS
 MAJOR DEPRESSIVE DISORDER (F32._ or F33._)
 Removed bereavement criterion
 New “with mixed features” and “with anxious distress” specifiers
 PERSISTENT DEPRESSIVE DISORDER (F34.1)
 PREMENTSTURAL DYSPHORIC DISORDER
(N94.3)
ANXIETY DISORDERS
 GENERALIZED ANXIETY DISORDER (F41.1)
 SPECIFIC PHOBIA (F40.___)
 PANIC DISORDER (F41.0)
 AGORAPHOBIA (F40.00)
 SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) (F40.10)
 SEPERATION ANXIETY DISORDER (F93.0)
 SELECTIVE MUTISM (F94.0)
OBSESSIVE-COMPULSIVE AND RELATED
DISORDERS
 OBSESSIVE COMPULSIVE DISORDER (F42)
 BODY DYSMORPHIC DISORDER (F45.22)
 TRICHOTILLOMANIA (Hair Pulling) (F63.2)
 EXCORIATION (Skin Picking) (L98.1)
 HOARDING (F42)
TRAUMA & STRESS-RELATED DISORDERS
 REACTIVE ATTACHMENT DISORDER (F94.1)
 ADJUSTMENT DISORDER (F43.__)
 ACUTE STRESS DISORDER (F43.0)
 PTSD (F43.10)
TRAUMA & STRESS-RELATED DISORDERS
 PTSD:
 CRITERION A – TRAUMATIC EVENT
 Directly experiences the traumatic event
 Witnesses the traumatic event
 Learns that the Traumatic event occurred to a close family
member or close friend or
 Experiences first-hand repeated or extreme exposure to
aversive details of the traumatic event
TRAUMA & STRESS-RELATED DISORDERS
 PTSD SYMPTOM CLUSTERS:
 Re-experiencing: spontaneous memories of the traumatic events,
recurrent dreams, flashbacks or psychological distress
 Avoidance: distressing memories, thoughts, feelings or external
reminders of the event
 Negative cognitions and mood: represents myriad feelings (e.g.,
distorted sense of blame of self or others, estrangement from
others, diminished interest in activities, inability to remember key
aspects of the event)
 Arousal: aggressive, reckless or self-destructive behavior, sleep
disturbances, hypervigilance, or related problems
SOMATIC SYMPTOM & RELATED
DISORDERS
 Eliminated the term “somatoform”
 Drops centrality of “unexplained medical symptoms”
 The disorders:
 Somatic Symptom Disorder
 Illness Anxiety Disorder
 Conversion Disorder
 Psychological Factors Affecting Other Medical Conditions
 Factitious Disorder
FEEDING AND EATING DISORDERS
 Feeding disorders: pica, rumination disorder, and
avoidant/restrictive food intake disorder
 Anorexia Nervosa (F50.__)
 Bulimia Nervosa (F50.2)
 Binge Eating Disorder (F50.8)
GENDER DYSPHORIA
 GENDER DYSPHORIA (F64._)
 Replaces the term “Gender Identity Disorder”
 Separated from Sexual Disorders
 Only diagnose if troubled by identification
DISRUPTIVE, IMPULSE-CONTROL AND
CONDUCT DISORDERS
 Oppositional Defiant Disorder (F91.3)
 Intermittent Explosive Disorder (F63.81)
 Conduct Disorder (F91._)
 Pyromania (F63.1)
 Kleptomania (F63.3)
NEUROCOGNITIVE DISORDERS
 Major Neurocognitive Disorder
 Mild Neurocognitive Disorder
 Delirium
NEUROCOGNITIVE DISORDERS
 EXAMPLES OF DEFICITS IN LEARNING AND MEMORY:
 Major: Repeats self in conversation, often within the same
conversation, can’t keep track of short list of items when shopping
or plans for day. Requires frequent reminders to orient to task at
hand.
 Minor: Difficulty recalling recent events and increased reliance on
list-making or calendar. Needs occasional reminders or re-reading
to keep track of characters in a movie or novel. Occasionally may
repeat self over a few weeks to the same person, loses track of
whether bills have already been paid.
