Who We Are. Who We Are 8/21/2013. The Narrative Institutewwww.narrativeinstitute.org

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1 Understanding the DSM-5 General Themes and Criteria for the New Diagnostics Brandy Hall, MA, LPC S. David Hall, PsyD, LMFT, LPC Who We Are S. David Hall, PsyD, LMFT, LPC Dr. David Hall the director of the Narrative Institute and is a licensed marital and family therapist and a licensed professional counselor in practice with Ebenezer Counseling Services in Knoxville, TN. Who We Are Brandy Hall, MA, LPC/MHSP Licensed professional counselor in Tennessee, practicing with Ebenezer Counseling Services in Knoxville, TN. She also serves as one of the teaching faculty with the Narrative Institute. Brandy s clinical and teaching interests include anxiety, addiction, and the clinical diagnostic process. 1

2 The Narrative Institute Is an educational and training group that is devoted to the study and application of narrative theory and the craft of story in the fields of psychotherapy, medicine, spiritual care, education, entertainment, creative expression, business, and personal enrichment. The history of DSM What we will not be spending time on Minor controversies We are not going to review all DSM-5 diagnoses, only those with significant changes between the DSM-IV-TR and the DSM-5 Important Dates Now Available: DSM-5 Diagnostic Criteria Mobile App (came out July 22, 2013 for $70) December 31, 2013: Insurance companies are expected to have transitioned fully April 2014: Examinations given by NBCC will reflect changes October 1, 2014: Everyone is required to start using the ICD-10-CM codes (the codes in parentheses) 2

3 The Importance of Language Language shapes the world (for good and ill) The language we use to describe our clients shapes how we think of them The language the client uses to describe themselves and their problems shapes how they think of themselves The language others use to describe the client and their problems affects how they see the client The Importance of Language The labels, or diagnoses, we apply, therefore, will mold how we think of our clients, how they think of themselves, and how the world will see them as well. The Importance of Language Potential clients who are afraid of certain diagnoses, or more correctly, of seeing themselves or of being seen in a certain way, will often avoid seeking help whether by avoiding coming in altogether or by masking their true concerns even when they do come in. This is one of the main reasons behind many of the name changes and new diagnostic names. Mental Retardation --> Intellectual Disorder Hypochondriasis --> Illness Anxiety Disorder 3

4 The Purposes of the DSM-5 For Clinicians & Researchers The idea that diagnosis means to know thoroughly To allow professionals to have an agreed upon basis of knowledge and understanding between each other Primarily designed to assist clinicians in conducting clinical assessment, case formulation, and treatment planning (pg. 25, DSM-5). To help professionals conceptualize the client - to understand the problem(s) and know how to treat For Clinicians & Researchers Does the DSM help in knowing thoroughly the disorders that we work with? The DSM does not provide treatment guidelines for any disorder, only the diagnostic criteria. The diagnostic guidelines set in the DSM are also given to provide criteria for improved research in mental disorders 4

5 Insurance Reimbursement Insurance utilizes the codes from DSM/ICD to determine reimbursement Inconsistent use of the multiaxial format December 31, 2013 Insurance Reimbursement The DSM Task Force has to take into consideration that insurance companies will not reimburse for conditions not included in the DSM/ICD. Discussed dropping Gender Identity Disorder; renamed as Gender Dysphoria The addition of Gambling Disorder Judicial Proceedings Criminal responsibility - Use of the insanity plea Involuntary commitment Competence to stand trial For more see page 25 of DSM-5 5

6 Pharmaceutical Implications Ability to research, produce medications for classified disorders and diseases Controversy More on this later Disability Workplaces are not allowed to discriminate Workplaces and schools have to allow for and provide for certain accommodations The possibility to file for disability pay Regarding disability, additional information is usually required beyond that contained in the DSM-5 diagnosis, which might include information about the individual s functional impairments and how these impairments affect the particular abilities in question. It is precisely because impairments, abilities, and disabilities vary widely within each diagnostic category that assignment of a particular diagnosis does not imply a specific level of impairment or disability (pg. 25, DSM-5). Why the Update? 6

7 To Stay Relevant with Current Research Validity and Reliability The APA recognizes, that past science was not mature enough to yield fully validated diagnoses - that is, to provide consistent, strong, and objective scientific validators of individual DSM disorders (pg 5, DSM-5). This is still a concern. Research continues. To Stay Relevant with Current Research Even though reliability is generally viewed as strong, diagnostic disagreement between clinicians on a given case still is common due to the overlap in symptoms between various diagnoses. High comorbidity rates & high rates of using NOS categories are evidence of this. More on this later. To Stay Relevant Socially, Culturally, and with Age and Gender Developmental age versus chronological age, gender differences, and cultural variabilities of norms Use of social media, online resources, and mobile apps 7

