DSM-5 and Clinical Diagnosis:
The Major Changes Every Clinician
Should Know
Thursday June 5, 2014
Jerome C. Wakefield, PhD, DSW, LCSW
Professor, School of Social Work and Department of Psychiatry
New York University
Agenda
Welcome and Introduction
Disclosure and Caveats
Emerging Measures
Neurodevelopmental Disorders
Depressive Disorders
Substance Use Disorders
Disclosure and Caveats - I
 DSM and DSM-5TM are trademarks of the American Psychiatric Association,
which is not affiliated with nor endorses anything in this presentation.
 All DSM-5 diagnostic criteria sets are copyrighted by the American
Psychiatric Association, and are cited here only to a degree that falls under
fair use in a professional educational setting.
 I was not officially involved in the development of the DSM-5.
 Nothing I say here about diagnosis should be taken to apply to any
particular individual without a full diagnostic assessment by a qualified
professional.
 Coverage today must be very selective and limited. Many major changes
cannot be covered. (NASW -- NYC is offering an all-day workshop Friday
June 13 in which I will cover DSM-5 in more detail.)
The DSM-5 is mainly about mental disorder
diagnosis, but it is important to recognize that
the mental health professions have several
functions; it is not only about mental disorder.
 The DSM’s “V Codes” acknowledge this by listing nondisordered conditions for which psychiatrists are commonly
consulted, such as normal bereavement, marital or parentchild conflict, and occupational or academic problems.
Why do we have a DSM with its categories
and detailed diagnostic criteria?
Communication
Access research
Address earlier criticisms of psychiatry
The symptom-based criteria addressed many
criticisms of the mental health professions
 Greater reliability and improved communication
 Symptom-based criteria contained no implicit psychoanalytic assumptions
 Because the same symptom syndrome could be recognized as a disorder by all
schools of thought (i.e., are theory neutral), the new criteria provided a level
playing field for competing theories of disorder etiology and cumulative
research on treatment
 Real disorders vs. anti-psychiatry based on definition of disorder
 Disorders more finely distinguished, better targets for drug development
(though it did not work out that way!)
 Easily applied to epidemiology and screening and general medical practice
 Response to Rosenhan, US/UK, and other reliability studies; reliability and
validity improved
DSM-5 Definition of Mental Disorder
 A mental disorder is a syndrome characterized by clinically significant
disturbance in an individual’s cognition, emotion 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 behavior (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.
Disorder as "Harmful Dysfunction"
A dysfunction is:
 A failure of an internal mechanism to perform one of its natural
functions (as ultimately determined by evolutionary design)
 A disorder if it causes harm, defined by social values to include harm
to individual or society
 Wakefield “The concept of mental disorder.” 1992 American
Psychologist
The “false positives” problem
“Many millions of people with normal grief, gluttony,
distractibility, worries, reactions to stress, the temper
tantrums of childhood, the forgetting of old age, and
'behavioral addictions' will soon be mislabeled as
psychiatrically sick.” (Frances, 2012)
The Clinician’s Dilemma
 Broader categories mean reimbursement to help more people
 But disorder diagnosis can have negative consequences and
may mean medication with side effects
 An ethical issue we all face within our flawed and selfdefeating system of help
DSM-5 Overarching/Structural Changes
 Arabic numbering of fifth edition – DSM-5
 Three sections plus appendices
 New chapter organization
 Disorders moved around
 The elimination of the multiaxial system
 Terminological changes to NOS and general medical
conditions
 Double ICD-9/ICD-10 coding
 Cultural interview
 Dimensionalization where possible
DSM
Question: When does DSM-5 become “official”?
Answer: there is no one answer.
When you look at a disorder in DSM-5, it will appear
as below. Bot the ICD-9-CM code and the ICD-10-CM
code are listed:
ICD-10: fuggedaboutit! (for now)
 ICD-10 was originally scheduled to be adopted in 2013, then delayed until
October 1, 2014.
 On April 1, 2014, Bill H.R. 4302, known as the PAM Act (Protecting Access
to Medicare Act), was signed into law by President Obama.
