Lance T. Laurence, Ph.D. Associate Professor, Dept of Psychology Director, University of Tennessee Psychological Clinic Director, Professional

Transcription

1 Lance T. Laurence, Ph.D. Associate Professor, Dept of Psychology Director, University of Tennessee Psychological Clinic Director, Professional Affairs, Tennessee Psychological Association October 31, 2013

2 DSM 5 & ICD- 10- CM Purpose: (1) A Primer on changes from DSM- IV- TR to DSM 5 (2) Help you understand DSM 5 and ICD- 10- CM relationship so that you get paid come October 2014 (when ICD- 10- CM goes into effect) (3) Familiarize you with how DSM 5 is organized so you can rapidly use it (4) Introduce you to new diagnostic entities and diagnostic instruments used in DSM 5. (5) An overview of the manual 900 pages in 3 hours so expect today to be a broad brushed peek at DSM 5

3 CE Interac3ve Ques3on We know interactive CE best learning mode for organized medicine (and by extension, health care providers) so. Question: Do You Have to Switch to DSM 5 or ICD- 10- CM? Do I Have to Change?

4 DSM 5 and ICD- 10- CM: Preliminary Remarks Lance, do I HAVE to use DSM 5 and ICD- 10- CM? Answer: Yes and No No: International Classification of Diseases became the universal coding requirement for billing purposes with the emergence of HIPAA (HIPAA required ICD coding, a development fought by the American Psychiatric Association) To get paid NOW: you MUST use ICD codes, NOT DSM numerical system

5 DSM 5 & ICD- 10- CM Since 2003, ICD- 9- CM coding system used for billing purposes With HIPAA requirements, DSM- IV- TR and ICD- 9- CM coding systems largely merged ; that is, most diagnostic code numbers are the same. Crosswalk of diagnostic codes occurred for those diagnostic code numbers of DSM- IV- TR that differed from ICD- 9- CM

6 DSM 5 & ICD- 10- CM ICD- 10- CM billing Codes to be used as of October 1, 2014 DSM 5 Code Numbers VERY different than ICD- 10- CM DSM 5 does provide ICD- 9- CM and ICD- 10- CM Code numbers in appendix and in text per se. For any diagnosis in DSM 5, under the name of the disorder, the first number listed is the ICD- 9- CM code and the second number in lighter text and in parentheses is the ICD- 10- CM code number

7 DSM 5/ICD Integra3on Example Posttraumatic Stress Disorder (F43.10) Red Number is ICD- 9- CM Code Green Number is ICD- 10- CM Code

8 DSM 5 & ICD- 10- CM If I have to use ICD- 10- CM codes to bill and get paid, then why should I have to buy and use DSM 5? Answer: You don t have to. For decades before HIPAA and the requirement to use the ICD coding system for billing, DSM was both a standard reference for clinical practice in the mental health field AND the billing code nomenclature. Not any more.

9 DSM 5 & ICD- 10- CM Why then use DSM 5? Educational Purposes & Clinical Utility Standard Reference for most mental health providers (500,000 of them: 200,000 LCSWs, 120,000 LPCs, 90,000 Psychologists, 50,000 LMFT, 40,000 Psychiatrists). Add nurses to this list of mental health providers? Psychology often critical of DSM 5 but others like it. Provides information such as developmental course, culture- related diagnostic issues, comorbidity, differential diagnosis, and other relevant data versus one paragraph, generic ICD- 10- CM descriptions (lacks specificity due to the need to potentially apply to those in all countries) Reimbursement Systems like it and are typically medically- dominated. Affordable Health Care Act likely to promote integrated care which will promote DSM 5 system

10 Historical Context DSM Classification System burst onto scene in 1952 (note Phenothazines emerge same time line) and has been the major diagnostic classification system for nervous and mental disorders in the U.S. (not the rest of the world) 1952: DSM I 1968: DSM II 1980: DSM III 1987: DSM III- R 1994: DSM IV 2001: DSM- IV- TR 2013: DSM 5