PERSONALITY DISORDERS
 DSM 5 maintained all 10 personality disorder categories
and criteria from DSM IV
 A new trait-specific model of personality disorders will be
included in Section 3 to encourage further study.
SUBSTANCE-RELATED & ADDICTIVE
DISORDERS
Alcoholic, Addict, Dependent?
Why does it matter?
Alcoholism
?
Use
Disorder
Addiction
Dependence
These words carry beliefs
and practitioner belief is a
major factor in client
improvement…
…our belief and our doubt
is often rooted in our
paradigms.
PARADIGM QUESTIONS
What is the nature of alcoholism?
"We're on the cusp of some major advances in how we
conceptualize alcoholism. The focus now is on the large
group of people who are not yet dependent. But they are at
risk for developing dependence."
Dr. Mark Willenbring, (formerly of NIAAA)
PARADIGM QUESTIONS
Are there different types of Alcoholism?
 Young Adult Subtype (31.5%)
 Young Antisocial Subtype (21%)
 Functional Subtype (19.5%)
 Intermediate Familial Subtype (19%)
 Chronic Severe Subtype (9%)
Moss, Howard B., Chen, Chiung M., and Yi, Hsiao-Ye (2007). Subtypes of alcohol dependence in a nationally
representative sample. Drug and Alcohol Dependence, 91, issues 2-3, Pages 149-158
RESEARCH SAYS...
• In 1953, Straus and Bacon published the first large
study of college drinking behavior.
• Twenty seven years later, Fillmore (1974, 1975)
followed up with the problem drinkers in Straus and
Bacon’s study.
• She found many heavy problem drinkers in college
were drinking small quantities with no problems 27
years later
RESEARCH SAYS...
Can they return to low-risk drinking?
Helger, et. al. (1985) followed people treated for alcoholism
and found:

Less than 2% of people with alcoholism returned to
“stable moderate drinking” for more than 1-2 years

Another 4.6% drank occasionally
RESEARCH SAYS...
Dawson’s 1996 National Alcohol Epidemiological study
on a general population found:
• Almost half of those ever qualifying for a DSM-IV
dependence diagnosis later returned to drinking
without problems
• Rates varied greatly with time elapsed, age, and
treatment status
• The phenomenon occurred in each group, and for
some, was sustained for at least two decades
CAN THEY RETURN TO LOW-RISK
DRINKING?
What Is Alcoholics Anonymous’ View?
“
…we have a certain type of hard drinker. He may have the habit
badly enough to gradually impair him physically and mentally. It
may cause him to die a few years before his time.
“
Alcoholics Anonymous, Page 20-21
ALCOHOLISM
Central Tenets…
 Characterized by loss of control
 Progressive
 Irreversible
ALCOHOLISM
AA laid the foundation
But what about the real alcoholic? He may start off as a
moderate drinker; he may or may not become a
continuous hard drinker; but at some stage of his drinking
career he begins to lose all control of his liquor
consumption, once he starts to drink.
“
“
Alcoholics Anonymous, page 20
AA was founded in 1935
ALCOHOLICS ANONYMOUS
The Disease Concept
“We believe, and so suggested a few years ago, that the action of
alcohol on these chronic alcoholics is a manifestation of an allergy;
that the phenomenon of craving is limited to this class and never
occurs in the average temperate drinker. These allergic types can
never safely use alcohol in any form at all; and once having formed
the habit and found they cannot break it, once having lost their selfconfidence, their reliance upon things human, their problems pile up
on them and become astonishingly difficult to solve”
Alcoholics Anonymous, page xxviii
DEPENDENCE
The Dependence Paradigm was born…
“Drug Dependence” had been introduced in diagnostic
nomenclature by the WHO in 1968 but it did not yet have
a separate identity.
Vernon Johnson used “Harmful Dependence” as his first
Phase of Alcoholism (I’ll Quit Tomorrow, 1973).
DEPENDENCE
Is the Concept “Alcohol Dependence”
the same as “Alcoholism?”
• Edwards suggested that dependence is made up of seven
symptoms that lie on a continuum.