 As a result of a quietly inserted clause piggybacking on this Bill,
implementation of ICD-10-CM was delayed by a further year. Centers for
Medicare & Medicaid Services (CMS) has confirmed that the effective
implementation date for ICD-10-CM is now October 1, 2015, a year-and-ahalf away.
 Until that time, the codes in ICD-10-CM (the U.S. specific adaptation of the
WHO’s ICD-10) are not valid for any purpose or use. You may only user
ICD-9-CM codes, the ones you have been using from DSM-IV (plus a few
modifications for DSM-5).
Emerging Measures and Models
Emerging Measures and Models
Assessment Measures
Cultural Formulation
Alternative DSM-5 Model for Personnalité
Disorders
Conditions for Further Study
Conditions for further study (or “emerging”
categories)-uncoded
 Attenuated Psychosis Syndrome
 Depressive Episodes with Short-duration Hypomanic Episodes
 Persistent Complex Grief Disorder
 Caffeine Use Disorder
 Internet Gaming Disorder
 Neurobehavioral Disorder Associated
With Prenatal Alcohol Exposure
 Suicidal Behavior Disorder
 Non-suicidal Self-injury Disorder
Assessment Measures
 A dimensional approach depending primarily on an individual’s subjective
reports of symptom experiences along with the clinician’s interpretation is
consistent with current diagnostic practice.
 Cross-cutting symptom measures modeled on general medicine’s review
of systems can serve as an approach for reviewing critical
psychopathological domains.
 Severity measures are disorder-specific, corresponding closely to the
criteria that constitute the disorder definition.
 The World Health Organization Disability Assessment Schedule, Version
2.0 (WHODAS 2.0) was developed to assess 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.
Fear Questionnaire – Agoraphobia Subscale
Never
Occasionall
y
Half of
the Time
Most of
the Time
All of the
Time
During the past month, I have…
1. felt moments of sudden terror, fear or fright in these situations
0
1
2
3
4
2. felt anxious, worried, or nervous about these situations
0
1
2
3
4
3. had thoughts about panic attacks, uncomfortable physical
sensations, getting lost, or being overcome with fear in these
situations
0
1
2
3
4
4. felt a racing heart, sweaty, trouble breathing, faint, or shaky in these
situations
0
1
2
3
4
5. felt tense muscles, on edge or restless, or trouble relaxing in these
situations
0
1
2
3
4
6. avoided, or did not approach or enter, these situations
0
1
2
3
4
7. moved away from these situations, left them early, or remained
close to the exits
0
1
2
3
4
8. spent a lot of time preparing for, or procrastinating about (putting
off), these situations
0
1
2
3
4
9. distracted myself to avoid thinking about these situations
0
1
2
3
4
10. needed help to cope with these situations (e.g., alcohol or
medications, superstitious objects, other people)
0
1
2
3
4
DSM-5 Self-Rated Level 1 CrossCutting Symptom Measure—Adult
DSM-5 Cultural Formulation Interview
 The Cultural Formulation Interview (CFI) is a set of fourteen
questions that clinicians may use to obtain information during
a mental health assessment about the impact of a patient’s
culture on key aspects of care.
 In the CFI, culture refers primarily to the values, orientations, and
assumptions that individuals derive from membership in diverse social
groups (e.g., ethnic groups, the military, faith communities), which
may conform or differ from medical explanations.
 The term culture also refers to aspects of a person’s background that
may affect his or her perspective, such as ethnicity, race, language, or
religion.
For example
 People often understand their problems in their own way,
which may be similar to or different from how doctors
describe the problem. How would you describe your
problem?
 Sometimes people have different ways of describing their
problem to their family, friends, or others in their community.
How would you describe your problem to them?
 Why do you think this is happening to you? What do you think
are the causes of your [PROBLEM]?
 PROMPT FURTHER IF REQUIRED:
 Some people may explain their problem as the result of bad
things that happen in their life, problems with others, a
physical illness, a spiritual reason, or many other causes.
 Additional level 2 detailed questions to follow up any answer
of interest in main level 1 interview.