8 To Stay Relevant Socially, Culturally, and with Age and Gender A variety of assessment measures for various disorders, as well as the Cultural Formulation Interview are available online at The DSM-5 is available as an online subscription at E-book DSM-5 Diagnostic Criteria Mobile App To Make Money In order to meet the first point of staying relevant with research, they really needed more time. However, it is estimated that the APA spent $20-$25 million on developing the DSM-5, and they could not afford to delay any longer as there are rumors that the APA was already in debt millions of dollars, and they needed to start generating more income. (hence the higher price tag). To Make Money APA intends, to make future revision processes more responsive to breakthroughs in research with incremental updates until a new edition is required. Since the research base of mental disorders is evolving at different rates for different disorders, diagnostic guidelines will not be tied to a static publication date but rather to scientific advances. These incremental updates will be identified with decimals, i.e. DSM-5.1, DSM-5.2, etc., until a new edition is required. 8

9 To Make Money It is not clear at this point in what form the updates will come or how often. It is likely these updates will be released online, though they will probably also have hard copies for sale as well as they did for the previous Text Revisions. As you can imagine, this could possibly lead to much confusion, and possibly more expense to professionals. To work better with the ICD System The International Classification of Diseases (ICD) is the official system for the US, and all World Health Organization Member States (over 100 countries) use it to report mortality and many for morbidity rates. Compatibility between DSM & ICD systems To work better with the ICD System The DSM-5 contains both sets of codes. The numerical codes we are already familiar with are the ICD-9-CM codes. The codes in parentheses, typically starting with an F or G in Section II of the DSM-5 and typically starting with a T or Z in Section III, are the ICD-10-CM codes that we will all be implementing on October 1,

10 To work better with the ICD System The ICD-11 is currently being revised and is set to be released in It will be used with electronic health applications and information systems. See for more information. Controversies & Criticisms Relationships with pharmaceutical companies To what extent has this impacted the formulation of the DSM? Does this effect its credibility? Much has been made of the ties that some of the people on the DSM Task Force have with pharmaceutical companies as 69% of the Task Force members had direct industry ties. It should be noted that 57% of DSM-IV Task Force members had ties to pharmaceutical companies (Cosgrove & Krimsky, 2012). 10

11 Relationships with pharmaceutical companies The first drafts of the DSM-5 under-emphasized the biopsychosocial model in favor of the bio-biobio model, as former APA President Steven Sharfstein, MD called it, which leads to an increasing, pill and an appointment, mentality. rticleid= This over-emphasis has decreased some in the final product, but notably more evident than in DSM-IV-TR. ICD vs DSM The difficulty and questionable necessity of maintaining both classification systems of the ICD and the DSM. The rest of the world uses the ICD system and it is the officially sanctioned system by the US government as well. The DSM has to line up with the ICD codes for insurance purposes. The ICD is available online for free, whereas the DSM-5 costs $199 The ICD system contains the codes, but it does not contain detailed diagnostic descriptions. 11

12 ICD vs DSM Is it justifiable? Will the DSM be superseded by the ICD? According to Dr. Geoffrey Reed, a WHO psychologist, There would still be a role for the DSM, because it contains a lot of additional information that will never be a part of the ICD. In the future, it may be viewed as an important textbook of psychiatric diagnosis rather than as the diagnostic Bible. National Institute of Mental Health (NIMH) Three weeks before the DSM-5 was released, Thomas Insel, MD, Director of the NIMH, questioned the DSM s validity as it continues to focus on symptomology, and he announced the launching of the Research Domain Criteria (RDoC) project, to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system National Institute of Mental Health (NIMH) Insel has since confirmed that the NIMH, has not changed it s position on DSM-5, and states that, DSM-5 and RDoC represent complementary, not competing, frameworks, and even says that findings from RDoC s research may even be incorporated into future revisions of the DSM. 12

13 Other Concerns Open Letter to the DSM-5: Published in October 2011, after the first draft of the DSM-5 was released for public feedback. The authors raises numerous concerns over some of the proposed changes. Many of these critiques have impacted the DSM-5 greatly. Summary Basically, NIMH and others criticizes DSM for not being neuro-biologically based enough and calls for more research to be done, while others criticize the DSM for focusing too much on medico-physiological theory without enough research to back it up while decreasing focus on other types of empirical knowledge such as psychological, social, cultural, etc. The DSM-5 Task Force has since sought to find a balance between these two extremes while not jumping ahead of validated research. Structural Changes To the Layout 13

14 Structural Changes to the Layout (Metastructure) The DSM Task Force has attempted to balance between various critiques, which has lead to both many of the structural changes that we do see in the DSM-5 as well as the lack of some of the changes we expected to see. The Discontinuation of Using Multiaxial Diagnosis Axis I: Axis II: Axis III: Axis IV: Axis V: Clinical Disorders Other Conditions that May Be a Focus of Clinical Attention Personality Disorders Mental Retardation General Medical Conditions Psychosocial & Environmental Problems Global Assessment of Functioning The Discontinuation of Using Multiaxial Diagnosis The DSM-5 combines the first three axes into Section II. All mental disorders, personality disorders, intellectual disabilities, and other medical diagnoses are seen as the primary diagnoses. When making diagnoses, all disorders should be listed together. Part of why Axis II existed was to call attention to disorders that needed more of a clinical and research focus. However, the APA states that, there is no fundamental difference between disorders described on DSM-IV s Axis I and Axis II (APA, Personality Disorders Fact Sheet). 14

