Nancy M. Birtley, DNP, APRN, PMHCNS-BC, PMHNP-BC Owner, Psychiatric Consultation Services Assistant Teaching Professor, University of Missouri, Columbia DSM-5 Task Force 13 workgroups led by task force member Scientific Review Committee 6 committee members, chair and vicechair Clinical and Public Health Committee 6 committee members, chair and vicechair Council on Psychiatry and Law (American Psychiatric Association [APA], 2013a) 1
Section I DSM-5 Basics Section II- Diagnostic Criteria and Codes Section III- Emerging Measures and Models (APA, 2013a) DSM-5 Basics 2
Lifespan approach Research-driven Coordination with International Classification of Diseases (ICD) Elimination of multi-axial system (APA, 2013a, 2013b; Escobar, 2013; Halter, Rolin-Kenny, & Dzurec, 2013; Kupfer, Kuhl, & Regier, 2013) Ongoing revisions DSM-5.1, DSM-5.2, etc., Current evidence Cultural considerations Cultural Formulation Interview Cross-cutting symptom assessment (APA, 2013a; Halter et al., 2013) 3
Neurodiagnostics Genetic work-ups Neuroimaging Neurochemistry Laboratory CSF Bloodwork Polysomnography (APA, 2013a; Halter et al., 2013; Kudlow, 2013) Not otherwise specified (NOS) is replaced with Not elsewhere classified (NEC) NEC rational and specifiers (APA, 2013a; Halter et al., 2013) 4
Diagnostic Criteria and Codes Neurodevelopmental disorders Schizophrenia spectrum and other psychotic disorders Bipolar and related disorders Depressive disorders Anxiety disorders (APA, 2013a, 2013b) 5
Obsessive-compulsive disorders Trauma- and stressor-related disorders Dissociative disorders Somatic symptom and related disorders (APA, 2013a, 2013b) Feeding and eating disorders Elimination disorders Sleep-wake disorders Sexual dysfunctions Gender dysphoria Disruptive, impulse-control and conduct disorders (APA, 2013a, 2013b) 6
Substance-related and addictive disorders Neurocognitive disorders Personality disorders Paraphilic disorders Other mental disorders (APA, 2013a, 2013b) Medication-induced movement disorders and other adverse effects of medication Other conditions that may be a focus of clinical attention (APA, 2013a, 2013b) 7
Measures and Models Assessment measures World Health Organization Disability Assessment Schedule (WHODAS 2.0) Cultural formulation Alternative DSM-5 model for personality disorders Conditions for further study (APA, 2013a; Halter et al., 2013) 8
Questioned the terms intellectual disability vs. mental retardation Chose the World Health Organization (WHO), International Classification of Diseases (ICD) terminology of Intellectual developmental disorder 9
New nomenclature may reduce stigma Conforms with national and international classification (Halter et al., 2013) Language disorder Speech and sound disorder Formerly phonological disorder Childhood-onset fluency disorder Formerly stuttering Social (pragmatic) communication disorder Cannot coexist with ASD 10
Combines DSM-IV disorders Formerly autistic disorder, Asperger s, childhood disintegrative disorder, and pervasive developmental disorder, nos Deficits in social communication and interaction AND Restricted repetitive behaviors, interests, and activities (RRBs) (APA, 2013a, 2013b; Halter et al., 2013; Kupfer et al., 2013) Prevalence Services and resources Asperger s stigmatized with ASD Research (Halter et al., 2013) 11
Symptoms remain essentially the same Criteria changes Onset prior to 12 years rather than 7 years Comorbid with ASD Symptom threshold allows for adult diagnosis 5 symptoms rather than 6 symptoms for younger persons Subtypes replaced by specifiers Combined Predominantly inattentive Predominantly hyperactive/impulsive 12
Random age of onset Prevalence Adult services Psychostimulant abuse (Halter et al., 2013; Kupfer et al., 2013) Symptoms remain essentially the same Subtypes changed to specifiers Reading Written expression Mathematics (APA, 2013a, 2013b) 13
