2013 FAADA Conference
“Introduction to the
New Diagnostic and Statistical Manual
For Mental Disorders, 5th Edition,
DSM-5 and the New ASAM Criteria”
8/7/13
Orlando, FL
© 2013, Shulman & Associates,
Training & Consulting in Behavioral Health
CAUTIONS
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•
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The rates of psychiatric disorders have
skyrocketed alongside the expanded DSM
increasing the list of what constitutes a mental
disorder
Most of the psychiatrist authors of the DSM-5
have ties to the pharmaceutical industry
There was a significantly sized group of
psychiatrists who actually tried to block the
release of the DSM-5
The DSM and Democracy
•
•
Winston Churchill said:
No one pretends that democracy is perfect or
all-wise. Indeed, it has been said that
democracy is the worst form of government
except all those other forms that have been
tried from time to time.
Sounds like the DSM!
General Changes
 Publication 5/22/13
 Two year phase-in
 Movement from categories to continuums
 Severity scales
 Simplification (but not simple!)
 Discontinuation of 5 Axis system for purposes of
diagnosis
 Replacement of NOS (Not Otherwise Specified) with
NEC (Not Otherwise Categorized)
 Coding will change to be consistent with the ICD-10
Dimensional Assessment
In DSM-IV, a categorical approach was
used:
 An individual either had a symptom of
the disorder or they didn’t
 They either met criteria (e.g., 4 of 7
symptoms) or they didn’t
 An individual either had a disorder or
they didn’t
Cross Cutting Symptom Assessment
 Assessment across areas that are relevant (and “cut
across”) but are not a specific diagnostic criterion
 depressed mood
 anxiety
 substance use
 sleep problems
 anger
 0-4 scale encouraged with 0 being absence of
difficulty
Five Axis
Diagnostic Structure
 Goes away for purposes of diagnosis
 Replaced with list of diagnoses
 I strongly recommend, ”Continue
using Axes 4, 5 and 6 for purposes of
informing the assessment, even if
not used for purposes of diagnosis”
Substance
Use
Disorders
DSM IV Criteria for Substance Dependence
A Maladaptive pattern of substance use, leading to clinically
significant impairment or distress, as manifested by three (or
more) of the following, occurring at any time in the same 12month period:
(1) tolerance
(2) withdrawal
(3) the substance taken in larger amounts or over a longer
period of time than was intended
(4) there is a persistent desire or unsuccessful attempts to cut
down or control substance use
(5) a great deal of time spent is in activities necessary to obtain
the substance, use the substance, or recover from its effects
(6) important social, occupational or recreational activities are
given up or reduced because of substance use
(7) substance use is continued despite knowledge of having
persistent or recurring physical or psychological problems
that are likely to have been caused or exacerbated by the
substance
DSM IV Criteria for Substance Abuse
A Maladaptive pattern of substance use leading to clinically
significant impairment or distress, as manifested by one (or more)
of the following occurring within a 12-month period:
(1) Recurrent substance use resulting in failure to fulfill
major
role obligations at work, school, or home
(2) Recurrent substance use in situations in which it is
physically hazardous
(3) Recurrent substance-related legal problems
(4) Continuing substance use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance
B The symptoms have never met the criteria for Substance
Dependence for this class of substance
The DSM-5 (May, 2013)
Changes from DSM-IV
 Use of the term “addiction”
 No longer diagnoses of “abuse” or “dependence”
 “Substance Use Disorders” (DSM-IV) > “Substance
Use and Addictive Disorders” (DSM-5)
 The seven criteria from the DSM-IV for dependence
and the four for abuse are collapsed into 11 criteria
 Substance-related legal problems (from abuse
criteria) has been removed???
 A new criteria of craving, strong desire or urge to
use a substance has been added
12
Removal of “Legal Problems”
Pro:
• Discrimination based on race and socioeconomic status
• Misuse of a DUI as equivalent to old “abuse”
• Geographic inequalities (crossing Colorado state line)
Con:
• For some, serves an SBIRT function, as early intervention
• May function as the impetus for treatment
• 54% of DUI offenders who received an abuse diagnosis
under the DSM-IV will receive no diagnosis under the
DSM-5 – what will this mean in terms of reoffending?
The DSM–5 (May, 2013)
Changes in the DSM-5 from Categories to
Continuums
 Meeting 0-1 of the 11 criteria results in No
Diagnosis
 Meeting 2-3 criteria qualifies as Mild (akin to old
“abuse”)
 Meeting 4-5 criteria qualifies as Moderate (akin to
old “abuse” or “dependence”)
 Meeting 6 or more qualifies as Severe (akin to old
“dependence”)
14
Cannabis Withdrawal
Peak symptoms 1 – 21 days post cessation of heavy cannabis
use, markedly reduced or absent by 4 weeks.