15 The Discontinuation of Using Multiaxial Diagnosis Axis IV is replaced with the last chapter in Section II: Other Conditions That May Be a Focus of Clinical Attention, which includes an expanded list of V-codes (and ICD-10, Z-codes), psychosocial and environmental factors, and other conditions or problems that would affect treatment. These can be reported to insurance or just noted in the client s file. The Discontinuation of Using Multiaxial Diagnosis Axis V, the Global Assessment of Functioning, or GAF score was dropped. The GAF score was being used as a standard to determine the need for treatment, and the APA believes it does not convey adequate information to that end. Instead of the single score, the APA recommends, that clinicians continue to assess the risk of suicidal and homicidal behavior...and use available standardized assessments for symptom severity, diagnostic severity, and disability such as the measures in Section III of DSM-5, including the WHO s Disability Assessment Schedule (APA, Insurance Implications of DSM-5). Diagnosing Under DSM-IV Multiaxial Diagnosis 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 & Environmental Problems Axis V: Global Assessment of Functioning Example: Axis I: Bipolar I Disorder, Most Recent Episode Mixed, Moderate Severity V61.10 Partner Relational Problem Axis II: Borderline Personality Disorder Axis III: Migraine Axis IV: Divorce Axis V: GAF= 45 (current) 15

16 Diagnosing Under DSM-5 Using ICD-9 Codes Bipolar I Disorder, Most Recent Episode Depressed, Moderate Severity, With Mixed Features Borderline Personality Disorder Migraine V61.03 Disruption of Family by Divorce WHODAS Cognition: 2 Mobility: 1 Self-Care: 2 Getting Along: 3 Life Activities: 3 Participation: 4 General Disability: 3 Using ICD-10 Codes F31.32 Bipolar I Disorder, Most Recent Episode Depressed, Moderate Severity, With Mixed Features F60.3 Borderline Personality Disorder G43 Migraine Z63.5 Disruption of Family by Divorce WHODAS Cognition: 2 Mobility: 1 Self-Care: 2 Getting Along: 3 Life Activities: 3 Participation: 4 General Disability: 3 Moving Toward a Dimensional Approach Categorical approach is dichotomous. Because the previous DSM approach considered each diagnosis as categorically separate from health and other diagnoses, it did not capture the widespread sharing of symptoms and risk factors across many disorders that is apparent in studies of comorbidity (pg. 12, DSM-5). This led to high comorbidity rates and the heavy reliance on NOS diagnoses. Moving Toward a Dimensional Approach The dimensional approach refers to a set of continuums on which an individual can have various levels of characteristics. All of the diagnoses listed in Section II are still categorical. In Section III, we see how the DSM is headed toward a dimensional approach in both the dimensional assessments offered as well as the alternate model for personality disorders. 16

17 Moving Toward a Dimensional Approach While the diagnoses in Section II are still categorical, the revised chapter organization signals how disorders may relate to each other based on underlying vulnerabilities or symptom characteristics. It also breaks out some disorders because of greater understanding of their basic causes. As an example, the previous single chapter on Anxiety disorders, including obsessive compulsive disorder and posttraumatic stress disorder now is three sequential chapters detailing Anxiety Disorders, Obsessive-Compulsive and Related Disorders, and Trauma- and Stressor-Related Disorders. This move both emphasizes the distinctiveness of the categories covered while signaling their interconnectedness. ( American Psychiatric Association Releases DSM-5) Moving Toward a Dimensional Approach These chapters are arranged in clusters which groups disorders together that relate to each other the most in overlapping symptoms and potential risk factors but divergent expressions Clusters Neurodevelopmental Disorders Internalizing Disorders Somatic Disorders Externalizing Disorders Neurocognitive Disorders Personality Disorders Full List of Clusters Neurodevelopmental Cluster Neurodevelopmental Disorders Schizophrenia Spectrum & Other Psychotic Disorders Internalizing Cluster Bipolar & Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive & Related Disorders Trauma- & Stressor-Related Disorders Dissociative Disorders 17

18 Full List of Clusters Somatic Cluster Somatic Symptom & Related Disorders Feeding & Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Externalizing Cluster Disruptive, Impulse-Control, & Conduct Disorders Substance-Related & Addictive Disorders Neurocognitive Cluster Neurocognitive Disorders Personality Cluster Personality Disorders Full List of Clusters Other Cluster Paraphilia Disorders Other Mental Disorders Medication-Induced Movement Disorders and Other Adverse Effects of Medication Other Conditions That May Be a Focus of Clinical Attention Conditions for Further Study Lifespan Approach The chapter in DSM-IV-TR, Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence has been eliminated in favor of placing these disorders in the chapters that they relate to most in symptomology. Research showed that some of these disorders last into adulthood, but were being missed due to the assumption that they were childhood disorders. (e.g., ADHD, Pica) 18

