DSM 5Changes that may affect adolescent care.

DSM-I (1952)132 pages

Mental disorders as “reactions”

Definitions were simple, brief paragraphs with prototypical descriptions

DSM-II (1968)134 pages

“Reaction” terminology dropped

Users encouraged to record multiple psychiatric diagnoses (in order of importance) and associated physical conditions

Coincided with ICD-8 (first time ICD included mental disorders)

DSM-III (1980)494 pp

Descriptive and neutral (“atheoretical”) regarding etiology.

Coincided with ICD-9.

Multiaxial classification system.

Goal to introduce reliablilty.

DSM-IV (1994)886 pp

Inclusion of a clinical significance criterion

New disorders introduced (e.g., Acute Stress Disorder, PTSD, Bipolar II Disorder, Asperger’s Disorder), others deleted (e.g., Cluttering, Passive-Aggressive Personality Disorder).

DSM-5 (2013)947 pages“5” instead of “V” Anticipates change e.g. DSM 5.1 … 5.2 …

Work Groups were to consider:⃝�Dimensional measures.

◦ e.g. severity scales ◦ or cross-cutting across disorders

⃝�Culture/gender issues.

NOS used in DSM IV = 41Other/Unspecified used in DSM-5 =65

(To match ICD-10)

Main DSM 5 Categories

Neurodevelopmental Disorders

Schizophrenia Spectrum and Other Psychotic Disorders

Bipolar and Related Disorders

Depressive DisordersAnxiety DisordersObsessive-Compulsive

and Related DisordersTrauma and Stressor

Related DisordersDissociative DisordersSomatic Symptom

DisordersFeeding and Eating

Disorders

Elimination DisordersSleep-Wake DisordersSexual DysfunctionsGender DysphoriaDisruptive, Impulse

Control, and Conduct Disorders

Substance Use and Addictive Disorders

Neurocognitive DisordersPersonality DisordersParaphilic DisordersOther Disorders

New Disorders

⃝�Social (Pragmatic) Communication Disorder

⃝�Disruptive Mood Dysregulation Disorder

⃝�Premenstrual Dysphoric Disorder

⃝�Hoarding Disorder⃝�Excoriation (Skin‐Picking)

Disorder⃝�Disinhibited Social Engagement

Disorder (split from Reactive Attachment Disorder)

⃝�Binge Eating Disorder ⃝�Central Sleep Apnea

⃝�Sleep-Related Hypoventilation

⃝�Rapid Eye Movement Sleep Behavior Disorder

⃝�Restless Legs Syndrome

⃝�Caffeine Withdrawal

⃝�Cannabis Withdrawal

⃝�Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other Medical Conditions)

⃝�Mild Neurocognitive Disorder

Eliminated

⃝�Sexual Aversion Disorder

⃝�Polysubstance-Dependence

Combined

⃝�Language Disorder◦ Expressive Language Disorder ◦ & Mixed Receptive Expressive Language Disorder

⃝�Autism Spectrum Disorder ◦ Autistic Disorder, ◦ Asperger’s Disorder, ◦ Childhood Disintegrative Disorder, ◦ Rett’s disorder

⃝�Pervasive Developmental Disorder-NOS) Specific Learning Disorder

◦ Reading Disorder, ◦ Math Disorder, ◦ Disorder of Written Expression

⃝�Delusional Disorder ◦ Shared Psychotic Disorder◦ & Delusional Disorder

Combined⃝�Panic Disorder

◦ Panic Disorder Without Agoraphobia

◦ Panic Disorder With Agoraphobia

⃝�Dissociative Amnesia ◦ Dissociative Fugue ◦ Dissociative Amnesia

⃝�Somatic Symptom Disorder ◦ Somatization Disorder◦ Undifferentiated Somatoform

Disorder◦ Pain Disorder

⃝�Insomnia Disorder ◦ Primary Insomnia ◦ Insomnia Related to Another

Mental Disorder

⃝�Hypersomnolence Disorder ◦ Primary Hypersomnia◦ Hypersomnia Related to Another Mental

Disorder⃝�Non-Rapid Eye Movement Sleep

Arousal Disorders ◦ Sleepwalking Disorder◦ Sleep Terror Disorder

⃝�*Substance* Use Disorder◦ *Substance* Abuse◦ *Substance* Dependence

⃝�Stimulant Use Disorder◦ Cocaine Abuse/Dependence◦ Amphetamine Abuse/Dependence

Major Changes Change Comment

Elimination of multiaxial system and GAF Clinicians wanted simplified, diagnosis-based system; distinctions between Axis I and Axis II disorders were never clearly justified; clinicians can still specify external stressors; new assessment measures will be introduced