Treatment options Educational services Legal rights Insurance reimbursement (Halter et al., 2013; Burgess, 2012) Formerly tic disorders Renaming of individual disorders Tourette s disorder (no change) Persistent chronic or motor tic disorder (Formerly chronic motor or vocal tic disorder) Provisional tic disorder (Formerly transient tic disorder) Addition of stereotypic movement disorder (APA, 2013a, 2013b) 14
Subtypes removed: Paranoid Disorganized Catatonic Undifferentiated Residual Bizarre delusion criteria removed Symptom severity developed (Section III) Schizoaffective mood episode to co-occur entire disorder s duration Delusional disorder criteria no longer requires delusions be non-bizarre Specifier for bizarre delusions Catatonia specifier Can be diagnosed with depressive, bipolar, and psychotic disorders, within context of medical disorder, or as an other specified diagnosis 15
Research Improved clarity Emphasis on change in activity or mood Mixed episode diagnosis replaced with mixed features specifier Anxious distress specifier 16
Research Prevalence Disruptive mood dysregulation disorder Includes children up to age 18 Reduces over-diagnosed BD Premenstrual dysphoric disorder New diagnosis Persistent depressive disorder Replaces dysthymia and chronic specifier for MDD (APA, 2013a, 2013b; Halter et al., 2013; Kupfer et al., 2013; Sorrell, 2013) 17
Removal of bereavement exclusion New specifiers Anxious distress Mixed features Mood-congruent psychosis Mood-incongruent psychosis Peripartum onset Obsessive-compulsive disorder (OCD) removed from chapter Post-traumatic stress disorder (PTSD) removed from chapter Panic disorder and agoraphobia now separate diagnoses (APA, 2013a, 2013b; Halter, 2013) 18
Panic attack specifier Can be included with applicable diagnoses Panic attack descriptors Unexpected panic attacks Expected panic attacks Specific phobia Duration of 6 months applies to all ages Subtypes now specifiers Animal, natural environment, bloodinjection, situational, other Social anxiety disorder Duration of 6 months applies to all ages Generalized specifier replaces performance only 19
Separation anxiety disorder Applies to all ages Duration of 6 months applies Selective mutism Research and prevalence Six month duration criteria reduces inclusion of transient fears (APA, 2013a, 2013b) Adult separation anxiety disorder prevalence greater than children (Shear, Jin, Ruscio, Walters, & Kessler, 2006) Agoraphobia not often associated with panic 20
Obsessive-compulsive disorder Insight specifiers Body dysmorphic disorder Moved to OCD chapter Hoarding disorder New diagnosis Trichotillomania Excoriation disorder New diagnosis Substance/medication-induced OCD & OCD due to another medical condition Other specified and unspecified obsessive-compulsive and related disorders (APA, 2013a, 2013b) 21
Prevalence Research Stressors may be experienced directly, indirectly, or witnessed Symptom categories Intrusion, negative mood, dissociation, avoidance, and arousal Acute stress disorder Post-traumatic stress disorder Separate criteria and thresholds for children (APA, 2013a, 2013b; Halter, 2013) 22
Reactive attachment disorder Disinhibited social engagement disorder Research Prevalence 23
Depersonalization/ derealization disorder Formerly dissociative disorder Dissociative fugue Specifier Dissociative identity disorder Observed or reported identity disruption Cultural variances Research Prevalence 24
Somatic symptom disorder Medical diagnosis or unexplained symptoms Abnormal thoughts, feelings, and behaviors Illness anxiety disorder Hypochondriasis Pain disorder Eliminated (APA, 2013a, 2013b; Frances, 2013; Frances & Chapman, 2013; Halter et al, 2013) Functional neurological symptom disorder Conversion disorder Emphasis upon neurological exam Psychological factors affecting other medical conditions Factitious disorder (APA, 2013a, 2013b; Frances & Chapman, 2013; Halter et al., 2013) 25
Justifies treatment of worry-warts People with real medical illnesses will be diagnosed with mental disorder Loss of service and employment benefits Research Prevalence (APA, 2013a, 2013b; Frances, 2013; Frances & Chapman, 2013; Halter et al., 2013) Pica and rumination disorder Inclusive of any age Avoidant/restrictive food intake disorder Broader presentation Anorexia nervosa Amenorrhea requirement removed Bulimia nervosa Change in binge eating frequency 26