Psychological symptoms may persist for up to a year
 Anger
 Decreased appetite
 Irritability
 Anxiety
 Restlessness
 Sleep difficulties
 Dream rebound
 Physical symptoms (frequent but mild)
 Depressed mood
Other Changes in Substance
Use and Addictive Disorders
Addition of:
 “Alcohol-Related Disorders” changed to
“Alcohol Use Disorders”
 Gambling Disorder (from a type of OCD
disorder to its own disorder)
 Tobacco-Related Disorders
 Caffeine withdrawal
Course Specifiers
 Early full remission
 From 1 month but less than 12 months in DSM-IV to 3
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month but less than 12 months in DSM-5, no criteria
met
Early partial remission
Sustained full remission
Sustained partial remission
Sustained remission
 No symptoms for 12 months except craving
Sustained partial remission
On agonist maintenance therapy
In a controlled environment
With physiological dependence
Without physiological dependence
The Conundrum
 Alcoholism/addiction is a chronic,
relapsing brain disease
 Alcoholism is an insidious, progressive,
incurable and fatal disease and if the
person doesn’t stop drinking/using, they
will end up either dead or
institutionalized
 Yet some alcoholics are able to go back
to “social” (non-problem) drinking???
RETHINKING THE
CONTINUUM OF SUBSTANCE USE
A
FOUR PHASE
RISK
MODEL
A New Way of
Conceptualizing Substance Use
Phase
Characteristics
Phase 1
Low Risk
Choices
DSM-5
Severity
Level 0-1
“Orphan”
(no dx.)
Outcomes
Response
• No significant Continue to
increase in
make low risk
tolerance
choices
Phases of
Substance
• Do
not use Use
illegal drugs
• Use
medications
only as
prescribed
• Use results in
no problems
Phase
Character-istics
Outcomes
Response
• Makes high • May develop Return to
risk choices
social
Phase 1 to
DSM-5
• Drinks high dependence
make low risk
Severity
amountsof • Substance
State
Usechoices
Level 2-3 risksPhases
dependent
– Mild –
learning begins
old
“abuse”
• Abstract
thinking skills
may become
impaired, e.g.,
illicit drug use
Phase 2
Phase
Character-istics
Outcomes
Response
• Development of
• Substance• Return to lowpsychological
related health risk drinking
DSM-5
dependence
or impairment choices may
Severity
• Substance use
problems
still be possible
Level 4-5 more integrated
• Blackouts
• May require
Phases
of Substance
Moderate into
life
• Drinking to Use
outside help to
– old
•State dependent
cure
change choices
“abuse” or learning
hangovers
• 50% are able
“depend- • High risk choices
• Continued
to return to
ence”
become more
use likely to
low-risk choices
important than
lead to
relationships
Phase 4
•Defense of choices
Phase 3
Phase
Character-istics
• Physical
addiction
DSM-5
• Withdrawal
Severity
Level 6+ • Loss of
Phases of
Severe – control
• Tolerance
old
“depend- continues to
ence”
increase
Phase 4
Outcomes
Response
• More
• Return to
negative,
low-risk
more severe
choices no
outcomes
longer
Substance
than in Phase Use
possible
3
• Requires
• Possible
abstinence
imprisonment • Usually
or death
requires
outside help
Disorders
Most Likely
to Co-Occur with
Substance Use
Disorders
Eating Disorders
 Anorexia Nervosa
 Bulimia Nervosa
 Binge Eating Disorder
Anorexia Nervosa
Anorexia Nervosa
Anorexia Nervosa is the most lethal of
all psychiatric disorders with 5%
dying per decade after diagnosis
either from medical complications
or suicide
Before 40 day fast
After 40 day fast
Bulimia Nervosa
People with bulimia:
 Binge on a regular basis. They eat large amounts
of food in a short period of time, often over a
couple of hours or less. During a binge they feel
out of control and feel unable to stop eating
 They purge to get rid of food and avoid weight
gain. The may makes themselves vomit, exercise
very hard or for a long time, or misuse laxatives,
enemas, diuretics or other medications
 All of this is based on how they feel about
themselves, on how much they weigh and how
they look
Prognosis more positive than with anorexia
Binge Eating Disorder
 The difference from Bulimia in the course is that no
compensatory behavior (e.g., purging) takes place
 Binge will be differentiated from garden variety
overeating in that the binger will have several of
these features:
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Eating more rapidly than normal
Feeling uncomfortably full
Feeling embarrassed or ashamed of eating behavior
Hiding eating
Eating when not hungry
 Frequency will likely be the same as for Bulimia
(averaging once/week for 3 months)
Prognosis more optimistic that Anorexia or Bulimia
Personality Disorders
 The essential element of personality disorder is that it is
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not an episodic condition in an otherwise well-functioning
individual
It is a chronic dysfunction that begins early in life and is
slow to change
The DSM-IV system for categorizing personality disorders
is unchanged in the DSM-5
Patients with these disorders are often not likeable, may
be seen as difficult rather than sick and may be rejected
by clinicians and payers (treatment refractory)
With Substance Use Disorders, Antisocial Personality
Disorder is often associated with the use of illicit
substances
Axis II has been eliminated
Personality Disorders Most
Likely to Co-occur with
Substance Use Disorders
 Antisocial Personality Disorder
&
 Borderline Personality Disorder
Non-Suicidal Self Injury Disorder
(Condition for Further Study)
 At present, surface self-mutilation behavior is
reflected only as a symptom of Borderline
Personality Disorder (BPD). In reality the
behavior occurs with a variety of psychiatric
disorders and not all cutters have BPD.