“Online Enhancements”
www.psych.org/dsm5
 Inclusion of clinical ratings scales and assessments in print
version is limited to those that are most relevant
 Additional measures used in the field trials are available on-line
linked to the various disorders
 Cultural Formulation Interview also available on-line
Terminology change - NOS
 “Not otherwise specified” (NOS) categories, for disorders that do not fit
under specific disorder categories (e.g., “depressive disorder not
otherwise specified”), are replaced by a combination of two categories:
 “other specified” (e.g., “other specified depressive disorder”), in which the
clinician provides the reason why the condition does not qualify for
specific diagnosis (e.g., subthreshold, or short duration). Options for other
specified classifications are provided.
 “unspecified,” used when no additional explanation is provided as to why
the disorder does not meet usual criteria.
Elimination of Multiaxial System
DSM-IV Multiaxial System
 Axis I Clinical Disorders, Other Conditions That May Be a
Focus of Clinical Attention
 Axis II Personality Disorders, Mental Retardation
 Axis III General Medical Conditions
 Axis IV Psychosocial and Environmental Problems
 Axis V Global Assessment of Functioning (GAF)
Why was the multiaxial system
eliminated?
To be more consistent with general medicine
To be more consistent with the WHO’s ICD
It was always stated that the first three axes are the
“real” diagnosis, consistent with general medicine.
The idea was already illustrated in DSM-IV
non-multiaxial recording
•
Example 1:
– 296.23 Major Depressive Disorder, Single Episode, Severe Without
Psychotic Features
– 305.00 Alcohol Abuse
– 301.6 Dependent Personality Disorder
– Frequent use of denial
•
Example 2:
– 300.4 Dysthymic Disorder
– 315.00 Reading Disorder
– 382.9 Otitis media, recurrent
•
Example 3:
– V61.1 Partner Relational Problem
DSM-IV-TR (ICD-9-CM Coding)
 AXIS I. Asperger disorder, 299.80
 AXIS II. Deferred
 AXIS III. Generalized non-convulsive epilepsy 345
 AXIS IV. Academic/educational problem V 62.3
 AXIS V. GAF 51
DSM-5 Single-Axis Coding
(ICD-9-CM and ICD-10-CM Codes)
299.00 Autism spectrum disorder; 345 Generalized
non-convulsive epilepsy (from chart); V 62.3
Academic/educational problem.
How do you record a medical disorder if you are not
an MD? One technique: indicate “diagnosis by
history” from patient or chart.
DSM-IV-TR Multiaxial Coding
 AXIS I. Dysthymia, 300.4;
 Noncompliance with treatment V51.81 (NOTE: Listed by V
code if a target of treatment; otherwise listed in Axis IV)
 AXIS II. Borderline Personality Disorder 301.83
 AXIS III. Obesity 278 (from history)
 AXIS IV. Noncompliance with medical treatment. (Listed here
if a factor in treatment planning but not a target of treatment]
 Problems with access to health care: Unavailability of
healthcare facilities (V63.9)
 AXIS V. GAF 43
DSM-5 Single-Axis Coding
(ICD-9-CM Codes)
300.4
Persistent
depressive
disorder
(dysthymia); 301.83 Borderline personality
disorder; 278 Obesity; V15.81 Non-adherence to
medical treatment; V63.9 Unavailability of
health care facilities.
Elimination of the Multiaxial System
AXIS 2:
 Personality disorders and intellectual disability
(labeled “mental retardation” in DSM-IV) were on a
separate axis 2, but are now listed with all the other
disorders, and will simply be listed as an additional or
primary diagnosis.
Axis 3:
 General medical disorders will be listed along with
the main psychiatric diagnosis.
Elimination of Axis IV, Expansion of V Codes
 Stressors (axis 4) are eliminated, but the V Codes are greatly
expanded to all manner of environmental stresses.
 Also, the V Codes can now be used not only for targets of
treatment but also, like the former Axis 4, to specify
important contextual factors that influence the target
condition’s nature, prognosis, or treatment.
 Overall, this change seems a plus for contextualizing disorder.