11 ICD System (Interna3onal Classifica3on of Diseases) Classifies ALL Disorders, not just Mental Health Mental Health Diagnoses in ICD System are in Section F in ICD- 10- CM system to be used 10/1/14 (that s why the code numbers listed in DSM 5 are F numbers) Each country permitted to modify the ICD classification system in order to factor in cultural differences in disorders between various countries hence the term Clinical Modification ICD- 9- CM system based on 1975 ICD- 9 system. ICD- 10 published in 1990, rest of the world uses it since early 2000, Canada in 2002, US to use ICD- 10- CM as of 10/1/14

12 ICD System Remember it is a coding system for diagnosis, NOT a Compendium of Physicians Terminology Procedure Code (i.e., 90834) Don t confuse ICD Diagnostic Codes with Procedure Codes. In ICD- 10- CM language, mental disorders are listed under F code numbers. There are other code numbers for other disorders (i.e., D are diseases of the blood, G codes are diseases of the nervous system)

13 ICD Coding and G Quality Codes G Codes in ICD- 10- CM refer to diseases of the nervous system In ICD- 10- CM coding, if one has a mental disorder secondary to a medical condition, the medical condition is listed first, then the mental disorder code If one has a disease of the nervous system causing a mental disorder, you listed the G nervous system disorder diagnostic code first, then your F code mental disorder A diagnostic G code nervous system disorder per ICD- 10- CM is NOT the same thing as a Medicare Quality Measure G code that you list with your CPT procedure code

14 Cri3cs of DSM 5 Human behavior, including psychopathology, does not lend itself to categorical classification systems versus a more dimensional approach, a criticism of past and current DSM efforts. There is some attempt to be more dimensional in DSM 5 but not enough Boundary between normal and abnormal behavior is becoming more blurry by lowering the diagnostic bar on some disorders (ADHD, GAD, PTSD), inclusion of some new disorders without strong empirical support (i.e., disruptive mood dysregulation disorder), discontinuation of bereavement exclusion in first two months of mourning. Concern: increase the number of disorders so that more conditions require treatment and certain kinds of treatment (i.e., meds)

15 Cri3cs of DSM 5 Over time DSM revisions have shifted significantly from its more analytic origins to endorsement of discovering the biological etiology of mental disorders ( the last two decades since DSM- IV was released have seen real and durable progress in such areas as cognitive neuroscience, brain imaging, epidemiology, and genetics ). Recent NIMH criticisms aside, the focus is on neuroscience and brain imaging, not relational or cultural viewpoints Bottom line: too medically- oriented in spite of seven (7) pages of Other Conditions That May Be a Focus of Clinical Attention (V Codes in ICD- 9- CM and Z Codes in ICD- 10- CM. Example: Placement of ADHD in neurodevelopmental disorders section versus disruptive, impulse- control, conduct disorder section of the manual

16 Key Changes in DSM 5 Called DSM 5, not DSM V. Why? Chapters are organized developmentally : from those disorders that tend to appear early in childhood (DSM 5 calls these neurodevelopmental disorders) to those that appear later in life ( Neurocognitive Disorders ) Within each disorder, text includes extensive reference to developmental course, age- related factors, risks, gender and cultural- related issues, and the latest research in genetics, neuroimaging, genetic vulnerability, and environmental exposure risks

17 Key Changes in DSM 5 Eliminates Multiaxial Approach that has been used in last 33 years. No more Axis I, Axis II, or Axis III disorders. Fear: movement toward all mental disorders reducible to their biological substrate and vicissitudes (some fear this trend, others welcome it) No Axis IV. Instead, use V Codes in ICD- 9- CM and Z Codes in ICD- 10- CM No Axis V. Instead, optional use of World Health Organization Disability Assessment Schedule 2.0 (pp in DSM 5 manual), 36 questions assessing one s understanding and communicating, getting around, self- care, getting along with people, life activities- household, life activities- school and work, and participation in society

18 Key Changes in DSM 5 Anxiety Disorders Rearranged removed PTSD, OCD from Anxiety Disorder Family Created New Obsessive- Compulsive & Related Disorder Group that includes OCD, brings Trichotillomania into this grouping, adds new Hoarding Disorder diagnosis and others Eliminates Separate Adjustment Disorder Grouping and includes Adjustment Disorders in new Trauma and Stress- Related grouping that includes PTSD, new Disinhibited Social Engagement Disorder, and others

