Psychiatry Update:
The DSM-5 and More
David J. Kupfer, M.D.
Professor of Psychiatry, University of Pittsburgh
Chair, DSM-5 Task Force
American College of Physicians Virginia Chapter
Richmond, VA
March 2, 2013
DSM-5

Review of Process

Revisions – Rationales

Table of Contents

Development of Primary Care
Version
DSM-5 Work Groups and Chairs

ADHD & Disruptive Behavior Disorders (David Shaffer, M.D.)

Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic,
and Dissociative Disorders (Katharine Phillips, M.D.)

Disorders in Childhood and Adolescence (Daniel Pine, M.D.)

Eating Disorders (Timothy Walsh, M.D.)

Mood Disorders (Jan Fawcett, M.D.)

Neurocognitive Disorders (Dilip Jeste, M.D., Dan Blazer, M.D.,
Ron Peterson, M.D.)

Neurodevelopmental Disorders (Susan Swedo, M.D.)
DSM-5 Work Groups and Chairs (Cont’d)

Personality and Personality Disorders (Andrew Skodol,
M.D.)

Psychotic Disorders (William Carpenter, M.D.)

Sexual and Gender-Identity Disorders (Kenneth Zucker,
Ph.D.)

Sleep-Wake Disorders (Charles Reynolds, M.D.)

Somatic Distress Disorders (Joel Dimsdale, M.D.)

Substance-Related Disorders (Charles O’Brien, M.D., Ph.D.)
Cross-Cutting Study Groups

Diagnostic Spectra

Life Span Developmental Approach Study
Group

Gender and Cross-Cultural Study Group

Psychiatric/General Medical Interface
Study Group

Impairment Assessment and Instruments

Diagnostic Assessment Instruments
DSM-5 Revisions: Rationales
DSM-5 Revisions: Rationales
DSM-IV’s organizational structure failed to
reflect shared features or symptoms of
related disorders and diagnostic groups
(like psychotic disorders with bipolar
disorders, or internalizing (depressive,
anxiety, somatic) and externalizing
(impulse control, conduct, substance use)
disorders.
 DSM-5 restructuring better reflects these
interrelationships, within and across
diagnostic chapters

DSM-5 Revisions: Rationales

The strict categorical approach of DSM-IV
failed to capture variations of disorders
(e.g., atypical, subthreshold, & common
comorbidities).

A strict application of diagnostic criteria did
not fit patient presentations resulting in
overuse of the NOS designation.

DSM-5 integrates cross-cutting
symptomatic descriptions that better reflect
the true presentation of disorders and may
reduce reliance on OS diagnoses.
DSM-5 Revisions: Rationales



DSM-IV did not adequately address the
lifespan perspective, including variations of
symptom presentations across the
developmental trajectory, or cultural
perspectives
DSM-5’s chapter structure, criteria revisions,
and text outline actively address age and
development as part of diagnosis and
classification
Culture is similarly discussed more explicitly
to bring greater attention to cultural variations
in symptom presentations
DSM-5 Revisions: Rationales

DSM-5 represents an opportunity to better
integrate neuroscience and the wealth of
findings from neuroimaging, genetics,
cognitive research, and the like, that have
emerged over the past several decades –
all of which are vital to diagnosis and
treatment development
 DSM-5 will be more amenable to updates
in psychiatry and neuroscience, making it
a “living document,” less susceptible to
becoming outdated than its predecessors
DSM-5 Revisions: Rationales

The multiaxial system in DSM-IV is not required
to make a mental disorder diagnosis and has
not been universally used
 DSM-5 has moved to a nonaxial documentation
of diagnosis (formerly Axes I, II, and III), with
separate notations for important psychosocial
and contextual factors (formerly Axis IV) and
disability (formerly Axis V)
 This approach is consistent with established
WHO and ICD guidance to consider the
individual’s functional status separately from his
or her diagnoses or symptom status
DSM-5 - Section II
Revised DSM-5 Chapter Structure
Clustering of Chapters

Neurodevelopmental Disorders

Emotional (Internalizing) Disorders
 Somatic Disorders

Externalizing Disorders
 Neurocognitive Disorders

Personality Disorders
Strategy to Improve DSM-5:
Revised Chapter Organization (1)

Neurodevelopmental Disorders

Schizophrenia Spectrum and Other Psychotic
Disorders

Bipolar and Related Disorders

Depressive Disorders

Anxiety Disorders

Obsessive-Compulsive and Related Disorders

Trauma- and Stressor-Related Disorders

Dissociative Disorders
Strategy to Improve DSM-5:
Revised Chapter Organization (2)

Somatic Symptom and Related Disorders

Feeding and Eating Disorders

Elimination Disorders

Sleep-Wake Disorders

Sexual Dysfunctions

Gender Dysphoria
Strategy to Improve DSM-5:
Revised Chapter Organization (3)

Disruptive, Impulse Control, and Conduct Disorders

Substance-Related and Addictive Disorders

Neurocognitive Disorders

Personality Disorders

Paraphilic Disorders

Other Mental Disorders
Living Document –
What does that mean?