No. of V Codes: DSM-IV, 23; DSM-5, 133
 Relational problems
 Problems Related to Family Upbringing
 Problems Related to Primary Support Group (e.g., disruption by
separation)
 Child abuse and neglect—physical, sexual, psychological
 Spouse or Partner neglect or abuse, Physical, sexual, psychological
 Adult neglect or abuse (e.g., abuse by non-spouse/non-partner)
 Problems of to Access or non-adherence to Medical Care
 Problems with crime or legal system (e.g., victim of crime, imprisonment)
 Housing and economic problems (e.g., homelessness, low income,
discord with neighbor)
 Problems with social environment (e.g., acculturation, discrimination)
 Other psychosocial problems (e.g., religious problems; victim of torture;
exposure to disaster; discord with social service provider)
 Family circumstances (e.g., high expressed emotion; sibling rivalry)
 Circumstances Personal history (e.g., military service, trauma, lifestyle)
Demise of the GAF
Axis 5’s Global Assessment of Functioning (GAF), now
required in many settings, is eliminated as an axis in
its own right.
Widely used, but criticized as combining functioning
and symptoms
– e.g., range 41-50: Serious symptoms (e.g., suicidal
ideation, severe obsessional rituals, frequent shoplifting)
OR any serious impairment in social, occupational, or
school functioning (e.g., no friends, unable to keep a job)
DSM-5 recommends the WHODAS for
assessing adaptive functioning
 World Health Organization Disability Assessment Schedule (WHODAS) – a
comprehensive inventory of social functioning.
 Focuses exclusively on adaptive functioning and does not depend at all on
symptom levels.
 Used across medical specialties, not specifically tailored for mental health.
 However, designed for general psychosocial screening, asks questions about
longer-term problems such as making new friends, joining in community
activities, and living with dignity.
 May be less suitable than the GAF for focused psychiatric disability evaluations,
and clinician time may be a problem.
WHODAS
Assesses disability across six domains, including
understanding and communicating, getting
around, self-care, getting along with people, life
activities (i.e., household, work, and/or school
activities), and participation in society.
Question
In DSM-5, personality disorders are
diagnosed:
 (a) on a separate axis from other mental disorders
 (b) without any separate axis, as one form of mental
disorder along with all the other categories
Neurodevelopmental Disorders
Autism spectrum
 Rates increased from 1/2000 to 1/50
 DSM-5 Autism Spectrum narrows definition- not clear how
much
Autism Spectrum Disorder - II
•
Persistent deficits in social communication and social interaction (ALL)
– Deficits in social-emotional reciprocity
– Deficits in non-verbal communication
– Deficits in developing and maintaining relationships
•
Restricted repetitive behaviors or interests (2 of 4)
– Stereotyped behavior or speech
– Need for sameness and routines
– Abnormal fixations or restricted interests
– Hyper- or hyporeactivity to sensory input
Spectrum of severity provided (“ranging from…”)
•
•
Specify current severity for Criterion A and Criterion B: Requiring very substantial
support, Requiring substantial support, Requiring support
Severity of Social
Communication deficits
Severity Level
Anchor
Level 3
Severe deficits; very little initiation of social
interactions and minimal response to others:
e.g., few words or intelligible speech, makes
unusual approaches only to meet needs
Level 2
Marked deficits; e.g., speaks simple
sentences, interaction limited to narrow
special interests
Level 1
Without supports in place, deficits cause
noticeable impairments; e.g., able to speak in
full sentences but conversation fails
ASD Controversy
 The main concern was that changes in diagnostic thresholds at the milder
end of the spectrum would eliminate some from diagnosis and lead to loss
of services, to which these diagnoses are closely tied.
 Some studies suggested possible loss of substantial numbers of cases of
Asperger’s and also of some autism cases
 Solution: grandfathering in all previous diagnoses to avoid loss of services
(!)
 “Note: Individuals with a well-established DSM-IV diagnosis of autistic
disorder, Asperger’s disorder, or pervasive developmental disorder not
otherwise specified should be given the diagnosis of autism spectrum
disorder.”
