Utah Valley University
“The DSM-5
for Addiction Clinicians”
© 2015, Shulman & Associates,
Training & Consulting in Behavioral Health
The Basic Assessment System for
Mental Health Disorders is the DSM-5
DSM-5 Conflicts
 NIMH stated that the
manual is reliable but
lacks validity and that
"patients with mental
disorders deserve better“
and "will be re-orienting its research
away from DSM categories."
CAUTIONS
•
•
•
•
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 is a significantly sized group of psychiatrists
who tried to block the release of the DSM-5 led by
the psychiatrist who chaired the DSM-IV revision
(Allen Frances, MD)
Diagnoses of Bipolar Disorder in children have
increased 40 times in the last 20 years, most of
whom have never had a manic or hypomanic
episode
Progress?
DSM-I (1952) – 132 pages
DSM-5 – (2013) - 947 pages
The DSM-5
 Has 257 different diagnoses organized in 20
chapters restructured on the disorders’
apparent relatedness to one another
 Is 947 pages in length
 Has a helpful section comparing changes
from the DSM-IV to the DSM-5 (p. 809)
U.R. Recommendation #1
 When talking to insurance or managed care
companies’ utilization reviewers, don’t talk about
recovery (it doesn’t compute for them)
 Talk about “REMISSION”
 Before doing a precertification, ask the reviewer if
they are using the DSM-IV or DSM-5
U.R. Recommendation #2
Our people with substance use or mental health
problems are “PATIENTS”
The people we treat are not “clients”
 Lawyers have “clients”
 Accountants have “clients”
 Prostitutes have “clients”
We have patients!
General Changes
 Published 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
Cross Cutting Symptom Assessment*
 Assessment across areas that are relevant (and “cut
across”) regardless of specific diagnostic category
 depressed mood
 anxiety
 substance use
 sleep problems
 anger
 Usually single page
 0-4 scale encouraged with 0 being absence of
difficulty
A Description of A Mental
Disorder (Allen Frances)
A Mental Disorder is a:
 Condition that clinicians treat
 Researchers research
 Educators teach and
 Insurers pay for!
Allen Frances , MD
Five Axis
Diagnostic Structure
 Goes away for purposes of diagnosis
 Replaced with list of diagnoses
 Recommendation #1: Keep the 5
Axis system “in your head” as a way
of organizing your assessment
 Recommendation #2: “Continue
using Axes III, IV and V for purposes
of informing the assessment”
Old Axis 3
General Medical Conditions
 A common reason for relapse to opioid
dependence is a chronic pain disorder
 Chronic pain disorders would have been
coded on Axis III
 Don’t use the Axis III term – describe in a
narrative form your findings
Old Axis IV
Psychosocial and
Environmental Problems
 A review of these problems can help to
develop a substance use or mental disorder
relapse prevention plan
 Don’t use the Axis IV term – describe in a
narrative form your findings
Axis V
 Global Assessment of
Functioning
Old Axis 5
Global Assessment of Functioning
 Assess for current level of functioning
 Assess for highest level of functioning in the
past year
 Determines whether the patient’s functioning
is deteriorating, improving or remain stable
 Questions about the GAF Scale number and
admission to residential or inpatient
treatment?
 Don’t use the Axis 5 term – describe in a
narrative form your findings
Substance
Use
and Addictive
Disorders
Why Start with
Substance Use Disorders?
 All of the other diagnoses in this training are
presented in the order found in the DSM-5
manual with the exception of substance use
disorders
 Substance use disorders co-occur with more
diagnoses than any other diagnosis
 Many of the disorders have as a type: “substance
use induced disorder”
 Example: Even though there are 257 different
diagnoses in the DSM-5, 16% of diagnostic
criteria are devoted to substance use disorders
Binge Drinking
 Most excessive drinkers (90%) did not meet the
criteria for alcohol dependence (DSM-IV)
 Excessive alcohol consumption is responsible for
an average of 88,000 deaths each year and cost
the United States $223.5 billion in 2006
 Half of these deaths and three-quarters of the
economic costs are due to binge drinking (i.e., ≥4
drinks for women and ≥5 drinks for men in a
single occasion
 Binge drinking is also associated with a myriad
of health and social problems (e.g., violence, new
HIV infections, unintended pregnancies, sexual
assault, and alcohol dependence)
DSM-IV Diagnostic Assessment
 Substance Dependence
 Substance Abuse
 Those individuals who do not meet the
criteria for abuse, but whose
drinking/drug use might still create
problems (“sub-threshold” abuse)
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
Diagnostic Criteria
for Substance Use
Disorders
The DSM-5
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
23
Removal of “Legal Problems”
Pro:
• Discrimination based on race and socioeconomic status
• Misuse of a DWI as equivalent to old “abuse”
• Geographic inequalities (crossing Colorado state line)
• A criterion that carried the least weight in making the
diagnosis
Con:
• For some, serves an SBIRT function, as early intervention
• May function as the impetus for treatment (drug courts)
• Potential insurance problems because of change in
diagnosis
DSM-5 Criteria for Substance Use Disorders
A maladaptive pattern of substance use, leading to
clinically significant impairment or distress, as
manifested by two (or more) of the following, occurring
at any time in the same 12-month 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
DSM-5 Criteria for
Substance Use Disorders (cont)
(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
(8) Recurrent substance use resulting in failure to fulfill
major role obligations at work, school, or home
(9) Recurrent substance use in situations in which it is
physically hazardous
(10) Craving
(11) Continuing substance use despite having persistent
or recurrent social or interpersonal problems caused
or exacerbated by the effects of the substance
Changes in the DSM–5 Diagnostic
Criteria for Substance Use Disorders
Changes from DSM-IV
 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”)
27
The Issue of Criteria “Weight”
 All criteria are not equal in implications
 Some criteria are found almost
exclusively among those in the severe
alcohol use disorder designation
 Other criteria are more common among
the mild to moderate alcohol use disorder
group
 Tolerance and dangerous use are actually
common among those with no diagnosis
The SUD Criteria Found Primarily
in the Severe Designation
The “Big Five”
 Wanting to cut down/unable to do so
 Craving with compulsion to use
 Sacrifice activities to use
 Failure at role fulfillment due to use
 Withdrawal symptoms
ALCOHOL CRITERIA PREVALENT
IN MILD & MODERATE GROUPS
 Unplanned use
 Time spent using
 Medical/psych. consequences of use
 Use where impairment is dangerous
 Interpersonal conflicts
Legal problems and use to relieve emotional
distress similar in distribution to those above
SAMPLE HYPOTHESES
 Hypothesis #1: Clients positive on three
or more of the “big five” (withdrawal, rule
setting, sacrificing activities, role
fulfillment failure, and
craving/compulsion to use) will find
recovery more difficult
(e.g., higher relapse rates)
 Hypothesis #2: Clients in mild or
moderate designations without any
positive findings on the “big five” may be
able to moderate use
CLINICAL IMPLICATIONS

