CMASA 2016 Stellenbosch. Dr David Swingler 02 June Acknowledgements

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1 CMASA 2016 Stellenbosch Dr David Swingler 02 June 2016 Acknowledgements

2 DSM-5 History & development What s new Concepts Overview A speed-dating surf through the disorders With particular reference to conditions of interest to Case Managers such as ADHD, Depression, Bipolar Disorder, Substance Use and Neurocognitive Disorders

3 DSM a brief history USA 1840 Census = idiocy & insanity USA 1880 Census = 7 disorders DSM-I (1952) Adolf Meyer / ICD-6 = 26 DSM-II (1968) reaction withdrawn / ICD-8 DSM-III (1980) New systems / ICD-9 DSM-III-R (1987) DSM-IV (1994) Approximation with ICD-10 DSM-IV-TR (2000) DSM-5 (2013) ICD-11 due 2017/8

4 Organisa6onal Structure Harmonization with ICD-11 Includes ICD-9-CM and ICD-10-CM codes Developmental / Lifespan approach Sequential Order starting with Neurodevelopmental Disorders, ending with Neurocognitive Disorders Dimensional approach Spectra Personality

5 The Mul6-Axial System RIP Nonaxial documentation of diagnosis (formerly Axis I,II and III) Principal Diagnosis: The condition chiefly responsible for current presentation. Followed by others in order of focus of attention and treatment. Can use provisional as a specifier where there is a strong presumption that full criteria will be met. Record important psychosocial and contextual factors (formerly Axis IV) using ICD-9-CM V codes or ICD-10-CM Z codes Disability (formerly Axis V): GAF dropped. WHODAS 2.0 included for further study. 36 item, self-administered scale. Rates difficulty in specific areas of functioning in past 30 days. Simple or complex methods for calculating summary score.

6 Chapters 1 Neurodevelopmental Disorders Schizophrenia-Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma and Stressor-Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions

7 Chapters 2 Gender Dysphoria Disruptive, Impulse-Control, and Conduct Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders Personality Disorders 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

8 Emerging Measures and Models Alternative DSM-5 Model for Personality Disorders Conditions for further study Attenuated Psychosis Syndrome Depressive Episodes with Short-Duration Hypomania Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Neurobehavioural Disorder Associated with Prenatal Alcohol Exposure Suicidal Behavior Disorder Non-suicidal Self-Injury

9 Neurodevelopmental Disorders Mental Retardation becomes Intellectual Disability Autism Spectrum Disorder encompasses (social/ behaviour) Autism Asperger s Rett s Pervasive developmental disorder NOS

10 Neurodevelopmental Disorders ADHD Examples added to facilitate application of criteria Often has difficulty waiting turn (e.g. waiting in line) Age of onset relaxed to < 12 (c.f. 7 years) Subtypes replaced with specifiers Comorbidity with Autism Spectrum now allowed Adult variant formalised and less restrictively at 5/9 (c.f. 6)

11 Schizophrenia Spectrum technical changes Schizophrenia *Spectrum & Other Psychotic Disorders Criterion A SZ subtypes eliminated Schizoaffective Disorder Delusional Disorder Catatonia Schizotypal (Personality) Disorder

12 DSM-5 Mood Disorders DSM-IV Mood Disorders split into Bipolar and Related Disorders Depressive Disorders Two new and contentious disorders Disruptive Mood Dysregulation Disorder Premenstrual Dysphoric Disorder

13 Bipolar and Related Disorders Bipolar I Disorder Defined by mania Mania defined by Elevated/expansive OR irritable mood for 7 days (or hospitalised) New: AND increased goal directed activity OR energy PLUS 3 (4) of 7 symptoms Bipolar II Disorder Rooted in Major Depressive Episode/s With Hypomanic Episode/s, defined by Elevated/expansive OR irritable mood for 4 days (or hospitalised) New: AND increased goal directed activity OR energy PLUS 3 (4) of 7 symptoms

14 Depressive Disorders MDE Criterion A unchanged 5/9 of which at least one of depressed mood or loss of interest or pleasure x 2 weeks Mixed Episode exclusion dropped specifier Distress/Dysfunction criterion elevated C to B Bereavement exclusion DROPPED Was 2/12 Now a Note with clinical judgement discretion Dysthymia now Persistent Depressive Disorder Folded into chronic major depressive disorder