Attention-Deficit/Hyperactivity Disorder – changes
to ease diagnosis in adults
 Age of symptom onset requirement raised from age 7 to age 12
 Rationale for change: individuals often cannot recall onset before age 7;
later “onset” cases the same as earlier age. Criticism: if it’s a
developmental disorder, it ought to emerge early
 Diagnosis in adolescents and adults requires only five
symptoms, rather than the six in DSM-IV
 Examples adjusted to illustrate adult ADHD
For example
 Often has difficulty sustaining attention in tasks or play
activities (e.g., has difficulty remaining focused during
lectures, conversations, or lengthy reading).
 Often has difficulty organizing tasks and activities (e.g.,
difficulty managing sequential tasks; difficulty keeping
materials and belongings in order; messy, disorganized
work; has poor time management; fails to meet
deadlines).
For example continued
 Often avoids, dislikes, or is reluctant to engage in tasks
that require sustained mental effort (e.g., schoolwork or
homework; for older adolescents and adults, preparing
reports, completing forms, reviewing lengthy papers).
 Often loses things necessary for tasks or activities (e.g.,
school materials, pencils, books, tools, wallets, keys,
paperwork, eyeglasses, mobile telephones).
 Is often forgetful in daily activities (e.g., doing chores,
running errands; for older adolescents and adults,
returning calls, paying bills, keeping appointments)…..
Specific Learning Disorder
 Replaces and combines all the DSM-IV learning-disorder
diagnoses
 Specifiers indicate specific problem areas (but must be coded
separately due to ICD coding)
 Reflects the fact that these disorders often occur together
Specific Learning Disorder
• Abandonment of the “discrepancy theory”: DSM-IV
required a disparity between level of achievement
and IQ to establish a learning disorder vs. poor
ability. This requirement is eliminated (only disparity
with chronological age and education is now
required).
• Changing federal regulations now prohibit the
diagnosis of learning disorder from requiring a
difference between disorder-specific learning and
overall IQ.
“B. The affected academic skills are
substantially and quantifiably below those
expected for the individual’s chronological
age,…”
Specific Learning Disorder
• Instead, performance is compared to average
expectations for one’s age.
• Also, DSM-5 adopts the “response to
intervention” (RTI) approach: a trial test of
educational interventions is required in order to
demonstrate the problem is not easily
ameliorable by standard educational techniques,
thus that the child requires special services.
• Opponents claim that RTI simply identifies low
achieving students rather than students with
learning disabilities
Specific Learning Disorder, Diagnostic
Criteria
• A. Difficulties learning and using academic
skills, as indicated by the presence of at least
one of the following symptoms that have
persisted for at least 6 months, despite the
provision of interventions that target those
difficulties…”
Questions
• In diagnosing ADHD in an adult, by what age
must symptoms have appeared?
• To what baseline must a child’s performance
now be compared in supporting a diagnosis of
learning disorder?
• Children who were diagnosed with Asperger’s
disorder in DSM-IV now appear in DSM-5
under what disorder?
Disruptive, Impulse Control, and
Conduct Disorders
• Oppositional-defiant disorder
– Sibling exclusion
• Intermittent Explosive Disorder
– Addition of verbal aggression
• Conduct disorder
– Addition of specifier for “with limited
prosocial emotions”
60
Depressive Disorders
Changes in Organization
• Unipolar depressive disorders are now
presented in a separate chapter
• Major depressive episode criteria are no longer
presented separately from major depressive
disorder criteria
– “This approach will facilitate bedside diagnosis…”
(p. xlii)
©
Disruptive Mood Dysregulation Disorder (DMDD)
296.99 (F34.8)
New Disorder
Initially called Temper
dysregulation disorder
with dysphoria
Ridiculed in Slate as “the new
temper tantrum disorder”
•Al Frances: this disorder "will
turn temper tantrums into a
mental disorder."
DMDD vs Normal Tantrums
• Tantrums occur on average at least three times
per week
• Mood between outbursts is persistently irritable
or angry
• Present for at least 12 months; no more than a 3
month period w/o symptoms
• Present in at least 2 of 3 settings (school, home,
with peers) and severe in at least one of these
Why was DMDD Added?