19 Key Changes in DSM 5 Bipolar and Depressive Disorders separated and given their own distinct grouping Somatic Symptom Disorders and pain problems reorganized and add Body Dysmorphic Disorders Autism, Asperger s Disorder and Pervasive Developmental Disorders all collapsed into one disorder category called Autism Spectrum Disorder Greater Specification of Major and Mild Neurocognitive Disorders Major changes in Substance Abuse Disorders: no more abuse vs. dependence usage, no polysubstance disorder

20 Key Changes in DSM 5 Eliminates subtypes of Schizophrenia diagnosis Eliminates NOS diagnoses; now use either Other Specified (Anxiety or Depressive) Disorder or Unspecified (Anxiety or Depressive Disorder Intellectual Disability now Intellectual Developmental Disorder Neurocognitive Disorders organized into Mild or Major Subtypes Many familiar disorders (substance use, ADHD, PTSD, others) have different diagnostic criteria

21 Key Changes in DSM 5: Examples of New Disorders (not all of them) Dysphoric Mood Dysregulation Disorder Persistent Depressive Disorder ( Dysthymia ) Binge Eating Disorder Minor Neurocognitive Disorder Hoarding Gambling Disorder (first behavioral addiction. Can you guess the next one in the next revision?) Social Pragmatic Communication Disorder Gender Dysphoria (replaces Gender Identity Disorder) Disinhibited Social Engagement Disorder Premenstrual Dysphoric Disorder

22 Key Changes in DSM 5- Dimensional Addi3ons Includes future personality disorder classification that moves in the direction of a dimensional approach to personality disorders (sure to be included in future revisions). Includes self (identity, self- direction) and interpersonal (empathy, intimacy) elements of personality rated on 0-4 points scale along with five broad trait domains (negative affectivity, detachment, antagonism, disinhibition, and psychoticism)

23 Key Changes in DSM 5- Dimensional Addi3ons In attempt to move toward more dimensional view of psychopathology, offers Cross Cutting Symptom Measures for Adults and Children. Adult Version is self- report measure consisting of 23 questions that assesses 13 psychiatric domains (depression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, seep problems, memory, repetitive thoughts and behaviors, dissociation, personality functioning, substance abuse), 5 point ordinal scale Parent/guardian assessment of 12 domains, 25 questions. Kids can also complete the instruments

24 Key Changes in DSM 5 Dimensional Addi3ons Clinician- Rated Dimensions of Psychosis Symptom Severity 5 point scale, 8 items rated on following domains: hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression, mania Accurate tracking of heterogeneous symptom variability important in treating planning and prognosis

25 Okay, how do I use this thing? Familiarize yourself with the range of disorders Select diagnosis from DSM 5 code types and use proper ICD- 9- CM or ICD- 10- CM number, including V or Z codes Some carriers may still want multiaxial usage versus narrative descriptions; we are in a reimbursement transition state Example 1 (ICD- 9- CM) Generalized Anxiety Disorder #300.02; Borderline Personality Disorder # ; Hypertension; Disruption of Family by Separation or Divorce #V61.03, low income V60.2; GAF 50 Example 2 Generalized Anxiety Disorder #F 41.1 Borderline Personality Disorder #F60.3 Hypertension Disruption of Family by Separation or Divorce# Z63.5, low income #Z 59.6 Optional WHODAS Score: 52

26 How to Use It Then use proper CPT Codes If Medicare, add G Codes when applicable Charts can still look like multiaxial system if you like for organizing purposes, just don t list Axis I or Axis II on diagnostic code section of your billing forms

27 A Closer Look at How DSM 5 is Organized Overview of Entire Manual Review of Changes for Selected Diagnoses BUT FIRST, LET S TAKE A BREAK.

28 DSM 5 Table of Contents: New and Reshuffled Categories

29 DSM 5 Manual Section I: Introductory Remarks Section II: Diagnostic Criteria & Codes: pp Contains all of the disorders you ll use Section III: Emerging Measures & Models Contains assessment measures (Cross- Cutting Symptom Measures for Adults and Children/Adolescents; Clinician- Rated Dimensions of Psychosis Symptom Inventory; WHODAS 2.0; Cultural Formulation Materials; Alternative DSM- 5 Model for Personality Disorders; Conditions for Further Study Appendix: Summary of Changes from DSM- IV to DSM 5, glossary of terms, ICD- C9- CM & ICD- 10- CMDiagnoses and Codes