Most of those in the “mild” designation can
probably benefit from moderation and related
harm reduction strategies (outpatient placement)

Those in the “severe” designation will require more
intensive and extended services where abstinence
is essential to recovery (residential/inpatient or
structured outpatient, IOP or PHP placement
depending on the ASAM severity profile)

The “moderate” group may contain cases that fit
the mild or severe characteristics (placement
dependent on the results of the ASAM severity
profile)
Changes in Course Specifiers
 Early remission
 From 1 month but less than 12 months in DSM-IV to
3 month in DSM-5, no criteria met except craving
 Early partial remission
 Sustained full remission
 No symptoms for 12 months except craving
 Sustained partial remission
 On agonist maintenance therapy
 In a controlled environment
Current Drug Use Status
 Alcohol: Significant declines in use by
adolescents and college students
 Palcohol: Powdered alcohol
 Cannabis: Significant increases in use by
adolescents and college students
Slight decrease in cannabis use last year

 Increase in pediatric overdoses
 Benzodiazepines: ER visits involving non-
medical use of Xanax doubled from 2005 to
2010 and most common prescribed
psychiatric medication in 2011
Opioids
 Sales of legal opioids have increased 400% in last 10 yrs
 O.D. deaths among adolescents and 20 years olds
 O.D. deaths associated with Rx. Opioids increased 200%







in last 15 years
Evzio, a device for delivering naloxone (Narcan), an opioid
antagonist to treat O.D.s, approved by the FDA,
estimated to prevent 20,000 O.D. deaths/yr. in US
Automatically injects correct dose in an easy to use device
Easy for anyone to administer and when turned on it
provides verbal instructions (like defibrillators)
Size of a credit card
FDA approved but not all states permit it
Available by Rx to friends, families, other caregivers
Now available as a nasal spray
The Great American Relapse:
An Old Sickness has Returned to
Haunt a New Generation
The face of heroin use in America has changed
utterly.
 Forty or fifty years ago people addicted to heroin
were overwhelmingly male, disproportionately
black, and very young (the average age of first
use was 16). Most came from poor inner-city
neighborhoods
 These days, more than half are women, and 90%
are white. The drug has crept into the suburbs
and the middle classes. And although users are
still mainly young, the age of initiation has risen:
most first-timers are in their mid-20s
 Heroin overdoses increased 39% in 2013
CANNABIS CONSIDERATIONS
Cannabis patterns empirically different
from other substance groups
Cannabis also most unique in terms of
which receptor sites are involved
Possible reasons for lack of severe cases
Amotivational syndrome not part of DSM
Cannabis users tend not to do wild things
Cannabis consequences may not be
associated with use
Cannabis Withdrawal (New)
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 (often viewed as “non-compliance)
 Anxiety
 Restlessness
 Sleep difficulties
 Dream rebound
 Physical symptoms (frequent but mild)
 Depressed mood
Three (0r more) withi9n one week of cessation of use
New Findings re: Cannabis
 Cannabis (particularly heavy use) is
associated with short term memory deficits
up to 2 years after stopping use
 Cannabis is associated with Social Anxiety
Disorder
 Cause vs. effect
 Screen Cannabis user for Social Anxiety Disorder
 Synthetic Marijuana is NOT cannabis – bath
salts, “K-2,” “Spice”
Caffeine Withdrawal (New)
A. Prolonged use of caffeine
B. Abrupt cessation or reduction in caffeine use,
followed within 24 hours by three (or more) of the
following signs or symptoms
1. Headache
2. Marked fatigue of drowsiness
3. Dysphoric mood, depressed mood or irritability
4. Difficulty concentrating
5. Flu-like symptoms (nausea, vomiting or muscle
pain or stiffness
Tobacco Use Disorder
 Labeled “Nicotine Use Disorder” in the DSM-IV
 Diagnoses for “Tobacco Use Disorder” and