15 New Depressive Disorders! Disruptive Mood Dysregulation Disorder To address over-diagnosis of Bipolar Disorder < 18 years Temper outbursts Severe, recurrent Verbal &/or behavioural Out of proportion in intensity/duration to situation/provocation Inconsistent with developmental level > 3 /week With background irritable/angry mood For at least a year, with no 3/12 period event-free Onset < 10 years First diagnosis 6-18 years Exclusions and Notes

16 New Depressive Disorders! Premenstrual Dysphoric Disorder A: Majority of menstrual cycles At least 5 Sx (of 11) from B + C below In last week prior to menses Improve within a few days of onset of menses Minimal/absent in the week post menses

17 New Depressive Disorders! 5 of 11 symptoms for B & C combined B: At least 1 of 4 Marked affective lability Marked irritability or anger or interpersonal conflicts Marked depressive mood / hopelessness / self-deprecation Marked anxiety/tension/being keyed up/on edge C: At least 1 of 7 Decreased interest in usual activity Difficulty concentrating Lethargy Appetite, overeating, food cravings Sleep disturbance: hyper-, insomnia Overwhelmed, out of control Physical symptoms: breast, joint/muscle, bloating, GOW

18 Anxiety Disorders technical changes Specific Phobia & Social Phobia Panic attacks: now a specifier to all DSM-5 Panic Disorder and Agoraphobia un-linked Separation Anxiety Disorder and Selective Mutism now find a home here

19 Obsessive Compulsive & Related Disorders Obsessive-Compulsive Disorder the anchor Body Dysmorphic Disorders move in New: Hoarding Disorder Excoriation (Skin-Picking) Disorder Substance/Medication induced Due to Another Medical Condition Trichotillomania gets (Hair-Pulling Disorder) clarifier

20 Trauma- & Stressor-Related Disorders Acute/Posttraumatic Stress Disorder Trauma more explicit Disempowerment requirement removed Three clusters Re-experience Avoidance/Numbing Arousal Becomes four, as #2 split Avoidance Persistent negative alteration in cognition & mood Threshold for children & adolescents lowered, now < 6 years

21 Soma6c Symptom & Related Disorders

22 DSM-5

23 Anorexia Nervosa DSM IV-TR: Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth) leading to body weight less than 85% of that expected DSM-5 Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

24 Bulimia Nervosa DSM-5 A. Recurrent episodes of binge eating B. Recurrent inappropriate compensatory behaviour C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. D. Self-evaluation E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

25 Binge Ea6ng Disorder A. Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following: 1. eating large amounts 2. A sense of lack of control over eating A. The binge eating episodes are associated with 3 or more of the following: 1. eating much more rapidly than normal 2. eating until uncomfortably full 3. eating large amounts of food when not feeling physically hungry 4. eating alone / feeling embarrassed by how much one is eating 5. feeling disgusted with oneself, depressed, or very guilty afterward B. Marked distress regarding binge eating is present. C. The binge eating occurs, on average, at least once a week for 3 months. D. The binge eating is not associated with repeated use of inappropriate compensatory behaviour as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa

26 SLEEP-WAKE DISORDERS DSM-5

Sleep-Wake Disorders (Previously Sleep Disorders) DSM-IV-TR Primary Insomnia (name changed) Primary Hypersomnia (name changed) Narcolepsy (same name) Breathing-Related Sleep Disorder (divided into 3

27 Sleep-Wake Disorders (Previously Sleep Disorders) DSM-IV-TR Primary Insomnia (name changed) Primary Hypersomnia (name changed) Narcolepsy (same name) Breathing-Related Sleep Disorder (divided into 3 disorders) Circadian Rhythm Sleep Disorder (name changed) Nightmare Disorder (same name) Sleep Terror Disorder (combined into Non REM Sleep Arousal Disorder) Sleepwalking Disorder (combined into Non REM Sleep Arousal Disorder) Sleep Disorders Related to Another Mental Disorder (removed) Sleep Disorders Due to a General Medical Condition (removed) Substance-Induced Sleep Disorder (name change) DSM-5 Insomnia Disorder Hypersomnolence Disorder Narcolepsy Breathing-Related Sleep Disorder - Obstructive Sleep Apnea Hypopnea - Central Sleep Apnea - Sleep-Related Hypoventilation Circadian Rhythm Sleep-Wake Disorder Non-Rapid Eye Movement Sleep Arousal Disorder Nightmare Disorder Rapid Eye Movement Sleep Behaviour Disorder Restless Legs Syndrome Substance/Medication-Induced Sleep Disorder