19 Lifespan Approach Some disorders can be precursors for other related disorders. e.g., Individuals with Separation Anxiety Disorder tend to develop other anxiety disorders later in life if left untreated Many of the chapters are internally, arranged developmentally, with disorders sequenced according to the typical age of onset. (DSM-5, pg. 189) General Diagnostic Changes Definition of Mental Disorder: DSM-IV DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR all used the same definition: A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever the original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction. Neither deviant behavior (e.g. political, religious, or sexual) and conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. 19

20 Definition of Mental Disorder: DSM-5 DSM-5: A syndrome characterized by clinically significant disturbance in an individual s cognition, emotional 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 behaviors (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. General Changes The DSM-5 replaces the NOS categories with two options: other specified disorder and unspecified disorder to enhance diagnostic specificity to the clinician Diagnosis or Condition Deferred is still available, though it is not listed. The provisional specifier is still available. General Changes Some cultural concepts have been integrated into various Other Specified diagnoses. e.g.,- Shubo-kyofu, Koro, & Jikoshu-kyofo are some of the options listed under Other Specified Obsessive-Compulsive and Related Disorder. Some of the disorders and subtypes share the same diagnostic code because DSM codes are now completely compatible with ICD codes, and therefore new codes could not be created for billing purposes. e.g., Hoarding Disorder and Obsessive-Compulsive Disorder share (F42). Therefore, the name of the diagnosis should always be recorded in the medical record, not only the code. Some of the names of DSM-5 disorders are different than names used in the ICD system. Again, this is due to the necessity of lining up the codes with the ICD system. 20

21 Different Names in DSM-5 from ICD-9 and ICD-10 DSM-5 Disorder Social (pragmatic) communication disorder Disruptive mood dysregulation disorder Premenstrual dysphoric disorder DSM-5/ ICD-9- CM Code Hoarding disorder Other specified obsessive compulsive and related disorder Unspecified obsessive compulsive and related disorder Excoriation (skin picking) disorder ICD-9-CM Title Other developmental speech or language disorder Other specified episodic mood disorder Premenstrual tension syndromes Obsessive- compulsive disorders Obsessive- compulsive disorders Obsessive- compulsive disorders DSM-5/ ICD-10- ICD-10-CM Title CM Code Other developmental F80.89 disorders of speech and language F34.8 N94.3 F42 F42 F42 Other persistent mood [affective] disorders Premenstrual tension syndrome Obsessive- compulsive disorder Obsessive- compulsive disorder Obsessive- compulsive disorder Dermatitis factitia [artefacta] L98.1 Factitial dermatitis Binge eating disorder Bulimia nervosa F50.8 Other eating disorders Coding Mistakes in DSM-5 In their rush in getting the DSM-5 released, the APA had several coding mistakes. Code mistakes and corrections can be found at NG%20CORRECTIONS%20FOR%20DSM-5% pdf Note that the last digits in the address are , as this was updated since the handouts were printed. Coding Corrections for DSM-5 and DSM-5 Desk Reference IN DSM-5: DESK REFERENCE: Name of Disorder Incorrectly Listed As Corrected Code Corrections on pgs: Corrections on pgs: 319 (70) Mild 317 (70) Mild xiii, 33, 848, 872 ix, 18 Intellectual Disability 319 (71) Moderate (71) Moderate (also delete coding (also delete coding (Intellectual 319 (72) Severe (72) Severe note on page 33) note on page 18) Developmental Disorder) 319 (73) Profound (73) Profound Language Disorder (F80.9) (F80.2) xiii, 42, 848, 871, 891 x, 24 Bipolar I, Most recent episode hypomanic, In (F31.73) (F31.71) xvi, 127, 842, 888 xiv, 70 partial remission Bipolar I, Most recent episode hypomanic, In (F31.74) (F31.72) xvi, 127, 842, 888 xiv, 70 full remission Selective Mutism (F94.0) (F94.0) xviii, 195, 859, 871 xvii, 116 Trichotillomania (Hair- Pulling Disorder) (F63.2) (F63.3) xix, 251, 861, 890 xviii, 133 xxii, 362, 848, 873, 892 (insert corrected ICD-9- Insomnia Disorder (G47.00) (F51.01) xxii, 181, 182 CM code on pg. 870; ICD- 10-CM code on pg. 890) Hypersomnolence (G47.10) (F51.11) xxii, 368, 369, 847, 873, xxii, 182, 183 Conduct Disorder, Adolescent Onset (F91.2) (F91.2) xxiv, 846, 871 xxv Kleptomania (F63.3) (F63.2) xxiv, 478, 848, 890 xxvi,

22 DSM-5 Disorders Clusters/Groups Neurodevelopmental Cluster Neurodevelopmental Disorders Schizophrenia Spectrum & Other Psychotic Disorders Internalizing Cluster Somatic Cluster Externalizing Cluster Neurocognitive Cluster Personality Cluster Other Cluster Neurodevelopmental Disorders Intellectual Disabilities Intellectual Disability (Intellectual Developmental Disorder) Global Developmental Delay Unspecified Intellectual Disability (Intellectual Developmental Disorder) 22