Binge-eating disorder Moved from DSM-IV appendix Change in binging frequency Labeling common eating behavior Research Prevalence 27
Separate chapter Complete overhaul Removal of the term primary Breathing-related sleep disorders Obstructive sleep apnea Central sleep apnea Sleep-related hypoventilation 28
Rapid eye movement sleep behavior disorder and restless leg syndrome Circadian rhythm sleep-wake disorders Advanced sleep phase syndrome Irregular sleep-wake type Non-24-hour sleep wake type Biological measures Research Prevalence 29
Formerly sexual and gender identity disorders Require 6 month duration Subtypes Lifelong vs. acquired Generalized vs. situational Gender-specific sexual dysfunctions (APA 2013a, 2013b; Halter et al., 2013) Female sexual interest/arousal disorder Sexual aversion disorder removed Genito-pelvic pain/penetration disorder 30
Research Prevalence New diagnostic class Neither sexual dysfunction nor paraphilia Diagnosed by mental health professionals, but often treated medically Separate criteria for children, adolescents, and adults Cross-gender identification and aversion toward one s gender merged Post-transition specifier 31
Insurance coverage Research Prevalence New chapter Antisocial personality disorder ADHD Oppositional defiant disorder Three types Conduct disorder no longer excluded Frequency criteria Severity rating 32
Intermittent explosive disorder Physical aggression Verbal aggression Non-destructive/non-injurious physical aggression Frequency criteria Minimum age of 6 years Conduct disorder Specifier of limited prosocial emotions Research Prevalence Willful vs. impulsive (Halter et al., 2013) 33
Gambling disorder Cannabis and Caffeine withdrawal Tobacco use disorder No distinction between substance use and dependence Recurrent legal problems removed Craving/strong desire/urge to use added Criteria threshold changed Severity criteria and remission rating (APA, 2013a, 2013b; Halter et al., 2013, Peer et al., 2012) More relaxed criteria offer early intervention (Halter et al., 2013) Inappropriate labeling and stigma (Halter et al., 2013) Prevalence (Peer et al., 2012; Dawson, Goldstein, & Grant, 2013) Research 34
Delirium criteria updated Change from prior level of functioning Major neurocognitive disorder Substantial cognitive and functional decline Mild neurocognitive disorder Gray zone (mild cognitive impairment) (APA, 2013a, 2013b; Halter et al., 2013; Mitchell, 2013; Sorrell, 2013) Etiological subtypes Alzheimer s Frontotemporal lobar degeneration Lewy body disease Vascular disease Traumatic brain injury Substance/medication use HIV infection Prion disease Parkinson s disease Huntington s disease (APA, 2013a, 2013b) 35
Early identification of dementia offers early intervention and planning Labeling normal aging as dementia Adding anxiety for non-curable diseases Terminology unfamiliar to public Criteria developed by the Alzheimer s Association and National Institute of Health still use dementia (APA, 2013a, 2013b; Halter et al., 2013; Horrell, 2013) Extreme overhaul of personality disorders removed from main text 36
New chapter Criteria essentially the same Addition of term disorder Specifiers In a controlled environment In remission Threat to others Research Prevalence Validating paraphilias as normal 37
Medication-induced vs. neurolepticinduced Neuroleptic-induced (and other medication-induced) Parkinsonism Neuroleptic malignant syndrome Medication-induced Acute dystonia Acute akathisia Postural tremor (APA, 2013a, 2013b) Tardive dyskinesia Neuroleptic withdrawal-emergent dyskinesia Tardive dystonia Tardive akathisia Antidepressant discontinuation syndrome (APA, 2013a, 2013b) 38
Research Prevalence A Google search of DSM-5 and controversy resulted in 776,000 results this is increased from >600,000 results documented in Halter et al. (2013) Allen Frances, Chair of DSM-IV task force offers much criticism of the DSM-5 (Porter, Mulder, & Lacey, 2013) 39