• The further a person progresses, the less likely that person is to
successfully return to drinking without problems.
• Again, loss of control and irreversibility were not assumed.
DEPENDENCE
Is DSM-IV Dependence a Synonym
for Alcoholism?
 What is required to have the diagnosis, “Alcohol
Dependent in Full Sustained Remission”?
 12 Months symptom-free (not abstinence)
DEPENDENCE
Is the Concept “Alcoholism” or Addiction”
the same as “Dependence”?
 Dependence was never meant as a synonym for
alcoholism/addiction as we understand it (loss of control).
 Meant to be a clinically useful tool for clinicians who accept
alcoholism/addiction as an irreversible disease and those who do
not.
 The field took the concept of “alcoholism” and the concept of
“dependence” and assumed the new term was just a restatement
of what we already held to be true. It was, in fact, different.
DEPENDENCE
Now Let’s Recap…
 The original concept of alcoholism centered on loss of
control.
 The concept of dependence is much broader and does
not require loss of control. It casts a “larger net.”
 Everyone with alcoholism (traditionally defined) will
have dependence.
 Not everyone with dependence will have alcoholism
(traditionally defined).
ADDICTION
Evolution:
 Initially referred to the presence of a withdrawal
syndrome when use was stopped.
 It evolved to a pattern of compulsive use, loss of
control over use, and often included negative
consequences.
ASAM DEFINITION OF ADDICTION
 Addiction is a primary, chronic disease of brain reward,
motivation, memory and related circuitry. Dysfunction in
these circuits leads to characteristic biological,
psychological, social and spiritual manifestations. This is
reflected in an individual pathologically pursuing reward
and/or relief by substance use and other behaviors.
ASAM DEFINITION OF ADDICTION
 Addiction is characterized by the inability to consistently
abstain, impairment in behavioral control, craving, diminished
recognition of significant problems with one’s behaviors and
a dysfunctional emotional response. Like other chronic
diseases, addiction often involves cycles of relapse and
remission. Without treatment or engagement in recovery
activities, addiction is progressive and can result in disability
or death.
WHAT IS DIFFERENT ABOUT THIS
DEFINITION?
 The focus in the past has been generally on substances associated
with addiction.
 The new definition clarifies that addiction isn't about drugs, it’s
about brains.
 It is not the substance or the quantity or frequency of use that makes
them an addict. Addiction is about what happens in the reward
circuitry of the brain when exposed to a rewarding substance or
behavior.
WHY IS THIS DEFINITION IMPORTANT?
It helps explain what is really happening with
addiction and that the behaviors of addiction are
understandable in the context of the alterations in
brain function.
DSM III-TR & IV PROBLEMS
 “Diagnostic Orphans”: Someone could meet 2 criteria for
dependence and none for abuse
 The reliability of DSM IV dependence diagnosis is better
than that of abuse
 Research fails to support that abuse is a prodromal phase of
dependence.
PROBLEM WITH THE TERM “DEPENDENCE”
 Most healthcare providers confuse the syndrome of
dependence (as defined in the DSM-IV) and physiological
dependence.
 To some the terms addiction or addict are stigmatizing
WHY CHANGE THE CRITERIA?
 Research shows that the symptoms of substance use
problems do not fall neatly into distinct criteria.
 The term dependence is misleading, since tolerance and
withdrawal can be experienced with normal use of
medications that affect the central nervous system.
DSM-5
NEW CHAPTER NAME
Substance Related and Addictive Disorders
Gambling Disorder
 Moved from Impulse Control Disorder
DSM 5 COMBINES ABUSE & DEPENDENCE
Instead of having substance abuse or
dependence you will have a substance
use disorder
SUBSTANCE USE DISORDER DEFINED
A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as
manifested by 2 or more of the following, occurring
within a 12 month period.
SUBSTANCE USE DISORDER DEFINED
1.
Recurrent substance use resulting in failure to fulfill major
role obligations.
2.
Recurrent substance use in situations where it is physically
hazardous
3.
Continued substance use despite having social or
interpersonal problems
SUBSTANCE USE DISORDER DEFINED
4.