23 Neurodevelopmental Disorders Intellectual Disability (Intellectual Developmental Disorder) A federal statute (Public Law , Rosa s Law) replaces the term mental retardation with intellectual disability, which is reflected in the DSM-5. The term Intellectual Developmental Disorder will be used in the ICD-11 Neurodevelopmental Disorders Intellectual Disability (Intellectual Developmental Disorder) Emphasis is placed in the wording on intellectual and adaptive functioning deficits, and changes the severity specifiers to the basis of adaptive functioning rather than IQ scores since adaptive functioning determines the level of support required. See pages for information to determine severity level. The ICD-9 coding is inaccurate in both the DSM-5 and the Desk Reference. Coding is done by specifier: 317 Mild, Moderate, Severe, Profound Neurodevelopmental Disorders Communication Disorders (F80.9) Language Disorder A combination of DSM-IV s Expressive and Mixed Receptive-Expressive Language Disorders (F80.0) Speech Sound Disorder Previously Phonological Disorder, changed to reflect the understanding that the etiology of the disorder may be from difficulty with phonological knowledge or with the ability to coordinate movements for speech. 23

24 Neurodevelopmental Disorders Communication Disorders (F80.81) Childhood-Onset Fluency Disorder (Stuttering) Criteria are mostly unchanged except: Criteria A deletes interjections as an option Criteria B adds anxiety about the disturbance as an option if other limitations are not present There is an additional criteria that the onset be in childhood as Adult-Onset Fluency Disorder has a separate diagnosis code. Neurodevelopmental Disorders (F80.89) Social (Pragmatic) Communication Disorder New diagnosis SCD is characterized by a persistent difficulty in the social use of verbal and nonverbal communication that cannot be explained by low cognitive ability. Symptoms include difficulty in the acquisition and use of spoken and written language as well as problems with inappropriate responses in conversation that result in functional limitations. Neurodevelopmental Disorders (F84.0) Autism Spectrum Disorder Research supports the combination of four separate disorders from the DSM-IV, Autistic Disorder (Autism), Asperger s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder NOS, into a continuum of symptom severity. ASD requires both deficits in social communication and social interaction and restricted repetitive behaviors, interests, and activities (RRBs) 24

25 Neurodevelopmental Disorders (F84.0) Autism Spectrum Disorder 3 Levels of Severity: (see table on pg. 52) Level 1: Requiring support Level 2: Requiring substantial support Level 3: Requiring very substantial support Note: Anyone with an established DSM-IV diagnosis of Autism, Asperger s, or PDD NOS should be given the diagnosis of ASD for continuity of care. Rett s Disorder has been dropped as a mental disorder as it is now understood to be a neurogenetic disorder with specific etiology. Neurodevelopmental Disorders 314.xx (F90.x) Attention Deficit Hyperactivity Disorder (ADHD) Research has shown that ADHD symptoms can often hold steady through adulthood, and so DSM-5 seeks to enable adults to receive care. The symptoms have not changed, but they have included examples to help clinicians identify the symptoms in clients of all ages. Children still need to exhibit at least 6 symptoms, but older adolescents and adults only need 5. Also, several symptoms must have been present before age 12, which was changed from age 7 in DSM-IV. Neurodevelopmental Disorders 315.xx (F81.x) Specific Learning Disorder Because various learning deficits commonly cooccur, the DSM-5 has combined Reading Disorder, Disorder of Written Expression, and Mathematics Disorder, though they still have separate diagnosis codes. 25

26 Neurodevelopmental Disorders Motor Disorders No substantial changes in this category, though criteria in stereotypic movement disorder differentiates from body-focused repetitive behavior disorders in the chapter on obsessive-compulsive and related disorders. Schizophrenia Spectrum & Other Psychotic Disorders (F20.9) Schizophrenia Regarding symptomatic changes to schizophrenia, the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (multiple voices conversing with one another) was eliminated. The special attribution of these two symptoms in the DSM-IV meant that the manifestation of only one of the symptoms was sufficient in and diagnosis of schizophrenia. The symptom threshold has been raised from 1 to 2 specific symptoms exhibited to qualify for diagnosis, including the requirement of the symptom of delusions, hallucinations, or disorganized speech Schizophrenia Spectrum & Other Psychotic Disorders (F20.9) Schizophrenia The DSM-5 has also done away with the subtypes of schizophrenia as research showed that these were too labile and/or too commonly overlapped with other subtypes. Certain subtypes are now descriptive specifiers and can be applied to other disorders such as schizoaffective disorder, major depressive disorder, and bipolar disorder. 26

27 Schizophrenia Spectrum & Other Psychotic Disorders (F25.x) Schizoaffective Disorder The changes regarding schizoaffective disorder involve a more stringent criterion that a major mood episode needs to be present for the majority of the time that schizophrenic symptoms are also being exhibited. The desire was to make schizoaffective disorder more of a longitudinal diagnosis rather than an episodic one. Under the ICD-10, we will specify either bipolar type or depressive type. Schizophrenia Spectrum & Other Psychotic Disorders (F22) Delusional Disorder The criterion that delusions be non-bizarre has been removed with the updates to the DSM-5, with an added specifier for bizarre content delusions. Explicit demarcation has also been added to exclude overlap with psychotic variants of obsessivecompulsive disorder and/or body dysmorphic disorder. If symptoms are better explained by either OCD or BDD, then those diagnoses are to be used. Schizophrenia Spectrum & Other Psychotic Disorders (F22) Delusional Disorder Shared delusional disorder is no longer separated from delusional disorder in DSM-5, if shared delusions are present but the criteria for delusional disorder is not, the diagnosis should be other specified schizophrenia spectrum and other psychotic disorder. 27