“Tobacco Withdrawal”
More people die from the use of
tobacco and second hand smoke
than die from the use of alcohol
and the other drugs combined
Smoking serve as a trigger for
relapse to other drugs
When the route of administration of the drug of
choice is smoking (e.g.,“crack”), the risk is increased
Smoking interferes with neurocognitive recovery
during abstinence from alcohol (first 8 months)
Implementing Tobacco Cessation
Success vs. Failure
 NOT tobacco cessation – don’t separate
 RECOVERY from substance use disorder
 Should be no different than cannabis use in the
facility in someone with a severe alcohol use
disorder
 The problem is not the drug of choice . . . It is
reliance on psychoactive substances to cope
 Tobacco use disorder treatment should be
reflected in the:
 Assessment
 Treatment plan
 Progress notes
Recent Study
 Psychiatric patients who took part in a smokingcessation program while they were in the hospital
for treatment of mental illness were more likely to
quit smoking and less likely to be hospitalized again
for mental illness, a new study shows
 224 patients at a smoke-free psychiatric hospital in
California
 Eighteen months after leaving the hospital, 20
percent of those in the treatment group had quit
smoking, compared with 7.7 percent of those in the
control group
 Forty-four percent of patients in the treatment
group and 56 percent of those in the control group
had been readmitted to the hospital.
Schizophrenia & Tobacco Use Disorder
 Addiction to nicotine is the most common form
of substance abuse in people with
schizophrenia
 They are addicted to nicotine at three times the
rate of the general population
Three Types of Outcomes from Smoking
 Addiction
 Toxicity
 Cancers (lung mouth, kidney)
 Death
 480,000 people/year in the US
 Equals 3+ 747 plane loads of people/day
 Vapor produced by e-cigarettes can contain
formaldehyde at levels five to 15 times higher
than regular cigarettes, a new study finds.
Formaldehyde is a known carcinogen
 Smoking causes 1/3 of all of the cancer deaths
in the U.S.
 This does not include the effects of
secondhand smoke
The “E-Joint”
 A new device known as an “e-joint” brings
together marijuana and an e-cigarette
 A brand of e-joint, JuJu Joint, holds 100
milligrams of THC, the psychoactive
ingredient in marijuana—twice as much as a
traditional joint
 It is disposable and comes filled with 150 hits.
The device produces no smoke and has no
smell.
Where Are You
RE: Behavioral
Health Patients
Continuing
Tobacco Use?
Gambling Disorder
Persistent and recurring problematic gambling
behavior leading to significant impairment and
distress 4 or more of the following:
 Increased tolerance
 Restless or irritable when cutting down or stopping
 Loss of control
 Gambling when feeling distressed
 “Chasing” losses
 Lies to conceal extent of gambling
 Jeopardized or loss significant relationship, job or other
opportunity
 Relies on other for money to relieve desperate financial
situations
Not better explained by a manic episode
Gambling Disorder
 One of most overlooked co-occurring
disorders with substance use disorders
 Two item screen – “Lie-Bet” Screening
Instrument
1) Have you ever felt the need to bet more
and more money?
2) Have you ever had to lie to people
important to you about how much
you gambled?
Gambling Treatment Issues
 Most addiction treatment programs do not
routinely screen for gambling disorders
 A major concern is that substance use and
gambling disorder treatment is almost totally
separate with separate and distinct programs
and certifications, a lack of screening of one
disorder when assessing for the other and even
separate conferences.
 All of this is reminiscent of the split between
substance use and mental heath disorders of 20
years ago
 At very least, SUD treatment providers should at
be screening for a co-occurring gambling
disorder and if screened in, be prepared to refer
to Gamblers Anonymous
Other Changes
from
DSM-IV to DSM-5
Mental Health
Disorders
Neurodevelopmental
Disorders
Neurodevelopmental Disorders
 Intellectual Disability (formerly mental
retardation)
 Assessment includes both IQ and adaptive
functioning with severity determined by adaptive
functioning rather than IQ
 Autism Spectrum Disorder (new and
encompasses previous Autism and Asperger’s
Disorder
 Assessment included deficits in (1) social
communication and social interaction & (2)
restricted repetitive patterns of behavior, interests
and activities
Other Neurodevelopmental
Disorders
 Communication Disorders (includes
stuttering)
 Attention-Deficit/Hyperactivity Disorder
(ADHD)
 Specific Learning Disorder
 Motor Disorders (included Tourette’s
Disorder)
 Other Neurodevelopmental Disorders
DSM-5 Criteria for ADHD
Inattention
 Six or more (of 9) symptoms persisting at
least 6 months to a degree that is
inconsistent with the developmental level
and negatively impacts directly on social and
academic/occupational activities
 For adolescents (17 and older) and adults at
least five symptoms are required
DSM-5 Criteria for ADHD
Hyperactivity and Impulsivity
 Six or more (of 9) symptoms persisting at
least 6 months to a degree that is
inconsistent with the developmental level
and negatively impacts directly on social and
academic/occupational activities
 Several inattentive or hyperactive-impulsive
symptoms were present prior to age 12
 Symptoms present in two or more settings
 For adolescents (17 and older) and adults at
least five symptoms are required
DSM-5 Criteria for ADHD
Specifications (subtypes):
 Combined presentation
 Predominantly inattentive presentation
 Predominantly hyperactive-impulsive presentation
Changes DSM-IV to DSM-5
 Some symptoms to several symptoms
 Onset changed from 7 to 12 years
 New language for subtypes but same as in DSM-IV
 Cut-off from 6 to five symptoms
 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
Consideration of the Use of ADHD
Medications in SUD
 Early in addiction recovery it is not prudent to begin
ADHD treatment with stimulants, and the use of
non-stimulants, like Stattera may be warranted
 For patients who have been abstinent for some
period of time, the risk of using stimulants to
effectively treat ADHD symptoms is generally
believed to be lower. In these cases, the use of
extended-release formulations of stimulants
including transdermal formulations is preferred
 Consider non-drug therapies such as cognitive
therapy, behavior modification, anger
management, social training & family therapy
 Combination of drug & non-drug tx. may be best
Note on Medications for ADHD
 Medication works better for
hyperactive than inattentive
symptoms
 Different disorders?
Schizophrenia Spectrum
& 0ther
Psychotic Disorders
Schizophrenia Spectrum & Psychotic
Disorders
 No bulleted type listing of disorders in section as
with DSM-IV-TR; also difference in ordering
 Delusional Disorder
 Brief Psychotic Disorder
 Schizophreniform Disorder
 Schizophrenia
 Schizoaffective Disorder
 DSM-5 differences in organization and emphasis
(e.g., no subtypes of schizophrenia in DSM-5) – only
catatonia as a specifier
 Follows concept of dimensions vs. categories
Schizophrenia
 Conditions defined by one or more of :