 Main Goal: To address the embarrassment that in just one decade,
the diagnosis of child bipolar disorder increased 4000% (40
times as much)
 Reason: Chronic irritability and tantrums interpreted as
childhood manifestations of manic symptoms
 Children inappropriately treated with mood stabilizers and antipsychotic medication with serious side effects and unknown
developmental effects
Differential Diagnosis
Bipolar disorder includes discrete episodes of mania,
not chronic irritability; expansive mood and grandiosity
do not occur in DMDD
Oppositional defiant disorder does not include chronic
mood symptoms prominent in DMDD, less severe
Bipolar overrides DMDD, DMDD overrides ODD
Axelson Study (2)
• “Conclusions—In this clinical sample,
DMDD could not be delimited from
oppositional defiant disorder and conduct
disorder, had limited diagnostic stability, and
was not associated with current, future-onset,
or parental history of mood or anxiety
disorders. These findings raise concerns about
the diagnostic utility of DMDD in clinical
populations.” (Axelson et al., 2012)
DSM-5 Persistent Depressive Disorder
Combines Dysthymia and Chronic MDD
 Research suggests that chronic major and chronic subsyndromal
depressions have prognostic factors in common. (However, this
research is not very extensive.)
 Criteria are similar to DSM-IV Dysthymic Disorder except the
exclusion of cases with MDE has been removed.
Persistent Depressive Disorder
Specifiers indicate the relationship between MDE
episodes and dysthymic periods during the preceding 2
years:
– With pure dysthymic syndrome (no MDE in preceding 2 years)
– With persistent major depressive episode (MDE for entire 2
years)
– With intermittent major depressive episodes, with current
episode (current MDE and at least one two month period below
threshold)
– With intermittent major depressive episode, without current
episode (no current MDE but one or more MDE in preceding two
years)
Major Depression Bereavement
Exclusion Eliminated
Just two weeks of general-distress
symptoms after loss can qualify for MDD
Critics:
 Danger of over-treatment with meds
 Reduces dignity of grief
Bereavement Exclusion Note
In response to criticism, DSM-5 added a “note”
reminding the clinician that responses to grief and
other significant losses may include feelings of
intense sadness and other depressive symptoms that
can resemble a depressive episode, and that clinical
judgment is required
What Does the Evidence Show?
Uncomplicated bereavement (and other-stressor) cases do
not have elevated recurrence on follow-up
Uncomplicated bereavement (and other stressor) cases do
not have elevated suicide attempts on follow-up
Premenstrual Dysphoric Disorder
(PMDD) 625.4 (N94.3)
Criteria emphasize that symptoms are marked
and that mood symptoms are primary
– B-criterion: There must be at least one of: marked affective lability (e.g.,
mood swings; feeling suddenly sad or tearful, or increased sensitivity to
rejection), irritability or anger or interpersonal conflicts, depressed mood
(e.g., hopelessness, self-deprecating thoughts), or anxiety in the week
before the onset of menses, which improves after onset, with sxs
minimal or absent in week post-menses
– C-criterion: There must be additional depressive symptoms (e.g.,
lethargy, decreased interest, trouble concentrating, appetite changes,
sleep changes, feeling overwhelmed) for a total of at least five B and C
symptoms.
PMDD (2)
– Not merely an exacerbation of pre-existing disorder
– Must be present for most cycles in previous year
– Confirmed by prospective daily ratings for two cycles
Almost all symptoms are depressive symptoms
(exception: “Physical symptoms such as breast
tenderness or swelling, joint or muscle pain, a sensation
of “bloating,”
or weight gain”)
“With Anxious Distress” Specifier
Addresses the frequent comorbidity of depression and
anxiety (a self-created problem)
Important because anxiety indicates more negative
MDD outcomes
 In addition, DSM-5 allows GAD to be diagnosed comorbidly
with MDD for the first time.
“With Anxious Distress” Specifier
• Can specify “With Anxious Distress” if at least two of the
following anxiety symptoms during the majority of days:
– Feeling keyed up
– Restless
– Difficulty concentrating
– Fear that something awful might happen
– Fear of losing control
• Can indicate severity (e.g., “with mild anxious distress”)
as follows:
– Mild: 2 sxs; Moderate: 3 sxs; Moderate-Severe: 4-5
sxs ; Severe: 4-5 sxs with motor agitation
Questions
• If someone is grieving the loss of a loved one,
for how many weeks must they manifest
depressive symptoms for a diagnosis of major
depressive disorder to be warranted?