28 Substance Related and Addictive Disorders in DSM-5 Previously Substance-Related Disorders in DSM-IV

29 Summary of Changes Removal of the distinction between substance abuse and dependence in DSM-IV DSM-5: Criteria are provided for substance use disorder (SUD) they are a combination of abuse and dependence criteria from DSM-IV (that required a threshold of 1-2 for abuse, and 3 or more for dependence) The threshold for SUD in DSM-5 is two or more (of 11) Severity of DSM-5 SUD is based on the number of criteria Ø 2-3 criteria indicate a mild disorder Ø 4-5 criteria, a moderate disorder and Ø 6 or more a severe disorder Cannabis- & caffeine-withdrawal are new for DSM-5

30 Summary continued Criteria groupings for Criterion A: Impaired control 1-4 Social impairment 5-7 Risky use 8-9 Physiological i.e. tolerance and withdrawal Lastly Gambling Disorder included & Internet gaming is described Behavioural addictions: sex addiction, exercise addiction and shopping addiction are not included due to insufficient peer-reviewed evidence on diagnostic criteria

31 Substance-Induced Disorders Remain the same for DSM-IV and DSM-5 SUBSTANCE INDUCED DISORDERS Substance Intoxication and Withdrawal Substance/Medication- Induced Mental Disorders

32 Neurocognitive Disorders of DSM-5

33 Major changes in DSM-5 DSM-IV-TR: Delirium, Dementia and Amnestic disorders DSM-5: Delirium retained Dementia and Amnestic Disorders subsumed under the newly named entity Major Neurocognitive Disorder the term dementia is not disallowed where the term is standard Addition of a new diagnostic category: Minor Neurocognitive Disorder

Delirium: main change DSM-IV A. Disturbance of consciousness (i.e.. reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention DSM-5 A.

34 Delirium: main change DSM-IV A. Disturbance of consciousness (i.e.. reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention DSM-5 A. Disturbance in attention (reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment).

35 Neurocognitive Disorders Major vs Mild 1. Severity Major and Mild NCDs exist on a spectrum of cognitive and functional impairment 2. Independence Relates to the individual's level of independence in everyday functioning Mild NCD will have preserved independence Major NCD will have impairment of sufficient severity so as to interfere with independence. 3. Usually a continuum with evolution The distinction between Major and Mild NCD is inherently arbitrary, and the disorders exist along a continuum.

36 Major Neurocognitive Disorder Diagnostic Criteria A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on: 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and 2. A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. B. The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications). C. The cognitive deficits do not occur exclusively in the context of a delirium D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

37 Diagnostic Criteria Mild Neurocognitive Disorder A. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual motor, or social cognition) based on: 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function; and 2. A modest impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. B. The cognitive deficits do not interfere with capacity for independence in everyday activities (i.e., complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater effort, compensatory strategies, or accommodation may be required). C. The cognitive deficits do not occur exclusively in the context of a delirium. D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

38 Domain Tasks Neurocognitive Disorders Domains Complex attention Major: diminished, multiple stimuli Mild: takes longer Executive function Major: abandon complex activities Mild: effort, multi-tasking Learning/memory Major: repeat self in conversation Mild: recent events, occasionally repeats Language Major: anomia, paraphasias Mild: naming, word finding Perceptual-Motor Major: can t drive, navigation, confused at dusk Mild: notes, maps, follows, effort Social cognition Major: insensitivity social contexts Mild: subtle personality change, empathy

39 Major or Mild NCD: Specify Alzheimer s disease Frontotemporal lobar degeneration Lewy body disease Vascular disease Traumatic brain injury Substance/medication-induced HIV infection Prion disease Parkinson s disease Huntington s disease Another medical condition / Multiple aetiologies

40 Not dealt with Sexual Dysfunctions Gender Dysphorias Paraphilic Disorders Disruptive, Impulse-Control, and Conduct Disorders Personality Disorders Medication-induced Movement Disorders V-codes Conditions for further study

41 Q & A

DSM-5 Table of Contents

DSM-5 Table of Contents DSM-5 Classification Preface Section I: DSM-5 Basics Introduction Use of DSM-5 Cautionary Statement for Forensic Use of DSM-5 Section II: Essential Elements: Diagnostic Criteria