Tolerance, as defined by either of the following:
 A need for markedly increased amounts of the substance to achieve intoxication
or the desired effect.
 Markedly diminished effect with continued use of the same amount of the
substance.
 Tolerance not counted if taking meds as directed under medical supervision.
5.
Withdrawal, as manifested by either of the following:
 The characteristic withdrawal syndrome for the substance
 The same or closely related substance is taken to relieve or avoid
withdrawal symptoms.
 Withdrawal isn’t counted if taking meds correctly under medical
supervision.
SUBSTANCE USE DISORDER DEFINED
6.
7.
8.
9.
10.
The substance is often taken in a larger amounts over a
longer period than was intended.
Persistent desire or unsuccessful efforts to cut down or
control substance use
A great deal of time is spent in activities necessary to
obtain the substance, or recover from its effects
Important social, occupational, or recreational activities
are given up or reduced
Continued use despite persistent or recurrent physical or
psychological problems
SUBSTANCE USE DISORDER DEFINED
11. Craving or a strong desire or urge to use a specific
substance.
A CAT CALLED CRAVING
A CAT CALLED CRAVING
A CAT CALLED CRAVING
1.
2.
3.
4.
5.
6.
Craving is misunderstood
Craving grows over time
It is a permanent relationship
Myth: Craving will stop growing
Myth: Cutting back will stop craving
Myth: Substituting other items will stop craving
A CAT CALLED CRAVING
In a relationship with a big, ever growing, mean, angry,
immortal, telepathic cat called craving
2. It is a permanent relationship
3. Solutions to cope with Craving
1.
 Don’t feed the cat
 Don’t try substitutions
 Ask for help from others
 Don’t go down the milk aisle
 Don’t go to “milk festivals”
DETERMINING SEVERITY
 0-1 criteria= No Disorder
 2-3 criteria= Mild Disorder
 4-5 criteria= Moderate Disorder
 6 or more criteria= Severe Disorder
ICD-10 CODES EXAMPLES
Alcohol Use Disorder
 Mild – F10.10
 Moderate – F10.20
 Severe – F10.20
Cannabis Use Disorder
 Mild – F12.10
 Moderate – F12.20
 Severe – F12.20
ANALYSES RELATED TO DEVELOPMENT OF
DSM-5 IN 663 PATIENTS
 Fit statistics indicate:
Abuse and Dependence criteria fit better as a unified single
dimension than as separate dimensions
2. Legal Criterion does not add to diagnostic criteria and
typically occurs when disorder very severe
3. Craving adds little to diagnostic accuracy but accords with
ICD
1.
NEW - CANNABIS WITHDRAWAL
 Irritability, anger, or aggression
 Nervousness or anxiety
 Sleep difficulty (e.g., insomnia, disturbing dreams)
 Decreased appetite or weight loss
 Restlessness
 Depressed Mood
 One of the following physical symptoms: stomach pain,
shakiness/tremors, sweating, fever, chills, or headache
WHY CLASSIFY GAMBLING DISORDER
WITH SUBSTANCE USE DISORDERS?
 Strong comorbidity of SUD. “Pathological Gambling”
 Convincing genetic literature: “behavioral disinhibition”=
measureable phenotype with high heritability that underlies SUD
gambling: different manifestations of one underlying problem.
 Considerable evidence for shared neurobiology: Imbalance of
motivation/reward systems vs inhibitory systems.
CONCERNS ABOUT DSM 5 CHANGES
Would significantly increase the number of people being
diagnosed with addiction.
2. The APA has not allowed enough discussion regarding
these changes (secondary gain).
3. It could create false epidemics and medicalication of
everyday behavior.
4. Possible boundary issues between DSM panel members
and the pharmaceutical companies.
1.