 The behavior is often labeled or interpreted as
suicidal when there is no suicidal intent
 Cutters are generally different and healthier than
suicide attempters in significant ways; better
self-esteem, better mood, better parental
relationships
 Cutting is a rare suicide method (.5%). However,
many will make an actual suicide attempt. Risk
increase with the number of incidents and
number of modalities
Attention-Deficit/
Hyperactivity Disorder
Changes in DSM-5:
 Onset prior to 12 years old rather than 7 years
old
 Have 3 rather than 6 of the characteristic
symptoms during childhood
 From 2 or more settings to “several”
Will make it easier to diagnose adults with
ADHD
ATTENTION DEFICIT/HYPERACTIVITY
DISORDER (ADHD)
• Incidence in the General Population is:
• Incidence in a cocaine using population
is:
2.3%
32-34%
•Up to 15% of adults with ADHD will still meet full criteria
by age 25
•Up to 65% of adults with ADHD will still meet in “partial
remission” criteria by age 30
•Rate of ADHD are higher among people with SUDs
Note on Medications for ADHD
 Medication works better for
hyperactive than inattentive
symptoms
 Different disorders?
People
DO NOT
Outgrow
ADHD!
Anxiety Disorders
The DSM-IV described five forms of anxiety disorder
1. Panic Disorder
2. Generalized Anxiety Disorder (GAD)
3. Phobias
4. Post Traumatic Stress Disorder (PTSD)
5. Obsessive Compulsive Disorder (OCD)
Anxiety Disorders
There is symptomatic overlap between among the
spectrum of anxiety disorders but they have
different clinical presentations and are in different
chapters of the DSM-5
 Generalized Anxiety Disorder is kept in the DSM-5
but renamed Generalized Anxiety and Worry
Disorder
 Post Traumatic Stress Disorder (PTSD)
 Obsessive Compulsive Disorder (OCD)
 Phobias
Obsessive-Compulsive
& Related Disorders
 Obsessive-Compulsive disorder (OCD)
 Body Dysmorphic Disorder
 Hoarding Disorder*
 Trichotillomania (hair pulling)
 Excoriation Disorder (skin picking disorder)*
 Substance-Induced Obsessive-Compulsive or
Related Disorder (“coke bugs”)
 Obsessive-Compulsive or Related Disorder
Attributable to Another Medical Condition
*New
Symptoms of OCD
Obsessions:
 Unwanted thoughts, ides and urges that occur
repeatedly and won’t go away
 They get in the way of normal thoughts and
cause anxiety and fear
 The thoughts may be violent or sexual or worry
about illness or infection
 Example include:
 Fear of harm to self or loved ones
 A need to do things perfectly
 Fear of getting dirty or infected
Symptoms of OCD
Compulsions:
 Repeated behaviors to try to control the obsessions
 Some have behaviors that are rigid and structured
while others have complex behaviors that change
 Examples include:
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
Washing (e.g., hands)
Checking (e.g., doors & windows to see if locked)
Counting, often while doing another compulsive action
Repeating things or always moving items to keep them in
perfect order
 Hoarding
 Praying incessantly
Substance-Induced Anxiety Disorder
 Prominent anxiety symptoms that are due to
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
the direct physiological effects of a substance
Symptoms may occur during intoxication or
withdrawal
The disturbance may not be better accounted
for by a mental disorder
The diagnosis is not made if the anxiety
symptoms occur only during the course of
delirium
The context may be specified as:
 Onset during intoxication
 Onset during withdrawal
Panic Attack – 4 or > Symptoms
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Sudden high anxiety- with or without cause
Heart palpitations
Sweating
Shaking
A smothering sensation or shortness of breath
A feeling of choking
Chest pain or discomfort
Nausea
Dizziness or faintness
A sense of unreality
A fear of going crazy or losing control
A fear of dying
Numbness or tingling
Chills or hot flashes
Panic Disorder
Panic disorder describes the negative impact on
an individual’s life from recurrent,
unexpected Panic Attacks, taking the form of
the restriction of daily or self-care activities to
avoid further attacks or marked fear or
distress while engaged in activities for fear of
further Panic Attacks
Phobias
 The classic picture of a specific phobia need
not lead to serious dysfunction and clinicians
rarely see these cases (arachnophobia)