28 Schizophrenia Spectrum & Other Psychotic Disorders (F06.1) Catatonia Criteria for this diagnosis is standardized across all disorders; whether it be depressive, bipolar, psychotic, medical, or unidentified. All contexts require three symptoms (up from the one or two symptoms) out of 12 in order to meet diagnosis for catatonia. Catatonia may be used as a separate diagnosis or as a specifier within psychotic, bipolar, or depressive disorders. Clusters/Groups Neurodevelopmental Cluster Internalizing Cluster Bipolar & Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive & Related Disorders Trauma- & Stressor-Related Disorders Dissociative Disorders Somatic Cluster Externalizing Cluster Neurocognitive Cluster Personality Cluster Other Cluster Bipolar & Related Disorders Chapter includes: Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Substance/Medication Induced Bipolar and Related Disorder Bipolar and Related Disorder Due to Another Medical Condition Other Specified Bipolar and Related Disorder Unspecified Bipolar and Related Disorder 28

29 Bipolar & Related Disorders The criteria for bipolar episodes, whether manic or hypomanic, now includes changes in activity level or energy level, in addition to changes mood. The diagnosis of bipolar I disorder, mixed episode, has been removed from the DSM-5 and replaced with the specifier with mixed features. This new specifier may be used with either bipolar I or bipolar II. A new specifier of with anxious distress has been added to delineate anxiety symptoms manifested along with the bipolar symptoms. Depressive Disorders New depressive disorders disruptive mood dysregulation disorder and premenstrual dysphoric disorder have been added to the DSM-5. Disruptive mood dysregulation disorder is intended for children up to the age of 18 years who exhibit many symptoms that were previously categorized as bipolar disorder. Depressive Disorders (F34.8) Disruptive Mood Dysregulation Disorder A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression) that are grossly out of proportion in intensity or duration to the situation or provocation. B. The temper outbursts are inconsistent with developmental level. C. The temper outbursts occur, on average, three or more times a week. D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., teachers, parents, peers). E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A-D. F. Criteria A-D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these. G. The diagnosis should not be made for the first time before the age of 6 or after age

30 Depressive Disorders (F34.8) Disruptive Mood Dysregulation Disorder H. By history or observation, the age of onset of Criteria A-E is before 10. I. There has never been a distinct period lasting more than one day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event, or its anticipation, should not be considered as a symptom J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, PTSD, separation anxiety disorder, persistent depressive disorder). Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, ADHD, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both DMDD and oppositional defiant disorder should only be given the diagnosis of DMDD. If the individual has ever had a manic or hypomanic episode, DMDD should not be assigned. K. The symptoms are not attributable to the psychological effects of a substance or to another medical or neurological condition. Depressive Disorders (N94.3) Premenstrual Dysphoric Disorder The results of significant research has led to premenstrual dysphoric disorder being classified in the main body of the DSM-5 (whereas in the DSM-IV it was included in appendix B as a diagnosis for further study ) Depressive Disorders 296.xx (F32.x, F33.x) Major Depressive Disorder The main diagnostic criterion for major depressive disorder remains unchanged in the DSM-5. The co-occurrence of manic symptoms which are insufficient for a diagnosis of a manic episode now fall under the specifier of with mixed features. The exclusion of bereavement has been removed from the DSM-5. This was done as research showed that the loss of a loved one often precipitated a major depressive episode. See section 3 for persistent complex bereavement disorder 30

31 Depressive Disorders (F34.1) Persistent Depressive Disorder (Dysthymia) This is disorder is a combination of both chronic major depressive disorder and dysthymic disorder. The merger came out of the lack of scientifically significant findings regarding differences between the two previously separate diagnoses. You would not give both of the diagnoses of major depressive disorder and persistent depressive disorder at the same time. Anxiety Disorders Changes to the anxiety disorders chapter of the DSM-5 include the removal of obsessivecompulsive disorder, posttraumatic stress disorder, and acute stress disorder; which of all been placed in different chapters related specifically to obsessive-compulsive and trauma-stressor disorders. Anxiety Disorders Agoraphobia, Specific Phobia, Social Anxiety Disorder Changes to the phobic disorders include the removal of the requirement that an individual over 18 recognizes that their anxiety is excessive or unreasonable, and instead simply qualifies that the anxiety is out of proportion to the actual threat or danger of the situation. Also, the requirement that the phobic features be present for six months is now applied to individuals all ages as opposed to simply individuals under the age of 18 31