30 DSM 5 Diagnos3c Codes/Criteria Neurodevelopmental Disorders Schizophrenia Spectrum & Other Psychotic Disorders Bipolar & Related Disorders Depressive Disorders Anxiety Disorders Obsessive- Compulsive & Related Disorders Trauma- and Stressor- Related Disorders Dissociative Disorders Somatic Symptom & Related Disorders

31 DSM 5 Diagnos3c Codes/Criteria Feeding & Eating Disorders Elimination Disorders Sleep- Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse- Control, & Conduct Disorders Substance- Related & Addictive Disorders Neurocognitive Disorders Personality Disorders

32 DSM 5 Diagnos3c Codes/Criteria Paraphilic Disorders Other Mental Disorders Medication- Induced Movement Disorders and Other Adverse Effects of Medication Other Conditions that May Be a Focus of Clinical Attention (V Codes, ICD- 9- CM; Z Codes, ICD- 10- CM)

33 Specific DSM 5 Diagnosis Before examining various sections, a look at some of the new kids on the block (some, not all of the new diagnoses)

34 CE Interac3ve Time Too Many Kids are Being Diagnosed Asperger s Disorder when their primary problem involve poor social skills. How did DSM 5 address this problem?

35 DSM 5: New Diagnosis Social (Pragmatic) Communication Disorder Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the of the following: (1) deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context, (2) impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playroom, talking differently to a child, than to an adult, and avoiding use of overly formal language, (3)difficulties following rules for

36 Social Pragma3c Communica3on Disorder conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction, and (4) difficulties stating what is not explicitly stated (e.g., making inferences) and nonliteral or ambigious meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation. Deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination.

37 Social Pragma3c Communica3on Disorder Onset of symptoms early in development but may not be particularly apparent until social communication demands exceed limited capacities Not due to another mental disorder NOTE: No ICD- 10- CM Code; find closest match Teachers: Kids with Social Skills Problems Asperger s? The SPCD kids have the social skills problem but do NOT have the history of restricted/ repetitive patterns of behavior, interests, or activities. If they do, diagnosis Autism Spectrum Disorder

38 CE Interac3ve Time Your seven year old male patient has a bad case of meltdowns. With DSM- IV- TR many of these kids are diagnosed with childhood bipolar disorder, resulting in overuse of this diagnosis. How does DSM 5 handle this issue diagnostically?

39 Meltdowns

40 DSM 5 New Diagnosis: Disrup3ve Mood Dysregula3on Disorder (DMDD)- - - Meltdowns Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation Temper outbursts are inconsistent with developmental level Temper outbursts occur, on average, 3 or more times per week Mood between outbursts persistently irritable or angry most of the day and observed by others

41 DMDD Diagnosis Criteria Present for 12 months, never 3 months of no outbursts Present 2 or 3 settings (home, school, peers) and severe in at least one setting No Dx before 6 or after 18, but before 10 Outbursts don t last continously for more than l day before remitting, only to reappear again (ruling out mania) Not manipulative like ODD or Conduct Disorder kids Can t have this dx with ADHD, ODD, Bipolar stands by itself Not due to medical disorder

42 DMDD Diagnosis: Why? Trying to respond/offset overdiagnosis of bipolar disorder in children and adolescence Increase thought to be due to providers combining two clinical presentations into one bipolar category: classic, episodic presentations of mania and non- episodic presentations of severe irritability. In DSM 5, bipolar specifically reserved for episodic presentation of symptoms The DMDD kids don t grow up and become bipolar disorders unlike the manic- depressive variant syndrome of childhood who do become true blue bipolar disorders. The DMDD kids grow up and become adult depressives (unipolar depressive disorders) or adult mixed anxiety- depressive disorders (sensory integration disorders who grow up). Note: DMDD kids can be oppositional, ODD kids don t meet DMDD criteria and even if do, don t give ODD diagnosis to these DMDD kids. Trying to identify vulnerability to mood and anxiety issues, not impulse- control concerns