Establishes 20 diagnostic classes or categories of mental disorders

Categories based on groupings of disorders sharing similar characteristics; some categories represent spectrums of related disorders

Introduction of new diagnostic category of Neurodevelopmental Disorders to include Autism Spectrum Disorder and ADHD and other disorders reflecting abnormal brain development

Increasing emphases on neurobiological bases of mental disorders and the developing understanding that abnormal brain development underlies many types of disorders

Major Changes

Change Comment

Introduces more dimensionality (severity ratings) but does not restructure personality disorders as some had proposed

Major changes in personality disorders held over until next revision, the DSM 5.1 (or maybe 5.2)

Roman numerals dropped: DSM-5, not DSM-V Allows for easier nomenclature for midcourse revisions, 5.1, 5.2, etc.

Removes obsessive-compulsive disorder from category of Anxiety Disorders and places it in new category of Obsessive-Compulsive and Related Disorders

Recognizes a spectrum of obsessive-compulsive type disorders, including body dysmorphic disorder; however, anxiety remains the core feature of OCD, so questions remain about separating it from anxiety disorders

Change Comment

Removes ASD and PTSD from Anxiety Disorders and places them in new category of Trauma and Stressor-Related Disorders

Groups all stress-related psychological disorders under the same umbrella; Adjustment Disorders may now be coded in context of traumatic stressors

Creates new diagnostic category of Substance-Related and Addictive Disorders

Now includes Gambling Disorder (previously Pathological Gambling) but other forms of nonchemical addiction, such as compulsive Internet use and compulsive shopping, don’t make it into the manual and remain under study

Eliminates distinction between substance abuse and dependence disorders, collapsing them into single category of substance use disorders

Recognizes that there is no clear line between substance abuse and dependence disorders; also brings certain compulsive patterns of behavior into a spectrum of addictive disorders

Major Changes

Change Comment

Provides a means of rating severity of symptoms, such as for ASD

Encourages clinicians to recognize the dimensionality of disorders

Greater emphasis on comorbidity; e.g., use of anxiety ratings in diagnosing depressive and bipolar disorders

Provides more explicit recognition of comorbidity in having clinicians rate level of anxiety in mood disorders

Major Changes

Change Comment

Elimination of term “somatoform disorders” (now Somatic Symptom and Related Disorders)

Eliminates a term few people understood (somatoform disorders) and now emphasizes the psychological reactions to physical symptoms, not whether they are medically based

Reorganization of mood disorders into two separate diagnostic categories of Depressive Disorders and Bipolar and Related Disorders

No major changes anticipated, but no clear basis for eliminating umbrella construct of mood disorders

Major Changes

Change CommentRemoval of developmental trajectory in organizing classification of disorders: Eliminates category of “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”

May make it easier to diagnose traditional childhood disorders like ADHD and even separation anxiety disorder in adults. Conversely, it may also make it easier to diagnose disorders typically seen in adults, like bipolar disorder, in children.

The new category of Neurodevelopmental Disorders includes many disorders previously classified as childhood onset disorders, however it excludes disorders involving abnormal emotional development, such as separation anxiety disorder and selective mutism.

Where does this new classification leave the study of child psychopathology?

Elimination of bereavement exclusion from major depression

Recognizes that a major depressive episode may overlay a normal reaction to loss; critics claim it may pathologize bereavement

Major Changes

Change Comment

Hypochondriasis dropped as distinct disorder Eliminates the pejorative term “hypochondriasis”; people formerly diagnosed with hypochondriasis may now be diagnosed with Somatic Symptom Disorder if their physical symptoms are significant or with Illness Anxiety Disorder if their symptoms are minor or mild

Factitious Disorder moved to Somatic Symptom and Related Disorders

Associated with other somatic symptom disorders, but is distinguished by intentional fabrication of symptoms for no apparent gain other than assuming medical patient role

Major Changes

A brief History of Substance Use Diagnostics

Over time the definition of the problem has changed…

In the 1930’s the APA called substance abuse a “mentally altered state deemed inappropriate, undesirable, harmful, threatening, or, at minimum, culture-alien."