OTHER
 DSM-5 is available as online subscription at PsychiatryOnline.org
ASAM CRITERIA
 12 years since last revision
 More user-friendly
 Compatible with DSM-5
 Follows the treatment process
 Sections:
 Special Populations
 Tobacco/gambling
 Working with managed care
 Terminology focused on:
 Behavior
 Strengths, not pathology
 Goal for the ASAM Criteria to be a resource for screening and
to determine the appropriate levels of care
UNDERLYING CONCEPTS OF THE ASAM
CRITERIA: INDIVIDUALIZED, CLINICALLYDRIVEN TREATMENT
Source: The ASAM Criteria
ASSESSMENT OF
BIOPSYCHOSOCIAL
SEVERITY AND LEVEL OF FUNCTION
 Dimension 1:
Acute Intoxication and/or Withdrawal Potential
 Dimension 2:
Biomedical conditions and complications
 Dimension 3:
Emotional/Behavioral/Cognitive Conditions and
Complications
 Dimension 4:
Readiness to Change
 Dimension 5:
Relapse/Continued Use/Continued Problem potential
 Dimension 6:
Recovery Environment
Source: The ASAM Criteria
BIOPSYCHOSOCIAL TREATMENT
TREATMENT MATCHING MODALITIES
 Motivate – Dimension 4
 Manage – All Six Dimensions
 Medication – Dimensions 1, 2, 3, 5
 Meetings – Dimensions 2, 3, 4, 5, 6
 Monitor – All Six Dimensions
Source: The ASAM Criteria
ASAM LEVELS
 Level 0.5: Early Intervention Services
 Level 1: Outpatient Treatment
(With & Without Withdrawal Management)
 Level 2: Intensive Outpatient and Partial Hospitalization
(With & Without Withdrawal Management)
 Level 3: Residential/Inpatient Treatment
(With & Without Withdrawal Management)
 Level 4: Medically-Managed Intensive Inpatient Treatment
Source: The ASAM Criteria
FOCUS ASSESSMENT AND TREATMENT
What Does the Client Want?
Does client have immediate needs due to
imminent risk in any of six dimensions?
Conduct multidimensional assessment
Source: The ASAM Criteria
FOCUS ASSESSMENT AND TREATMENT
DSM-5 diagnoses?
Multidimensional Severity/LOF Profile
Which assessment dimensions are most important to determine Tx priorities
Specific focus/target for each priority dimension
What specific services needed for each dimension
What “dose” or intensity of these services needed
Where can these services be provided in least intensive, but “safe” level of care?
What is progress of Tx plan and placement decision; outcomes measurement?
Source: The ASAM Criteria
REFERENCES
 American Psychiatric Association (APA). (2013). Diagnostic and statistical Manual of Mental Disorders
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(5th ed) DSM-5. Arlington,VA: American Psychiatric Association.
American Psychiatric Association (APA). (2010). American Psychiatric Association DSM-5 development.
Retrieved from http://www.dsm5.org/Pages/Default.aspx.
American Psychiatric Association (APA). (2013). Highlights of Changes from DSM-IV-TR to DSM-5.
Retrieved from http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/Changes-from-DSM-IVTR--to-DSM-5.pdf
First, M. B. (2010). Paradigm shifts and the development of the diagnostic and statistical manual of
mental D/Os: Past experiences and future aspirations. The Canadian Journal of Psychiatry, 55, 692-700.
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Kupfer, D. J. (2013, March). Psychiatry update: The DSM-5 and more. Retrieved from
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REFERENCES
 Moore, Scott. (2009). Cat Called Craving.
 Moran, M. (2013). Continuity and Changes Mark New Text of DSM-5. Psychiatric News,
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48(2), 1-6.
Moran, M. (2013). DSM-5 Fine-Tunes Diagnostic Criteria for Psychosis, Bipolar Disorders.
Psychiatric News, 48(3), 10-11.
Moran, M. (2013). DSM-5 Provides New Take on Neurodevelopment Disorders. Psychiatric
News, 48(2), 6-23.
Moran, M. (2013). DSM-5 updates depressive, anxiety and OCD criteria. Psychiatric News,
48(4), 22-43.
Moran, M. (2013). Somatic chapter drops centrality of unexplained medical symptoms.
Psychiatric News, 48(5), 7-7.
Olfson, M., & Marcus, S. C., (2010). National trends in outpatient psychotherapy. American
Journal of Psychiatry, 167, 1456-1463.