43 DSM 5 New Diagnosis: Hoarding Persistent difficulty discarding or parting of possessions, regardless of their actual value Usually not OCD; if so, hoard things such as trash, feces, urine, nails, used diapers hoarders don t use accumulate these types of items. Excessive acquisition unusual in OCD. If both present, hoarder dealing with sense of incompleteness and hence, need to document/preserve all life experiences. Exposure therapy + SSRI s more effective for OCD than hoarding

44 DSM 5 New Diagnosis: Binge Ea3ng Disorder Was in back of book in DSM- IV- TR. Those in the back of the bus typically move to the front in future additions (i.e., internet gaming disorder one day) Within 2 hour period, eat an amount larger than what most would eat and a sense of lacking control over eating during this time period. Eat more rapid than normal, uncomfortably full, eat large amounts when not hungry, eat alone because embarrassed at how much one is eating, disgusted/depressed/guilty when episode is over Occurs at least once a week for 3 months Differentiate from bulimia nervosa, anorexia nervosa or other disorders. Specific severity, full or partial remission

45 DSM 5 New Diagnosis: Gambling Disorder First behavioral disorder ( non- substance- related disorder ) 4 or more in 12 month period: need to gamble with increasing amounts of money in order to achieve desired excitement; restless/irritable when trying to stop or cut back; unsuccessful cutback attempts; preoccupied with thoughts about gambling past, present, future; gambles when feeling distressed; chases losses; lies to conceal; jeopardizes significant relationship, job, career opportunity; relies on others for money help Specifers: episodic, persistent, early or sustained remission; mild, moderate severe Next non- substance- related disorder: internet gaming Not likely to see sex addiction due to rapist & pedophile concerns

46 New Diagnosis: Disinhibited Social Engagement Disorder DSM- IV- TR combined clinical pattern of withdrawal/ disengagement with disinhibition into one diagnosis: reactive attachment disorder. DSM 5 separates the clinical picture into two distinct diagnostic types. Social neglect is a diagnostic requirement for both reactive attachment disorder and disinhibited social engagement disorder. Although the two disorders share a common etiology, the former is expressed as an internalizing disorder with depressive symptoms and withdrawn behavior, while the latter is marked by disinhibition and externalizing behavior

47 New: Disinhibited Social Engagement Disorder Child actively approaches and interacts with unfamiliar adults Overly familiar physical or verbal behavior Disinhibited attachment behavior not due to ADHD History of insufficient/neglectful adult caregiving

48 DSM 5 Samples of Diagnos3c Categories A quick look at SOME categories (not all) and some key elements of each category A look at some of the changes within any given diagnostic category

49 Neurodevelopmental Disorders Intellectual Disabilities Communication Disorders Autism Spectrum Disorder Attention- Deficit Hyperactivity Disorder Specific Learning Disorder Motor Disorders Other Neurodevelopmental Disorders

50 Intellectual Disability (ICD- 11 calls it Intellectual Developmental Disorder) Deficits in (1) intellectual functions AND (2) adaptive functions that MUST appears in developmental period. Diagnosis based on both standardized intelligence testing AND REQUIRED clinical assessment of adaptive domains (sidebar: which providers can administer intelligence testing and what tests are considered intelligence testing?) Note: Use of the term developmental period. DSM 5 NOT using developmental period as stage of development, first three years of life, preoedipal period, etc. DSM 5 uses the term developmental period to refer to brain development Severity levels rated from tables describing range of impairment from mild to moderate to severe to profound across three domains: (1) conceptual, (2) social and (3) practical. Assessing ability for personal independence and social responsibility Drops DSM- IV- TR use of the term mental retardation (consistent with federal law Rosa s Law) Many sources of impairment: genetic, head injury, environmental factors

51 Communica3on Disorders: Deficits in the development and use of language, speech and social communication Language Disorder (Expressive, Receptive in DSM- IV- TR) Speech Sound Disorder (Phonological Disorder DSM- IV- TR) Childhood- Onset Fluency Disorder (Stuttering) Social (Pragmatic) Communication Disorder (New) Unspecified Communication Disorder (Communication Disorder NOS in DSM- IV- TR)

52 Au3sm Spectrum Disorder ELIMINATES ASPERGER S DISORDER AS SEPARATE DIAGNOSTIC CATEGORY Combines Autistic Disorder, Rett s Disorder, Asperger s Disorder, Childhood Disintegration Disorder and Pervasive Developmental Disorder into same category Must have deficits in BOTH social communication and social interaction AND restrictive, repetitive patterns of behavior, interests, or activities Uses Level 1-3 ( requiring support, requiring substantial support, requiring very substantial support ) on both domains. Rate severity on BOTH domains Sidebar: controversial change

