Overview of Changes from DSM IV-TR to DSM-5 and Their Implications for the GAIN-I 5.7 This document provides a description of the substantive changes from DSM IV-TR to DSM5 and how the GAIN Coordinating Center addressed them in the new GAIN-I 5.7 and clinical reports. Please note: the GAIN 5.6 will remain available so agencies can decide when to begin using the GAIN 5.7. Agencies can adopt the 5.7 on their own schedule at their own convenience based on their adoption and use of DSM-5. At the end of this document sample clinical reports are included for reference. For questions regarding this information please contact [email protected] For a sample GAIN-I 5.7 and clinical reports please see our website at http://www.gaincc.org/about-gain/. The DSM IV diagnostic codes were replaced with a new set of codes that map onto ICD-9 that is currently required for billing in most systems in the US and ICD-10 codes that are used in the rest of the world and will become the standard in the U.S. during the coming year. Since the exact timing of the later change is still uncertain and likely to vary by funder and program, the GAIN is being updated to allow clinicians to switch back and forth between DSM-IV and DSM-5 (ICD-9 and ICD-10) at will. This also allows programs to be able to evaluate the impact of the changes on the diagnostic profiles of their clients. Roman numerals (V) were replaced by Arabic numerals (5) in DSM-5. The multi-axial system was removed in DSM-5 in favor of collapsing Axis I, II and III into just diagnosis and the remaining axis’s into other conditions that may be of clinical attention. In the GRRS and ICP the heading "DSMIV/ICD-9 Diagnosis" and "Axis I-V" headings are replaced by "DSM-5/ICD-9 (ICD-10) Diagnosis" (formerly Axis I III), "DSM-5/ICD-9 (ICD-10) Other Conditions That May Be a Focus of Clinical Attention" (formerly Axis IV). DSM-5 eliminated the old Axis V, but did recommend a new optional scale discussed further below. When running the GAIN-I 5.7 clinical reports at intake (GAIN Recommendation and Referral Summary and Individual Clinical Profile) in GAIN ABS, staff will have the option of running a DSM-IV, DSM-5 ICD-9 or DSM-5 ICD10 version of the reports. The only difference between the DSM-5 ICD 9 and DSM-5 ICD 10 versions of the reports is the use of the specific diagnostic code set. Regarding the M90 reports, because the M90 ICP uses diagnostic information from the intake ICP, both reports must match (DSM-IV or DSM-5 and ICD-9 or ICD-10). When staff run the M90 ICP GAIN ABS will check the version of the intake ICP and automatically generate the correct M90 ICP. However, if an intake ICP does not yet exist, the user will be prompted by GAIN ABS to indicate what version to create. Both an intake and M90 ICP will be generated based on the user selected version. Within “Substance Use Disorders”, the “Substance Abuse” and “Substance Dependence” diagnoses were replaced with "Substance Use Disorder” with the addition of – mild (2-3 symptoms), - moderate (4-5 symptoms), or - severe (6-11 symptoms). These changes were made throughout the clinical reports. Note that with the new DSM-5 classification, if a client only endorses one symptom for a particular drug, they will not meet criteria for substance use disorder – mild for that substance. For example, from a GRRS ICD-10 using the GAIN-I 5.7: Substance/Class Changes were made throughout the clinical reports to account for new DSM-5 classification (see above): Amphetamine and Cocaine were collapsed into Stimulant Use Disorder PCP was collapsed into Hallucinogen Use Disorder. All substance use disorders allow specification of primary form of a drug used within a class (e.g., Amphetamine, Methamphetamine, Cocaine, Crack, PCP, OxyContin) DSM-5 Replaced "Not Otherwise Specified" to "Unspecified”, and "Rule Out" to "Provisional". These changes were made throughout the clinical reports. DSM-5 includes a new substance use disorder criterion regarding craving. We add two new items to the GAIN-I 5.7. S9cua "When was the last time that you had such strong urges to use alcohol or other drugs you could not think of anything else?" and S9cua1-99 in the S9 matrix "you had such strong urges to use you could not think of anything else?" DSM-5 dropped the substance use criterion "recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)" because it was associated with social injustice as much as individual severity. For scoring purposes in the GAIN-I 5.7 DSM-5, this criterion was dropped for all substances in S9 matrix (S9k, S9k1-99). The item, however, was retained to allow clinicians to switch between DSM-IV (which requires it) and DSM-5, as well as to allow us to examine how this change impacts programs. See the sample S9 text below from the GAIN-I 5.7. DSM-IV DSM-5 DSM-5 added cannabis withdrawal symptoms as endorsing 3 or more of 1) Irritability, anger, or