 One change in the DSM-5 is removal of the
requirement that phobias be recognized by
patients who suffer from them as irrational
 Social Anxiety Disorder (previously social
phobia) , because of the high prevalence of
social anxiety and shyness in community
populations may be too broadly defined (e.g.,
anxiety about speaking in public)
Social Phobia
Social phobia renamed Social Anxiety
Disorder has significant implications
for treatment for when it co-occurs
with substance use disorders:
 For treatment
 For self-help recovery groups
Generalized Anxiety and Worry
Disorder
 Characterized by excessive, exaggerated
anxiety and worry about everyday life for no
obvious reasons
 Patients tend to expect disaster and can’t
stop worrying about health, money, family,
work or school
 The worry is often unrealistic or out of
proportion for the situation
Post Traumatic Stress Disorder
 Such disorders reflect a biological
predisposition or vulnerability
 Most people who are exposed to trauma
do not develop PTSD
 The DSM-5 combines a recognized cause (a
traumatic event) with a set of characteristic
symptoms
 The traumatic event is either life
threatening, could lead to serious injury or
rape
Broadening the Diagnosis of PTSD
 The DSM-5 diagnosis has been broadened
to incidents that consist only of hearing
about the trauma
 Specifically, the DSM-5 :
 Allows being a witness to a disaster
 Reactions to learning about disasters
Depressive Disorders
 Disruptive Mood Dysregulation Disorder
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(previously combined with Attention Deficit,
now a Depressive Disorder)
Major Depressive Disorder, Single Episode
Major Depressive Disorder, Recurrent
Dysthymic Disorder (renamed “Persistent
Depressive Disorder” but criteria the same)
Substance-Induced Depressive Disorder
Depressive Disorder Associated with Another
Medical Condition
Premenstrual Dysphoric Disorder
Major Depressive Disorder (MDD)
 As many as 40% of those diagnosed with MDD
actually have Bipolar Disorders
 If misdiagnosed as MDD and prescribed antidepressive drugs instead of a mood stabilizer,
the anti-depressive medication may precipitate
mania or hypomania
 When do you medicate for an anxiety, depressive
or bipolar disorder?
 When the risk of not medicating exceeds
the risk of medicating!
Time for Medications to Work
 6 to 8 weeks minimum
 To find the correct drug in the correct dose
may take up to 6 months
 Complicated by who prescribes (PCPs)
 Antidepresssant drugs now the most
commonly prescribed class of drug in the U.S.
(1 in 10 people)
 Work best for very severe cases of depression
and have little or no benefit over placebo
(inactive pills) in less serious cases.
Depression - Bereavement
 Many symptoms are characteristic of a major
depressive episode
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
Feelings of sadness
Insomnia
Loss of appetite
Weight loss
 In the DSM-IV a diagnosis of MDD was made for
a death unless symptoms persist for over 2
months but not other losses
 In the DSM-5, don’t diagnose MDD if
bereavement symptoms best account for the
depressive symptoms
 “Persistent Complex Bereavement Disorder”*
*Proposed for further study
Bipolar Disorder
Unipolar disorders present with only depression
Bipolar Disorder presents with both depression
and mania and is divided into two types:
 Bipolar I: with full mania (not changed in the
DSM-5)
 Bipolar II: with hypomania
Bipolar Disorder is one of the most
misdiagnosed, over-diagnosed psychiatric
disorder
Bipolar Disorder Misdiagnosis*
 Total misdiagnosis
 Times individual misdiagnosed
69%
3.5
 Physicians consulted before correct
diagnosis
 Misdiagnosed as:
 Unipolar Depression
4
60%
 Anxiety Disorder (especially PTSD)
26%
 Schizophrenia
18%
 Borderline or Antisocial Personality Disorder 17%
* Hirschfield, RM et al. J Clin Psychiatry. 2003, 64(2):161-174
Autism Spectrum Disorder
 Now encompasses range from Asperger’s to
Autism
 Concern: Many higher functioning Asperger’s or
those with Pervasive Developmental Disorder
may not be diagnosed with ASD
 If so, may lose services available through
Medicaid waivers available in a number of states
through the Social Security Act. Under a waiver
program, states can choose to waive income
when determining Medicaid eligibility.