Delusions
Hallucinations
Disorganized thinking
Disorganized/abnormal motor behavior
Negative symptoms: anhedonia, diminished
emotional expression, avolition, etc.
 Impairments in functioning; duration of 6 month
minimum
 Rule out schizoaffective or substance related Dx
Schizophreniform Disorder
 Same symptoms as Schizophrenia
 Differs from Schizophrenia in terms of duration of
illness (at least one month but less then 6 months)
 Course:
 About 1/3 of initial cases recover within 6 mo.
 About 2/3 go on to be diagnosed as Schizophrenia
or Schizoaffective Disorder
 DSM-5 provides no guidance as to clinical services or
case management issues
Brief Psychotic Disorder
A. One or more of the following, with one of (1), (2) or
(3) required:
1. Delusions
2. Hallucinations
3. Disorganized speech (frequent derailment or
incoherence)
4. Grossly disorganized or catatonic behavior
B . Duration at least one day but less than one month
C. Not better explained by major depressive or bipolar
disorder with psychotic features or other psychotic
disorder such as schizophrenia or the physiological
effects of a substance
Schizoaffective Disorder
 Diagnostic criteria
 Uninterrupted period of illness with major mood
episode concurrent with Criterion A of schizophrenia
 Delusions or hallucinations for 2+ weeks in absence
of a major mood episode during some period
 Major mood episode criteria met for majority of
illness duration
 Diagnosis can change to schizophrenia if
psychotic systems persist without recurrent
mood episode
Substance/Medication-Induced
Psychotic Disorder
Between 7% and 25% presenting with a first
episode of psychosis in different setting are
reported to have Substance/Medication-
Induced Psychotic Disorder
Schizophrenia & Substance Use
 Some people who abuse drugs show symptoms
similar to those of schizophrenia. Therefore,
people with schizophrenia may be mistaken for
people who are affected by drugs.
 Most researchers do not believe that substance
abuse, particularly cannabis, causes
schizophrenia
 However, people who have schizophrenia are
much more likely to have a substance or alcohol
abuse problem than the general population
Schizophrenic Disorder
RATE OF LIFETIME SUBSTANCE USE
DISORDER
 In the General Population:
17%
 For Persons With Schizophrenia: 48%
Schizophrenia & Substance Abuse
 Substance abuse can make treatment for
schizophrenia less effective. Some drugs, like
marijuana and stimulants such as
amphetamines or cocaine, may make
symptoms worse
 Research has found increasing evidence of a
link between marijuana and schizophrenia
symptoms
 People who abuse drugs are less likely to follow
their treatment plan
Schizophrenia & Tobacco Use Disorder
 Addiction to nicotine is the most common form
of substance abuse in people with
schizophrenia
 They are addicted to nicotine at three times the
rate of the general population
Bipolar
&
Related
Disorders
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
One of the most common features of the mania or
hypomania is the decreased need for sleep (feels
rested after only 3 hours of sleep) as contrasted
with insomnia in which the individual wants to
sleep or feels the need to sleep but is unable
Bipolar Disorder is one of the most misdiagnosed,
over-diagnosed psychiatric disorder
Bipolar Disorder Misdiagnosis*
 Total misdiagnosis
69%
 Times individual misdiagnosed
 Physicians consulted before correct
diagnosis
 Misdiagnosed as:
 Unipolar Depression
3.5
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
Connection Between
Bipolar Disorder and Alcohol Problems
 Women with bipolar disorder are SEVEN
times more likely to have alcohol problems than
women without
 Men with bipolar disorder are FOUR
times more likely to have alcohol problems than
men without
Substance Use
& Bipolar Disorders
 Substance abuse is very common among
people with bipolar disorder, but the reasons
for this link are unclear
 Some people with bipolar disorder may try to
treat their symptoms with alcohol or drugs
 However, substance abuse may trigger or
prolong bipolar symptoms, and the
behavioral control problems associated with
mania can result in a person drinking too
much.
Cyclothymic Disorder
 A chronic fluctuating mood disturbance
involving a number of periods of hypomanic
symptoms and depressive symptoms that are
distinct from one another
 Both the hypomanic and depressive
symptoms are of insufficient number, severity
pervasiveness or duration to meet full criteria
for a hypomanic or major depressive episode
Rapid Cycling Bipolar Disorder
 This is when a person has four or more
episodes of major depression, mania,
hypomania, or mixed symptoms within a year
 Some people experience more than one
episode in a week, or even within one day.
 Rapid cycling seems to be more common in
people who have severe bipolar disorder and
may be more common in people who have
their first episode at a younger age
Recent Research
 Premature mortality in Bipolar Disorder
 Die an average of 9 years earlier than rest of the
population (study of 6.6 million adults, 6600 with
BPD)
 Death associated with:





Ischemic heart disease
COPD, flu or pneumonia
Unintentional injuries
Suicide
Colon cancer (women only)
 Possible solution – better provision of primary
medical care
Depressive
Disorders
Depressive Disorders
 Disruptive Mood Dysregulation Disorder*
 Major Depressive Disorder, Single Episode
 Major Depressive Disorder, Recurrent
 Dysthymia (Persistent Depressive Disorder, also




include chronic major depression)*
Substance-Induced Depressive Disorder
Depressive Disorder Associated with Another
Medical Condition
Premenstrual Dysphoric Disorder (no longer “for
further study”)*
* New
Changes from the DSM-IV
 Depressive disorders now its own chapter,
separated from Bipolar & Related Disorders
 Premenstrual Dysphoric Disorder* (no longer
in Appendix B, “for further study”)
 Disruptive Mood Dysregulation Disorder is
new
Major Depressive Disorder (MDD)
 MDD is the product of a complex interaction
between multiple “vulnerability” genes and
environmental factors (and early trauma?)
 MDD is not only chronic and recurrent, it may be
progressive
 Sustained functional changes in the brain may
precipitate a change in structure
 Mood disorders are associated with changes in
endocrine, immune, autonomic function and
earlier mortality (cardiac problems)
Major Depressive Disorder (MDD)
Requires meeting 5 of 9 criteria (unchanged)
 Depressed mood most of day, nearly every day
 Loss of interest or pleasure
 Significant weight loss or gain
 Insomnia or hypersomnia
 Psychomotor agitation or retardation
 Fatigue or loss of energy nearly every day
 Feelings of worthlessness
 Reduced ability to concentrate or think or
indecisiveness
 Recurrent thoughts of death or suicidal ideation
Accompanied by clinically significant distress
Dysthymia
 Clinically depressed mood that occurs for





most of the day more days than not, for at
least 2 years (one years in children &
adolescents)
No symptom free interval for longer than 2
months in the 2 years
Free of manic or hypomanic episodes
Can be diagnosed with MDD after 2 years if
meets the MDD criteria
Meet 2 of criteria (subclinical)
Renamed “Chronic Depressive Disorder”
Time for Anti-Depressant
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)
 Antidepressant 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.
When Do You Medicate for
Psychiatric Disorders?
When the risk of not
medicating exceeds
the risk of medicating!
Depression - Bereavement
 Many symptoms are characteristic of a major depressive
episode