aggression, 2) Nervousness or anxiety, 3) Sleep difficulty, 4) Decreased appetite or weight loss, 5) Restlessness, 6) Depressed mood , and 7) Physical discomfort. In the GAIN-I 5.7 we added two new withdrawal symptoms to cannabis withdrawal: Irritability, anger, or aggression (new item S3c19a), and depressed mood (S3c19b). The other symptoms for cannabis withdrawal were already in the GAIN-I. The new items can be seen in the section from the GAIN-I 5.7 below. Items 5-17 not shown… DSM-5 replaced “Tobacco dependence” with tobacco use disorder (mild, moderate, severe). These new questions match the criteria for other drugs currently in the GAIN and the exact wording of the new craving item. We added four items to the GAIN-I 5.7 for tobacco use. R4cch: repeatedly caused you not to meet your responsibilities at work, school or home, R4ccj: you repeatedly used in unsafe situations, R4ccm: did you keep using even though it was leading to fights or getting you into trouble with other people, R4ccua: when was the last time that you had such strong urges to take the drug that you could not think of anything else. Below are the new items in the GAIN-I 5.7. R4cc. Changes to specifiers were made throughout the clinical reports to account for DSM-5 changes: Removal of specifiers "with physiological symptoms” and "without physiological symptoms." The remission specifiers were deleted. Remission specifiers "Sustained Partial Remission" and "Sustained Full Remission" replaced with "In Sustained Remission". The remission specifiers were changed. Remission specifiers "Early Partial Remission" and "Early Full Remission" replaced with "In Early Remission” and the craving item is exempt from remission. According to DSM-5 Major Depressive Disorder includes a new symptom, "Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).” We added a new item (M1b11) "Feeling worthless or that the bad things that have happened in your life are your fault.” The wording of the item was simplified from the DSM-5 symptom for ease of administration. M1b. Items 4-8 not shown… DSM-5 has renamed "Pathological Gambling" to "Gambling Disorder". The criterion “paid for your gambling with bad checks, someone else's money, or with something that didn't belong to you” is no longer included in diagnostic criteria for DSM-5 and we changed the terminology throughout the reports. Item V9h was kept to allow clinicians to switch between DSM-IV and DSM-5 and to evaluate the impact of the change. DSM-5 included several changes to ADHD which we have made: "Attention Deficit Hyperactive Disorder - Combined Type" changed to "Attention-Deficit/Hyperactivity Disorder - Combined presentation". Criterion changed to up to age 16 requires 6 or more inattention symptoms and 6 or more hyperactivity/ impulsivity symptoms; age 17 and older requires 5 or more inattention symptoms and 5 or more hyperactivity/impulsivity symptoms. “Attention Deficit Hyperactive Disorder - Inattentive Type" changed to "Attention-Deficit/Hyperactivity Disorder - Predominantly inattentive presentation". Criterion changed to up to age 16 requires 6 or more inattention symptoms; age 17 and older requires 5 or more inattention symptoms. "Attention Deficit Hyperactive Disorder - Hyperactive Type" changed to "AttentionDeficit/Hyperactivity Disorder - Predominantly Hyperactive/Impulsive Presentation”. Criterion changed to up to age 16 requires 6 or more hyperactivity/impulsivity symptoms; age 17 and older requires 5 or more hyperactivity/impulsivity symptoms. ADHD age of on-set criteria raised from age 7 to 15. The higher ages of onset is still allowed as provisional. DSM-5 recommends the use of V Codes from ICD-9-CM or Z codes from ICD-10-CM for previous sections of Axis IV. We have included appropriate V codes and Z codes to describe client self-report where possible. However, the previous list of psychosocial problems will also print in the clinical reports. See below sample text from the GAIN-I 5.7 GRRS. Additional items not shown… DSM-5 dropped Axis V GAF scores. DSM-5 recommends use of WHODAS 7 General Disability Score in order to provide a global measure of disability. We have added 8 items (XDX2g-q) at the end of the GAIN-I 5.7 and in the GRRS and ICP section “Other Conditions that May be a Focus of Clinical Attention.” The items correspond to the 7 subscale and total score for the WHODAS 7 General Disability Scores (Understanding and communicating, Getting around, Self-care, Getting along with people, Life activities-Household, Life activitiesschool/work, Participating in society, and Total). In addition, the ability to add additional diagnoses at the end of the GAIN-I, has been expanded to include 1) the ability to indicate whether the diagnoses are DSM-IV (Axis I, II, III, IV), or DSM-5 (ICD-9 or ICD-10) and 2) a location to add other clinical ratings that may be in use. XDX.