Not waiting 20 years for revision
 Allows advances to be incorporated into
DSM-5.1, etc.
 Deals with unanticipated “events”
•
Prevalence changes
• Unclear criteria

Development of electronic-online
enhancements to accommodate
advances
Next Step

Primary care version – how to further
integrate psychiatry with general
medicine

To provide easier strategies for
assessment of the most common
disorders with the greatest public health
impact
Primary Care Version:
Key Questions

How to determine which disorders
 Should there be two versions – pediatric
and adult?

Printed vs. online version
 Levels of assessment

Advice needed
DSM-5 PC Content Options

Brief (10 disorder groups), low specificity

Moderate (33 specific disorders)

Complex (entire DSM-5: approximately
160 disorders)
Brief List: 10 Disorder Groups

Neurodevelopmental Disorders

Psychotic Disorders
 Bipolar Disorders

Depressive Disorders
 Anxiety Disorders

Trauma and Stress-related Disorders
 Somatic Symptom and Related Disorders

Eating Disorders
 Sleep Disorders

Substance Use Disorders
Moderate Complexity:
33 Specific Disorders Within Disorder Groups (1)

Neurodevelopmental Disorders
•
Intellectual Developmental Disorder (Intellectual
Disability)
• Autism Spectrum Disorder
• Specific Learning Disorder
• Attention Deficit/Hyperactivity Disorder

Psychotic Disorders
•
•
•
Brief Psychotic Disorder
Schizophrenia
Psychotic Disorders NOS
Moderate Complexity:
33 Specific Disorders Within Disorder Groups (2)

Bipolar Disorders
•

Depressive Disorders
•
•

Bipolar I/II Disorder
Major Depressive Disorder
Depression due to another medical condition
Anxiety Disorders
•
•
•
Generalized Anxiety Disorder
Panic Disorder
Anxiety due to another medical condition
Moderate Complexity:
33 Specific Disorders Within Disorder Groups (3)

Obsessive-Compulsive and Related Disorders
•

Trauma and Stress-related Disorders
•
•
•

Unspecified Obsessive-Compulsive and Related
Disorder
Adjustment Disorder
Acute Stress Disorder
Posttraumatic Stress Disorder
Somatic Symptom and Related Disorders
•
•
Somatic Symptom Disorder
Illness Anxiety Disorder
Moderate Complexity:
33 Specific Disorders Within Disorder Groups (4)

Eating Disorders
•
•

Sleep Disorders
•

Binge Eating Disorder
Anorexia and Bulimia
Insomnia Disorder
Sexual Dysfunctions
•
•
•
•
Erectile Disorder
Female Orgasmic Disorder
Substance/Medication-Induced Sexual Dysfunction
Unspecified Sexual Dysfunction
Moderate Complexity:
33 Specific Disorders Within Disorder Groups (5)

Disruptive, Impulse-Control, and Conduct
Disorders
•

Conduct Disorder
Substance Use Disorders
•
•
•
Alcohol Use Disorder
Substance Use Disorder
Tobacco Use Disorder
Moderate Complexity:
33 Specific Disorders Within Disorder Groups (6)

Neurocognitive Disorders
•
•

Delirium
Major and Mild Neurocognitive Disorder
Personality Disorders
•
Personality Disorders, general
Primary Care Version:
Key Questions

How to determine which disorders
 Should there be two versions – pediatric
and adult?

Printed vs. online version
 Levels of assessment

Advice Needed
A Potential Strategy for DSM-5 PC (1)

DSM-5 PC provides a guide for primary
care clinicians to facilitate the
assessment of mental disorders.
 This guide recognizes that primary care
clinicians will vary in their choice of the
level of specificity of a mental disorder
diagnosis required for optimal care,
depending on the clinician’s expertise,
available treatment resources, and
patient preferences.
A Potential Strategy for DSM-5 PC (2)

With this guide the clinician can
proceed as needed from the least to the
most specific level of assessment for
mental disorders in primary care.
Stepped Care Overview
(
Initial Clinical Assessment (1)
Key tasks at this stage include:

Attaining a targeted history and physical exam

Ordering targeted laboratory and imaging
studies if indicated

Performing targeted Screening Measures
Assessing/ensuring safety


Assessing environmental stressors including
exposure to trauma and loss
Initial Clinical Assessment (2)

Assessing current functioning including capacity
for relationship

Assessing medical and iatrogenic comorbidities
Assigning either a symptom based, Level I or
Level II (Specific ) DSM-5 PC diagnosis

More Advanced Assessments
Key tasks at this stage include:

Additional history

Review laboratory and imaging studies if obtained

Continuing psychological assessment

Severity Measures (to support diagnosis and/or
monitoring)

Assigning a Level I DSM-5 PC diagnosis
Primary Care Version:
Key Questions

How to determine which disorders
 Should there be two versions – pediatric
and adult?

Printed vs. online version
 Levels of assessment

Advice Needed
What do you Need?
 Pre-visit
screening tools?
 On-line diagnostic algorithms?
 Brief
assessment measures for
monitoring change:
•
•
clinician administered?
self-report?
 Other
needs?
Printed vs. Electronic Materials
 Which
are you most likely
to use?
 Do
you want/need both?
What have I forgotten to ask?