53 A_en3on- Deficit Hyperac3vity Disorder Combined presentation Predominantly inattentive presentation Predominantly hyperactive/impulsive presentation Other Specified ADHD disorder ( not quite inattentive enough ) Unspecified ADHD disorder (you prefer not to specify why just shy of meeting diagnostic criteria; does this open the door for overdiagnosis e.g., borderline ADHD getting diagnosis and treatment/services?)

54 ADHD Changes Before age 12, not age 7 as in DSM- IV- TR (adult recall of life before 7 often difficult) Greater lifespan coverage in examples, not just kids 5 Symptoms for Adults, 6 for kids Specify Mild, Moderate or Severe Can also have a comorbid Autism Spectrum Disorder (couldn t in DSM- IV- TR)

55 Specific Learning Disorder With Impairment in Reading (specify kind: fluency, rate, comprehension With Impairment in Written Expression (specify kind: spelling, grammar, punctuation, etc.) With Impairment in Mathematics (specify kind: facts, calculation, math reasoning, etc.) Specify Current Severity: Mild, Moderate, Severe Evidence of persistent learning difficulties may be derived from cumulative school reports, portfolio s of the child s evaluated work, curriculum- based measures, or clinical interview Categories not fully consistent with IDEA s Specific Learning Disorder categories No ability- achievement discrepancy criterion as in DSM- IV- TR

56 Motor Disorders Developmental Coordination Disorder Stereotypic Movement Disorder (new; driven, repetitive, purposeless motor behavior such as head banging, body rocking, etc.). Specific with or without self- injury and if due to known medical or genetic condition with severity (mild, moderate, severe) Tic Disorders: Tourette s (both multiple motor or vocal tics) versus Persistent (Chronic) Motor or Vocal Tic Disorder versus Provisional Tic Disorder (less than l year) versus Other Specified or Unspecified Tic Disorder. Renamed Tic Disorders from DSM- IV- R and moved this section from independent grouping to under Motor Disorders

57 Schizophrenia Spectrum & Other Psycho3c Disorders Schizotypical (Personality)Disorder (moved out of Personality Disorders) Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizophrenia Schizoaffective Disorder: Specify Bipolar or Depressive Type Substance/Medication- Induced Psychotic Disorder Psychotic Disorder: Specify with Delusions or Hallucinations Catatonia: With Another Mental Disorder vs. Another Medical Condition vs. Unspecified Catatonia Other Specific Schizophrenia Spectrum and Other Psychotic Disorder versus Unspecified Schizophrenia Spectrum and Other Psychotic Disorders

58 Schizophrenia Spectrum Disorders You ve see the diagnoses in this group. Which diagnoses are missing? That is, in DSM from the beginning of time but no longer present? You didn t think you d get any from the CE interactive stuff, did you?

59 Schizophrenia Spectrum Disorders Eliminates Schizophrenia Subtypes i.e., paranoid, disorganized, catatonic, undifferentiated, residual To give diagnosis, must have two of the following and one from the first three below: a) Delusions b) Hallucinations c) Disorganized Thinking (Speech) d) Grossly Abnormal Psychomotor Behavior e) Negative Symptoms (diminished emotional expression, avolition, etc.) Eliminates DSM- IV- TR exception of only l from a- e ( Criterion A symptoms) if person has either delusions or first rank auditory hallucinations (i.e., hearing voices)

60 Schizophrenia Spectrum Symptoms Delusional Disorder: delusions don t have to be bizarre any longer Specify type of delusions If schizoaffective schizophrenia, mood disorder must be present for most of the disorder Catanoia becomes a specifier that can be added to various disorders (psychotic, bipolar, depressive, etc). Adds key dimensional assessment of severity via the Clinician Rated Dimensions of Psychosis Symptom Severity (0-4 rating across dimensions of hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms (restricted emotional expression or avolition), impaired cognition, depression, mania). Not all schizophrenics alike; dimensional ratings capture the uniqueness of the individual and associated with prognosis.