Feelings of sadness
Insomnia
Loss of appetite
Weight loss
 In the DSM-IV a diagnosis of MDD was made for a death




if symptoms persisted for over 2 months but not other
losses
Was a V code (V62.82)
In the DSM-5, don’t diagnose MDD if bereavement
symptoms best account for the depressive symptoms
“Persistent Complex Bereavement Disorder” (for further
study)
Don’t diagnose unless symptoms last more than 12
month, 6 months for children
Bereavement
To distinguish grief from a major depressive episode (MDE):
Grief
 Predominant affect is feelings of loss or emptiness
 Dysphoria associated with grief is likely to decrease in
intensity in days and weeks and occurs in waves and
associated with thoughts and reminders of the deceased
 Self-esteem is generally preserved
MDE:
 Predominant affect is persistent depressed mood and the
inability to anticipate please or happiness
 Depressed mood of MDE are persistent and not tied to
thoughts and reminders of the deceased
 Feelings of worthlessness and self-loathing are common
Anxiety
Disorders
Anxiety Disorder
The DSM-IV described five forms of anxiety disorder
1. Panic Disorder
2. Generalized Anxiety Disorder (GAD)
3. Phobias

Change: For social anxiety disorder, if over 18, no longer have
to recognize their anxiety is excessive or unreasonable
4. Post Traumatic Stress Disorder (PTSD)
5. Obsessive Compulsive Disorder (OCD)
Specific Anxiety Disorder
Diagnoses in the DSM-5
 Separation Anxiety Disorder
 Selective Mutism
 Specific Phobia
 Social Anxiety Disorder (Social Phobia in DSM-IV)
 Panic Attack (not a diagnosis)
 Panic Disorder
 Specific Phobia
 Agoraphobia
 Generalized Anxiety and Worry Disorder
Panic Attack 4 or > Symptoms
Panic Attack is a Specifier and not
a Mental Disorder
DO NOT CODE
Panic attacks can now be a specifier for
all DSM-5 diagnoses
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
 Change in the delinking of Panic Disorder and
Agoraphobia
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 but
rather out of proportion to the threat
 Social Anxiety Disorder (previously social
phobia), may be too broadly defined because of
the high prevalence of social anxiety and shyness
in community populations (e.g., anxiety about
speaking in public)
Specific Phobia
 Having a phobia includes feeling stressed
about being near the object, being in the
situation or doing the activity
 It also includes being afraid of the object,
situation or activity itself
 Patient is aware that the fear is
unreasonable or excessive
 Persistent for more than 6 months
Agoraphobia
 A mental disorder characterized by an
irrational fear of leaving the familiar setting
of home, or venturing into the open, so
pervasive that a large number of external life
situations are entered into reluctantly or
avoided; often associated with Panic Attacks
 Now a stand alone diagnosis, not part of
Panic Attacks
 Sufferers less likely to show up for treatment
Social Phobia
(renamed “Social Anxiety Disorder”)
 Social Anxiety Disorder is a psychological
condition that causes overwhelming fear of
situations that require social interaction or
performance in front of others, such as public
speaking
 The fear often triggers physical symptoms
such as blushing, rapid heartbeat and trouble
concentrating and it may interfere with
activities of daily living
Social Anxiety Disorder
Social Anxiety Disorder has significant
implications for treatment for when it
co-occurs with substance use and
mental health disorders :
 For treatment
 For self-help recovery groups
Symptoms of GAD














Excessive, ongoing worry and tension
An unrealistic view of problems
* Muscle tension
* Restlessness or a feeling of being “on edge”
* Irritability
Headaches
Sweating
* Difficulty concentrating or mind going blank
Nausea
The need to go to the bathroom frequently
* Easily fatigued
* Trouble falling or staying asleep
Trembling
Being easily startled
Diagnosis of GAD
 Three of more of 6 specific symptoms
(asterisked) with at least some
symptoms for more days than not in
the past 6 months
 Only one symptom required for
children
Renamed “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
Substance-Induced Anxiety Disorder
 Substance-Induced Anxiety Disorder may
include prominent anxiety, Panic Attacks,
phobias or obsessions or compulsions
 Substance-Induced Anxiety Disorder may
resemble Panic Disorder, Generalized
Anxiety and Worry Disorder, Social Anxiety
Disorder but will not meet full criteria for
these disorders
Substance/Medication-Induced
Anxiety Disorder
 Prominent anxiety symptoms that are due to




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
Obsessive-Compulsive
and
Related Disorders
Obsessive-Compulsive
& Related Disorders
 Obsessive-Compulsive disorder (OCD)
 Body Dysmorphic Disorder
 Hoarding Disorder*
 Trichotillomania (hair pulling disorder)
 Excoriation Disorder (skin picking disorder)*
 Substance/Medication-Induced ObsessiveCompulsive 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:
 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
Body Dysmorphic Disorder
 Preoccupation with defects in physical
appearance not observable or slight to others
 Performs repetitive behaviors (e.g., excessive
grooming) in response to appearance concerns
 Clinically significant distress or impairment
 Appearance preoccupation not better explained
by concerns with body fat or diagnosis of eating
disorder
Specify if: With muscle dysmorphia
Preoccupation that body build is too small or
insufficiently muscular
Hoarding Disorder General Criteria (New)
 The individual has great difficulty disposing of possessions or