• but they have enough symptoms to qualify for
major depression, are they diagnosed as
normally bereaved or as having major
depression?
Substance Use Disorders
• Lumps Abuse and Dependence
Adds symptoms to dependence list
Reduces diagnostic threshold
Critics
• Stigmatizes the non-addicted
• Different outcome and prognosis
Substance Use Disorder
DSM-5™ substance use (2 out of 11)
•
•
•
•
•
•
•
•
•
•
•
Larger amounts taken than intended
Persistent desire to cut down or control use
Great deal of time to obtain, use or recover
Craving or strong desire to use
Failure to fulfill role obligations
Use despite social/interpersonal problems
Activities given up or reduced
Use where physically hazardous
Use despite physical/psychological problem
Tolerance
Withdrawal
DSM-IV dependence/abuse
•
•
•
•
•
•
•
•
•
•
•
Dependence (3)
Dependence (4)
Dependence (5)
Not in DSM-IV
Abuse (1)
Abuse (4)
Dependence (6)
Abuse (2)
Dependence (7)
Dependence (1)
Dependence (2)
80
When tolerance and withdrawal don’t
count for dependence
 When taking opioids, sedatives, or stimulants under medical
supervision, it is expectable that tolerance and withdrawal will
develop. This is NOT evidence of a substance use disorder, which
must include compulsive use.
 “Appropriate” medical supervision precludes shopping for
multiple prescriptions. Criteria can still be met when taking the
substance under medical supervision if two other symptoms of
compulsive use are present.
For example, opioid use disorder
•
10. Tolerance, as defined by either of the following:
– a. A need for markedly increased amounts of opioids to achieve intoxication or desired
effect.
– b. A markedly diminished effect with continued use of the same amount of an opioid.
•
Note: This criterion is not considered to be met for those taking opioids solely
under appropriate medical supervision.
•
11. Withdrawal, as manifested by either of the following:
– a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria
set for opioid withdrawal, pp. 547–548).
– b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal
symptoms.
•
Note: This criterion is not considered to be met for those individuals taking
opioids solely under appropriate medical supervision. (p. 541)
Substance Use Disorder Specifiers
Severity specifiers
– Mild: 2-3 symptoms
– Moderate: 4-5 symptoms
– Severe: 6 or more symptoms
Polysubstance use disorder eliminated
83
New Withdrawal Categories in DSM-5™
Cannabis withdrawal
Caffeine withdrawal
• Cessation of prolonged cannabis
use followed by
3 or more of
• Abrupt cessation of daily use
followed by 3 or more of
Irritability, anger, or aggression
Nervousness or anxious
Sleep difficulty
Decreased appetite or
weight loss
– Depressed mood
– Restlessness
– Physical symptoms
(e.g., sweating, fever, chills,
headache, etc)
–
–
–
–
–
–
–
–
–
Headache
Marked fatigue or drowsiness
Dysphoric mood or irritability
Difficulty concentrating
Flu-like symptoms (nausea, vomiting,
muscle pain)
• Causes clinically significant distress
or impairment
• Causes clinically significant
distress or impairment
84
Questions
An individual presenting with 3 out of a possible 11
substance use disorder symptoms would be classified
as what level of severity?
What new symptom criterion has been added to
DSM-5 substance use disorder that did not appear in
either DSM-IV abuse or dependence?
Thank you for listening
 If you have further questions about the presentation, you may
email them to:
 wakefield@nyu.edu (responses may be delayed)
 If you wish to get further in-depth coverage of DSM-5 changes
and controversies, NASW-NYC is presenting a workshop by me
on Friday, June 13, titled “Mastering DSM-5: Changes,
Controversies, and Parts Unknown.”
 See: https://m360.naswnyc.org/event.aspx?eventID=102534\
 Slides are available online:
http://www.ctacny.com/dsm-5-and-clinical-diagnosis-the-majorchanges-every-clinician-should-know-about.html