32 Anxiety Disorders Panic Attacks The main diagnostic structure of panic attacks remains the same. However, the descriptions of the different types of panic attacks have been simplified to unexpected or expected panic attacks. As panic attacks were seen as an indicator for the severity of many diagnoses, with panic attacks can be listed as a specifier with all DSM-5 diagnosis. Anxiety Disorders (F41.0) Panic Disorder (F40.00) Agoraphobia The previous connection of panic disorder and agoraphobia from the DSM-IV is done away with in the DSM-5, with panic disorder and agoraphobia being two completely separate diagnoses. In instances where there is co-occurrence of panic disorder and agoraphobia they are coded as two separate diagnoses. Agoraphobia now requires the presence of two or more situations causing fear, this to help distinguish agoraphobia from other specific phobias. Anxiety Disorders Specific Phobias The only change to the diagnostic criteria for specific phobias is that insight and/or belief in the excessiveness or unreasonableness of the phobic fear is no longer required for individuals over 18 years old to receive the diagnosis. 32

33 Anxiety Disorders (F40.10) Social Anxiety Disorder (Social Phobia) Like specific phobias, individuals over the age of 18 are not now required to recognize the excessiveness or unreasonableness of their fear in order to be diagnosed. 2 diagnostic specifiers added to social anxiety disorder are generalized and performance only. This change was done as research had shown that those who experience social anxiety only in the context of performance situations, such as public speaking, represented a distinct subgroup in terms of both etiology and treatment. Anxiety Disorders (F93.0) Separation Anxiety Disorder This disorder has been moved from the section of disorders usually first diagnosed in infancy, childhood, or adolescence and is now classified in the anxiety disorder section. The disorder may now be diagnosed even if the onset has been shown after the age of 18. An addition to the criterion is that the anxiety must be present for 6 months or more. Anxiety Disorders (F94.0) Selective Mutism Like separation anxiety disorder, this disorder has been moved from the section of disorders usually first diagnosed in infancy, childhood, or adolescence and is now classified in the anxiety disorder section as research has shown that anxiety is a major feature of individuals with selective mutism. 33

34 Obsessive-Compulsive & Related Disorders This chapter on obsessive-compulsive and related disorders is new to the DSM-5. Because recent studies have shown that obsessive-compulsive disorder involves distinct neurocircuits, it and several related disorders constitute their own chapter instead of being addressed in the chapter on anxiety disorders (The Organization of DSM-5). Disorders in this section include the DSM-IV diagnoses of obsessive-compulsive disorder, body dysmorphic disorder, and trichotillomania (hair-pulling disorder); as well as new disorders including excoriation (skin-picking) disorder, hoarding disorder, substance-/medication-induced obsessive-compulsive and related disorder and obsessive-compulsive and related disorder due to another medical condition. Obsessive-Compulsive & Related Disorders New specifiers for obsessive-compulsive and related disorders The three specifiers of good or fair insight, poor insight, and absent insight/delusional are given for use in obsessive-compulsive disorder with analogous specifiers also added to body dysmorphic disorder and hoarding disorder. The absent insight/delusional specifier now allows individuals who meet the criteria to be diagnosed with a obsessive-compulsive or related disorder rather than a schizophrenia spectrum disorder. An added tic-related specifier for obsessive-compulsive disorder has also been added due to growing research showing the comorbidity between obsessive-compulsive disorder and a tic disorder and how this might have relevance in the clinical situation. Obsessive-Compulsive & Related Disorders (F45.22) Body Dysmorphic Disorder Relevant to the reclassification of body dysmorphic disorder from a somatic disorder into the new section of obsessivecompulsive and related disorders, the new criterion for body dysmorphic disorder involves the patient engaging in repetitive behaviors or mental acts in response to their preoccupation with perceived defects or flaws in their physical appearance. A new specifier of with muscle dysmorphia has also been added to reflect growing research regarding the particulars of those whose fixation is related to their muscles. The specifier of absent insight/delusional with body dysmorphic disorder is now to be utilized with those presenting with the delusional variant of body dysmorphic disorder as opposed to the DSM-IV duel-diagnosis of delusional disorder, somatic type, and body dysmorphic disorder. 34

35 Obsessive-Compulsive & Related Disorders (F42) Hoarding Disorder This represents a new diagnosis for the DSM-5 that is seen as related to obsessive-compulsive disorder but has been shown by the available data not to be a variant of OCD or any other mental disorder. This diagnosis involves the patient presenting with persistent difficulty discarding or parting with possessions and noted distress associated in discarding them. Obsessive-Compulsive & Related Disorders (F63.3) Trichotillomania (hair-pulling disorder) The parenthetical hair-pulling disorder is the only noted change to trichotillomania beyond the categorization shift from the DSM-IV to the DSM (L98.1) Excoriation (skin-picking) Disorder Excoriation represents a new disorder in the DSM-5. It is characterized by the recurrent urge to pick at one's own skin, often to the point of causing dermatological damage. Obsessive-Compulsive & Related Disorders (F06.8) Obsessive-Compulsive and Related Disorder Due to Another Medical Condition This new diagnosis replaces the DSM-IV diagnosis of anxiety disorder due to a general medical condition with obsessivecompulsive symptoms (Fxx.xx) Substance/Medication-Induced Obsessive- Compulsive and Related Disorder This diagnosis replaces the DSM-IV diagnosis of substanceinduced anxiety disorder with the obsessive-compulsive symptoms specifier. 35