So What Now?
 Even if you are not permitted under your
scope of practice to do a formal diagnosis,
you can always do a “diagnostic impression”
 Become familiar enough with the DSM-5
diagnoses to assure that your patients/clients
with co-occurring disorders are getting what
they need in treatment
 As complex as the DSM-5 is, it will get easier
over time
What’s New
in the
ASAM Criteria?
ASAM CRITERIA BACKGROUND
 Previous Editions
 PPC ( 1991)
 PPC-2 (1996)
 PPC-2R (2001)
 Upcoming Edition:
 “The ASAM Criteria”
 Release October, 2013
Assessment of Biopsychosocial Severity
and Level of Function
Dimensions are not changed in the new ASAM
Criteria
1. Acute Intoxication and/or Withdrawal Potential
2. Biomedical conditions and complications
3. Emotional/Behavioral/Cognitive conditions and
complications
4. Readiness to Change
5. Relapse/Continued Use/Continued Problem
potential
6. Recovery Environment
Broad Treatment Levels of Service
Description of the Continuum of Care
1. Outpatient Treatment
2. Intensive Outpatient and Partial Hospitalization
3. Residential/Inpatient Treatment
4. Medically-Managed Intensive Inpatient Treatment
No changes except:
 New edition changes to Arabic numerals from Roman
numerals e.g., Level II.1 becomes Level II.1
 The old Level III.3, Clinically Managed Moderate Intensity
Residential Treatment becomes Level 3.3, High-Intensity,
Population-Focused Residential Treatment
What’s new in The ASAM
Criteria?
The Title!
 The Title: “The ASAM Criteria” - Treatment Criteria
for Substance, Addictive and Co-Occurring
Conditions
 Shift away from “placement” criteria to “treatment”
criteria: it’s more than just “placement”
 Diagnostic Admission Criteria terminology changed
to be compatible with DSM-5
 Section on working with managed care
 Section on the Affordable Care Act
What’s new in The ASAM Criteria?
The Table of Contents!
•
Re-ordered to be more user-friendly and follow the
flow from Historical Foundations to Guiding
Principles to Assessment, Service Planning and
Placement decisions
•
ADOLESCENT CRITERIA NO LONGER
SEPARATE/STAND-ALONE: consolidated Adult and
Adolescent content to minimize redundancy while
preserving adolescent-specific content
•
Appendices include Withdrawal Management
instruments, Dimension 5 constructs, and a Glossary
What’s new in The ASAM Criteria?
 The wording in the Levels of Care for Withdrawal
Management
 The overall section that used to be called
“detoxification” is now called “Withdrawal
Management” and the Levels are now called
 1-D is now 1-WM; 2-D is now 2-WM; 3-D is now 3WM and 4-D is now 4-WM
 New approaches described to support increased
use of lower levels of care for safe/effective
management of withdrawal
What’s new in The ASAM Criteria?
 Updated/revised terminology, to be
contemporary and strength-based,
recovery-oriented:
• “dual diagnosis” becomes “co-occurring
disorders”
• “inappropriate use of substances”
becomes “high risk use of substances”
• “admitted” becomes “stated”
• “compliance” becomes “adherence”
What’s new in The ASAM Criteria?
• Specialized services for opioid use disorder
re-named:
“Opioid Maintenance Therapy”(OMT)
becomes “Opioid Treatment Services”(OTS)
Within OTS, mention is made of the use of
opioid antagonist medications as well as
opioid agonist medications that can be
used in OTPs (regulated “Opioid Treatment
Programs”) or in office-based opioid
treatment (OBOT)
New Content and Sections
Additional text to improve application to address
addiction treatment for Special Populations:
 Older Adults
 Persons in Safety Sensitive Occupations
 Parents with Children and Pregnant
Women
 Person in the Criminal Justice System (CJS)
New Content and Sections
Additional text to address treatment of
conditions not traditionally included in
specialty addiction treatment services:
 Tobacco Use Disorder
 Gambling Disorder
New Content and Sections
Revision of the text to address emerging issues:
 Health Reform and the integration of
addiction treatment into general medical care
 The role of physicians in the care team,
addiction specialist physicians in particular
(addiction medicine physicians, addiction
psychiatrists)