61 Mood Disorders Separates Depressive Disorders & Bipolar Disorders into discrete categories versus combined category in DSM- IV- TR. Emphasis on specifiers in Bipolar Disorders, consistent with movement toward dimensional approach ( not all bipolars or depressives alike ) Eliminates 2 month requirement before Bereavement can merit a Major Depressive Disorder Diagnosis Bereavement not just loss of a person can be loss of a pet, profession, home, etc. Concern: too broad, lowering the bar too much? Especially since anti- depressant meds not terribly effective with bereavement populations

62 Depressive Disorders Disruptive Mood Dysregulation Disorder Major Depressive Disorder Persistent Depressive Dysthymic Disorder (used to be called Dysthymia) Premenstrual Dysphoric Disorder Note: Difference between DMDD and bipolar: persistent versus discrete episodes

63 Bipolar Disorders Bipolar Disorder I Bipolar Disorder II Cyclothymic Disorder Other Specified Bipolar & Related Disorder Unspecified Bipolar & Related Disorder In Bipolar Diagnoses, the most recent episode identifies the diagnosis If Manic Episode= Bipolar I automatic diagnosis Major Depresion + Hypomanic= Bipolar II diagnosis Emphasis is on change in activity and energy

64 Bipolar Disorders Severity rating: mild, moderate, severe, with psychotic features, partial or full remission Key Change: A Host of Specifiers Specifiers Highlight Dimensional Analysis to increase diagnostic precision: i.e., with anxious distress. Clinically, bipolar disorder with a good deal of anxiety and rapid cycling increases suicide risk

65 Soma3c Symptoms & Related Disorders Somatic Symptom Disorder; pain, persistent, severity (mild, mod, severe) Illness Anxiety Disorder (formerly hypochondriasis) Conversion Disorder (Functional Neurological Symptoms Disorder). Lots of Specifiers Psychological Factors Affecting Other Medical Conditions Factitious Disorder (imposed on self vs another) Specified or Unspecified SSRD

66 Soma3c Symptom & Related Disorders Ends focus on unspecified medical illness movement away from problematic mind- body views i.e., no somatoform disorder Key: focus on the suffering patient No psychogenic pain or hypochrondriasis One of those sections that bears strong resemblance to the clinical research on these types of patient: the desire to be taken seriously, to have their suffering validated, and the important role of attachment compromises with these types of populations

67 Disrup3ve, Impulse- Control & Conduct Disorders Oppositional Defiant Disorder. Three types: a) angry/irritable mood, (2) argumentative/defiant behavior, (3) vindictiveness Intermittent Explosive Disorder: not just physical aggression but verbal aggression too; must be at least 6 Pyromania Kleptomania Conduct Disorder: with limited prosocial emotions Includes Antisocial Personality Disorder here as well in Personality Disorders Section Note: No ADHD here Note: This new category essentially pulls together externalizing disorders of various categories in DSM- IV- TR; movement toward dimensional classification of categories you are likely to see in future DSM revisions

68 Substance- Related & Addic3ve Disorders Rids of Abuse and Dependence Criteria Adds craving in criteria Drops recurrent legal problems from criteria that was present in DSM- IV- TR Drops polysubstance diagnosis In DSM- IV- TR needed l of 4 symptoms for substance abuse and 3 or 7 for substance dependence. Now need 2 of 11 symptoms from criteria set Specifiers for severity, early or partial or full remission Types: alcohol, caffeine, cannabis, hallucinogen, phencyclidine, inhalants, opioids, sedative- hypnotic- anxiolytic, stimulants, cocaine, tobacco, non- substance (gambling)

69 Substance- Related & Addic3ve Disorders Problematic pattern of use with at least 2 of the following occurring within a 12 month period: 1) using larger amounts than intended 2) unsuccessful attempts to stop or control substance use 3) spending a great deal of time obtaining, using, or recovering from the effects of the substance 4) craving or strong urge to use substance 5) failure to fulfill major role obligations at work, home, or school 6) continued use despite recurrent substance- related social or interpersonal problems

70 Substance- Related & Addic3ve Disorders 7) important activities given up or reduced because of substance use 8) use in physically hazardous situations (e.g., drunk driving) 9) continued use despite substance- related physical or psychological problems 10) tolerance 11) withdrawal