36 Obsessive-Compulsive & Related Disorders (F42) Other Specified and Unspecified Obsessive- Compulsive and Related Disorders Conditions under this category include body-focused repetitive behavior disorder, obsessional jealousy, and unspecified obsessive-compulsive and related disorder. Body-focused repetitive behavior disorder involves recurrent body focused behaviors, other than hair pulling and skin picking, (i.e., nail biting, etc.). Obsessional jealousy involves a preoccupation with perceived infidelity of one's partner that does not qualify as delusional. Trauma- & Stressor-Related Disorders This new category allows for broader qualification in traumatic experience in many of the trauma-based diagnoses, with vicarious experiences of stress and trauma now seen as legitimate underlying causes for many of the Trauma-& Stressor-Related Disorders. Trauma- & Stressor-Related Disorders (F43.10) Posttraumatic Stress Disorder Compared to DSM-IV, the diagnostic criteria for DSM-5 draw a clearer line when detailing what constitutes a traumatic event. Sexual assault is specifically included, for example, as is a recurring exposure that could apply to police officers or first responders. Language stipulating an individual s response to the event intense fear, helplessness or horror, according to DSM-IV has been deleted because that criterion proved to have no utility in predicting the onset of PTSD 36

37 Trauma- & Stressor-Related Disorders (F43.10) Posttraumatic Stress Disorder PTSD now also covers exposure to what is often called secondhand trauma : Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related. There is now a separate set of criteria for children under 6. The criteria are similar in nature, but take developmental age into consideration. Fewer criteria are necessary for children as well. Trauma- & Stressor-Related Disorders (F43.10) Posttraumatic Stress Disorder The DSM-5 attempts take into account behavioral symptoms that manifest with PTSD. To this end, 4 diagnostic clusters of reexperiencing, avoidance, negative cognitions and mood, and arousal. The addition of the set of criteria regarding negative alterations in cognition and mood includes: Previous criteria of amnesia, detachment, and diminished interest or participation in activities. Adds persistent and negative beliefs or expectations about self, others, or the world; persistent and distorted beliefs about the event that lead to blame; and restricted positive affect. Trauma- & Stressor-Related Disorders (F43.0) Acute Stress Disorder An explicit qualification of the traumatic event experienced is now required for the diagnosis of acute stress disorder; with the qualifiers being that the event was experienced directly, was witnessed, or was experienced indirectly. The DSM-IV criteria that the person s response involved intense fear, helplessness, or horror has been removed due to the lack of supporting research in the diagnostic validity of that requirement. 37

38 Trauma- & Stressor-Related Disorders 309.xx (F43.2x) Adjustment Disorders The DSM-5 reclassified adjustment disorders in the context of stress-response conditions occurring in reaction to distressing events. This is a reconceptualization of the adjustment disorders, which in the DSM-IV were used to diagnose individuals exhibiting clinically significant symptoms without meeting the criteria for a range of other disorders. All of the DSM-IV subtypes have been retained in the DSM-5 without changes. Trauma- & Stressor-Related Disorders (F94.1) Reactive Attachment Disorder The two subtypes of reactive attachment disorder, emotionally withdrawn/inhibited and indiscriminately social/disinhibited, that were found in the DSM-IV have been redefined as distinct disorders in the DSM-5. Reactive attachment disorder now entails only the emotionally withdrawn/inhibited subtype whereas the indiscriminately social/disinhibited subtype fits into the new diagnosis of (F94.2) Disinhibited Social Engagement Disorder. Both disorders are seeing as an outcome of social neglect and healthy attachment. Yet reactive attachment disorder is seen as more closely related to internalizing disorders, while disinhibited social engagement disorder is more closely linked with ADHD and the Neurodevelopmental cluster. Dissociative Disorders (F44.81) Dissociative Identity Disorder The criteria for diagnosis of dissociative identity disorder now allows for self-report, as well as observance by others, as meeting criterion A for diagnosis. Criterion B now allows for recurrent gaps in recall for events that are not necessarily consider traumatic. There is also now a greater willingness to consider certain possession-form phenomenon and neurological symptoms in accounting for the diversity of presentation in this disorder. 38

39 Clusters/Groups Neurodevelopmental Cluster Internalizing Cluster Somatic Cluster Somatic Symptom & Related Disorders Feeding & Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Externalizing Cluster Neurocognitive Cluster Personality Cluster Other Cluster Somatic Symptom & Related Disorders What was known in the DSM-IV as somatoform disorders are now called somatic symptom and related disorders in the DSM-5. There is a reduction of number and subcategories of these disorders in the DSM-5 in order to decrease diagnostic overlap. Somatic Symptom & Related Disorders (F45.1) Somatic Symptom Disorder This new disorder is designed to replace the DSM-IV diagnosis of somatization disorder and undifferentiated somatoform disorder, which was problematic due to its high symptom count required for diagnosis and its preclusion against the diagnosis of another medical condition. The new diagnosis of somatic symptom disorder is designed to diagnose individuals maladaptive thoughts, feelings, and behaviors with somatic symptoms that may or may not be related to a known medical condition. 39