assessing relative importance
The individual feels compared to keep these possessions and is
pained by the idea of disposing of them
These possessions impair the use or safety of the individual’s
home, or utility of the home is only maintained by the
intervention of others
Clinically significant distress of impairment
Some individuals will be aquisitive, others simply let things
pile up without excessive shopping
Some individuals will have insight into the hoarding related
problems, others will have insight impaired to varying degrees
Some medical conditions can produce this problem (e.g., brain
injury, cerebrovascular disease) – rule out
Traumaand
Stressor-Related
Disorders
Trauma- and Stressor-Related Disorders
 Reactive Attachment Disorder
 Disinhibited Social Engagement
Disorder
 Posttraumatic Stress Disorder
 Adjustment Disorders
 Acute Stress Disorder
Post Traumatic Stress Disorder
 Such disorders reflect a biological
predisposition or vulnerability (and early
trauma?)
 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
New Findings
PTSD & Alcohol Use in
College Students
 Heavy drinking is common on college
campuses and related to risk for sexual
assault, interpersonal violence and serious
injury, any of which may trigger PTSD
 Alcohol use and associated problems are
linked over time to an exacerbation in PTSD
symptoms, and that PTSD symptoms show a
similar effect on alcohol consumption
Childhood Psychological Abuse as
Harmful Sexual or Physical Abuse
 5,616 youths with lifetime histories of one or more of
the three types of abuse
 Psychological maltreatment include caregiver bullying,
terrorizing, coercive control, severe insults,
debasement, threats, overwhelming demands,
shunning and/or isolation
 Psychologically abused children suffered anxiety,
depression, low self-esteem, symptoms of PTSD and
suicidality at same rate or greater than children who
had been sexually or physically abused
To be published in the APA Journal, Trauma: Theory, Research, Practice & Theory
Dissociative
Disorders
Dissociative Disorders
 Dissociative Identity Disorder
(commonly called “Multiple
Personality Disorder”)
 Dissociative Amnesia (dissociative
fugue now a specifier for Dissociative
Amnesia)
 Depersonalization/Derealization
Disorder
Dissociative Identity Disorder
 Disruption of identity characterized by two or
more distinct personality states
 Recurrent gaps in recall of everyday events,
personal information and/or traumatic events
inconsistent with ordinary forgetting (DSMIV only included traumatic events)
 Clinically significant distress or impairment
Somatic Symptom
and
Related Disorders
(in DSM-IV –
“Somatoform Disorders”)
Somatic Symptom and Related Disorders
 Somatic Symptom Disorder (replaces
Somatization Disorder and Hypochondiasis)
 Illness Anxiety Disorder
 Conversion Dis0rder (Functional Neurological
Symptom Disorder)
 Factitious Disorder
 Imposed on self - commonly Munchausen’s
Syndrome
 Imposed on others - commonly Munchausen’s
Syndrome by Proxy
Somatization Disorder
 Somatization disorder is a long-term
(chronic) condition in which a person has
vague physical symptoms in at least four
different functions or parts of the, but no
physical cause can be found.
 The pain and other symptoms people with
this disorder feel are real, and are not created
or faked on purpose (malingering).
Hypochondriasis
 People with hypochondriasis are very worried
about getting a disease or are certain they have a
disease, even after medical tests show they do
not.
 Further, these people often misinterpret minor
health problems or normal body functions as
symptoms of a serious disease. An example is a
person who is sure that her headaches are
caused by a brain tumor.
 The symptoms associated with hypochondriasis
are not under the person's voluntary control, and
can cause great distress and/or can interfere with
a person's normal functioning.
Conversion Disorder
 Conversion disorder is a condition in which people
show psychological stress in physical ways. The
condition was so named to describe a health
problem that starts as a mental or emotional crisis
— a scary or stressful incident of some kind — and
converts to a physical problem.
 Conversion disorder signs and symptoms appear
with no underlying physical cause, and you can't
control them.
 Signs and symptoms of conversion disorder
typically affect your movement or your senses,
such as the ability to walk, swallow, see or hear.
Conversion disorder symptoms can be severe, but
for most people, they get better within a couple of
weeks.
Symptoms
Include the loss of one or more bodily functions, such
as:
 Blindness
 Inability to speak
 Numbness
 Paralysis
Common signs of conversion disorder include:
 A debilitating symptom that begins suddenly
 History of a psychological problem that gets better
after the symptom appears
 Lack of concern that usually occurs with a severe
symptom
Feeding
and
Eating Disorders
Eating Disorders






Pica (in children or adults)
Rumination Disorder
Avoidant/Restrictive Food Intake Disorder
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Anorexia Nervosa
Anorexia Nervosa
Their lives become focused on controlling their
weight. They may:
 Obsess about food, weight and dieting
 Strictly limit how much they eat
 Exercise a lot, even when they are sick
 Vomit or use diuretics to avoid weight gain but
no binging
Anorexia Nervosa is the most lethal of all
psychiatric disorders with 5% dying per decade
after diagnosis either from medical
complications or suicide
Bulimia Nervosa
Change: reduction in binge eating &
compensatory behavior from twice to once
weekly
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.
 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
 Difference on how much they weigh and how
they look (their perception)
Prognosis more positive than with anorexia
Binge Eating Disorder
Change: reduction in binge eating
from twice to once weekly
Criterion A will likely be the same as DSM-IV Bulimia
Nervosa
 Recurrent episodes of binge eating characterized by
both of the following:
 Eating within a discrete period of time (e.g.,
usually less than any 2 hour period of time), an
amount of food that is definitely larger than most
people would eat in a similar period of time under
similar circumstances
 A sense of lack of control over eating during that
period
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:





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)
 Causes marked distress
Prognosis more optimistic that Anorexia or Bulimia
Sleep-Wake
Disorders
Insomnia Disorder
 Difficulty initiating Sleep
 Difficulty maintaining Sleep
 Early morning awakening with inability to
return to sleep
 At least 3 nights/week for at least 3 months
 Occurs despite adequate opportunity for sleep
 Not better explained by another sleep disorder
(e.g., narcolepsy), the physiological effects of a
substance or a co-occurring mental health
disorder
Sexual
Dysfunctions
Sexual Dysfunctions
 Erectile Disorder – persistence of the problems for 6







months, 75% of the time
Female Orgasmic Disorder – same persistence; removal
of “normal excitement phase;” recognition that orgasm is
“not all or nothing;” allows for comorbid diagnosis of
Arousal Disorder and Orgasmic Disorder
Delayed Ejaculation
Premature Ejaculation
Female Sexual Interest/Arousal Disorder – only change
is persistence
Male Hypoactive Sexual Desire Disorder
Genito-Pelvic Pain/Penetration Disorder- this diagnosis
will likely be made for those previously diagnosed with
either Vaginismus or Dyspareunia
Substance/Medication Induced Sexual Dysfunction
Neurocognitive
Disorders
Neurocognitive Disorders (NCD)
 Delirium
 Major or Mild NCD due to Alzheimer’s Disease
 Major or Mild Frontotemporal NCD
 Major or Mild NCD with Lewy Bodies
 Major or Mild Vascular NCD
 Major or Mild NCD Due to Traumatic Brain Injury
 Major or Mild NCD Due to HIV Infection
 Major or Mild NCD Due to Prion Disease
 Major or Mild NCD Due to Parkinson’s Disease
 Major or Mild NCD Due to Huntington’s Disease
Delirium
 An alteration of mental status characterized by
an inability to appreciate and respond normally
to the environment, often with altered
awareness, disorientation, inability to process
visual and auditory stimuli, and other signs of
cognitive dysfunction.
 Causes include fever, infection, toxicity
(including to alcohol), dehydration, overhydration, certain drugs and extreme sleep
deprivation.
 Generally has acute onset.
 Delirium can often be reversed with proper
medical treatment.
Kinds of Dementia
 Alzheimer disease (affects 66 per cent of people





with dementia)
Vascular dementia caused by stroke (the second
most common form)
Lewy body dementia (affects 15 to 20 per cent of
people with dementia)
frontal lobe dementia (affects two to five per cent of
people with dementia)
alcohol-related dementia and Korsakoff’s Psychosis
Dementia secondary to AIDS or Prion disease (e.g.,
mad cow disease)
*SIGNIFICANT
LOSS OF
COGNITIVE FUNCTIONING
(enough to interfere with
activities of daily living)
IS NOT
A NORMAL PART
OF AGING!
Personality
Disorders
Personality Disorders
Cluster A Personality Disorders
 Paranoid Personality Disorder
 Schizoid Personality Disorder
 Schizotypal Personality Disorder
Cluster B Personality Disorders
 Antisocial Personality Disorder
 Borderline Personality Disorder
 Histrionic Personality Disorder
 Narcissistic Personality Disorder
Cluster C Personality Disorders
 Avoidant Personality Disorder
 Dependent Personality Disorder
 Obsessive-Compulsive Personality Disorder
Personality Disorders Most
Likely to Co-occur with
Substance Use Disorders
 Antisocial Personality Disorder
&
 Borderline Personality Disorder
Borderline Personality Disorder
Non-Suicidal Self Injury Disorder
(Condition for Further Study)
 The disorder entails repeated and intentional self




inflicted damage to the body
May include burning or bruising as well as cutting
Is associated with the build up of negative feelings
and preoccupation with the behavior
The act is stated to be, and appears to be, nonsuicidal in nature and intent
The behavior is not associated with a primary
medical or substance related cause, nor a quasi
sanctioned cultural activity such as piercing or
tattoos
The behavior is done to provide relief, distraction or
release from the negative affective state
Paraphilic
Disorders
Paraphilic Disorders








Voyeuristic Disorder
Exhibitionistic Disorder
Frotteuristic Disorder
Sexual Masochism Disorder
Sexual Sadism Disorder
Pedophilic Disorder
Fetishistic Disorder
Transvestic Disorder
Specifier for all “In a controlled environment” or
“In remission”
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
with disorders are getting what they
need in treatment
 As complex as the DSM-5 is, it will get
easier over time
If patients
can’t get
better the way
we provide
treatment,
maybe we should
provide
treatment
the way
they can