71 Medica3on- Induced Movement Disorders & Other Adverse Effects of Medica3on Neuroleptic- Induced Parkinsonism Neuroleptic Maglignant Syndrome Tardive Dyskinesia, Dystonia, Akathisia Antidepressant Discontinuation Syndrome Others

72 Personality Disorders Controversial area amongst the experts. Clearly some wanted to change this categorical classification to a dimensional approach but the votes weren t there so this section is largely unchanged. Alternate DSM 5 Model for Personality Disorders in Section III and very likely to become the new classification for personality disorders the next time revisions occur dimensional approach Keeps Cluster A (paranoid, schizoid, schizotypical), Cluster B (antisocial, borderline, histrionic, narcissistic) and Cluster C (avoidant, dependent, obsessive- compulsive) category system and respective criteria

73 Anxiety Disorders Generalized Anxiety Disorder Specific Phobia Panic Disorder Agoraphobia Social Anxiety Disorder (Social Phobia) Separation Anxiety Disorder (not just for kids anymore) Selective Mutism

74 Anxiety Disorders PTSD and OCD no longer in this section; includes Separation Anxiety Disorder & Selective Mutism No longer requires those over 18 realize their anxiety excessive or unreasonable; just out of proportion to the danger or threat of the situation 6 most duration requirement applies to all, not just those under 18 Social Phobia has performance only specifier GAD same as in DSM- IV- TR Agoraphobic independent diagnosis; uncoupled from Panic Disorder Combine Panic Disorder with or without agroaphobia into one Panic Disorder Criteria

75 Feeding & Ea3ng Disorders Pica Rumination Disorder Avoidant/Restrictive Food Intake Disorder Anorexia Nervosa; specify restricting or binge- eating/ purging type Bulimia Nervosa Binge- Eating Disorder (new) Other Specified/Unspecified Feeding or Eating Disorder

76 Feeding & Ea3ng Disorders Combines kid and adult eating/food disorders New Binge- Eating Disorder: criteria of on average once a week over last three months includes more people than before this diagnostic bar lowered No longer need amenorrhea for Anorexia Nervosa Dx and use Body Mass Index versus 85 th percentile criteria Bulimia Nervosa binge requirement lowered from twice a week to once weekly Note: issue is not gaining or losing weight per se as in obesity

77 Obsessive- Compulsive & Related Disorders Obsessive- Compulsive Disorder (focus on urges, not impulses). Specify degree of insight. No longer requires the patient to recognize symptoms are excessive or unreasonable Body Dysmorphic Disorder (in this section, not in Somatic Disorders section; adds with muscle dysmorphia specifier for those body builders Hoarding (new) Trichotillomania (moved here) Excoriation (Skin- Picking) Disorder Substance/Medication- Induced OCD & Related Disorder; specify during intoxication or withdrawal OCD & Related Disorder Due to Another Medical Condition Specified/Unspecified OCD & Related Disorder

78 Trauma & Stress- Related Disorders Reactive Attachment Disorder Disinhibited Social Engagement Disorder (new) Posttraumatic Stress Disorder Acute Stress Disorder (specify if experienced directly, witnessed, or experienced indirectly) Adjustment Disorders Note: Adjustment Disorders no longer have separate category, moved here. Symptom class remains: anxiety, depressed, mixed. These are stress- response syndromes Kids and Adult Disorders from DSM- IV- TR combined here

79 PTSD: Lots of Changes Diagnostic thresholds lowered for children and adolescents with new, separate criteria for children under 6 Criteria says experienced first hand repeated or extreme exposure to the aversive details of the traumatic event. Permits lst responders and even therapists dealing with crisis intervention/debriefing/trauma work to be vulnerable to PTSD effects. Is bar appropriate or too low? Says not due to exposure through electronic media, TV, movies or pictures unless exposure is work- related. How about kids watching CNN 9/11 happenings over and over again? Eliminates subjective reaction to PTSD event in criteria (experiencing fear or helplessness or horror)

80 Other Changes/Criteria: Read Your DSM 5 Neurocognitive Disorders Sexual Dysfunctions Sleep- Wake Disorders Gender Dysphoria Paraphilic Disorders Dissociative Disorders Elimination Disorders V and Z Codes

81 The End Thanks hope it was helpful! LTL