In the 1960’s the terms ‘misuse’ and ‘abuse’ emerged as distinctly different, and dependence was considered a part of ‘abuse’.

In the 1970’s and 1980’s the terms ‘dependence’ and ‘drug-induced’ were included in official definitions of the problem as separate entities.

A few Definitions…

Clinically Significant Impairment

Decreased functioning in one or more

life area (school, work)

Legal problems

Recurrent social/

interpersonal problems

A few Definitions…

Substance Abuse

Clinically Significant

Impairment

Use in spite of

problems

Excessive risk taking/

ignoring risk

A few Definitions…

Substance Dependence(Addiction)

Clinically Significant

Impairment

Physical symptoms of

tolerance/ withdrawal

Lifestyle centers

around use

Current diagnostics…

At least 1 of 4 symptoms

At least 3 of 7 symptoms

Substance Abuse

Dependence

Either one or the other, maximum number of problems anyone can experience is 7.

Future Diagnosis: Substance Use Disorder

No disorder: 0-1 Symptom Mild: 2-3

symptoms Moderate: 4-5 symptoms Severe: 6 or

more

11 Symptom continuum that ranks Substance Use Disorder from mild to severe.

Prevalence

Prevalence

• NIAAA estimates that alcohol and drug abuse are associated with 100,000 deaths per year and cost society $180 billion per year.• The overall cost of drug abuse rose 5.3 percent annually between

1992 and 2002, increasing from $107.5 to $180.9 billion. The most rapid growth in drug costs came from increases in criminal justice system activities, including productivity losses associated with growth in the population imprisoned due to drug abuse.

Drug use by age Group…

Source: NSDUH 2011

31.5% of young people have used in the past

month

Alcohol use by age…39.8% Of

young people aged 18-25 were

bingeing

Source: NSDUH 2011

All other drugs…

20.6% increase in MJ use since 2007

Source: NSDUH 2011

Adolescent use is on the rise…

65-87% increase in MJ use since 1990

Source: NSDUH 2009

Most commonly Abused Drugs…

1 Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically.

Perception of risk by Adolescents…

Risk perception decreases

with age for ETOH and MJ

Perceived risk among clinicians

Alcohol by far outranks most perceptions of

harm

30

Perc

en

t in

Reco

very

Years from first use to 1+ years abstinence

302520151050

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: Dennis et al 2005 (n=1,271)

20+

0-9*

10-19*

Years

to 1

st T

x G

roups

* p<.05 (different from 20+)

CAREERS OF USE LAST DECADES…

Careers are shorter the sooner they

get to treatment

Careers of use last decades…

31Years from first Tx to 1+ years abstinence

2520151050Perc

en

t in

Reco

very

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: Dennis et al 2005 (n=1,271)

Median duration of 9 years and 3 to 4 episodes of care

Relapse Rates of chronic illnesses

TYPE I DIABETES

DRUG ADDIC TION

HYPERTENSION

ASTHMA

0% 10% 20% 30% 40% 50% 60% 70% 80%Source: McLellan, et al., 2000

50% to 70%

50% to 70%

40% to 60%

30% to 50%

Lapse vs. relapseLapse

Impulsive Short duration Accompanied by guilt Small amount/duration of

use Relatively low

consequence Desire to return to change

process

Relapse Planned Longer duration High defensiveness Large amount/duration of

use Uncertain about desire to

return to change process

The Majority Stay in Tx Less than 90 days

34

Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

52

42

20

33

0

30

60

90

Outpatient IntensiveOutpatient

Short TermResidential

Long TermResidential

Level of Care

Med

ian

Len

gth

of

Sta

y in

Days

DEPRESSIVE DISORDERS ⃝�DISRUPTIVE MOOD DISREGULATION

◦ Severe, age inappropriate temper outbursts 3+x weekly◦ Daily irritable, angry mood 12 months, not asymptomatic 3

months; 2/3 settings◦ Dx between 6-18 years; onset <10 years◦ Not meeting criteria for manic/hypomanic for full day or ODD or

IED◦ (Purpose: Prevent Manic dx & subsequent antipsychotic

medication)

⃝�MAJOR DEPRESSIVE DISORDER◦ “Bereavement exclusion” removed◦ Includes “note”: significant loss may result in some Criterion A

symptoms. MDD may also be considered in context of clinical judgment, history, and cultural norms.

⃝�PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA)

◦ MDD may be present 2 years (previously excluded)

DEPRESSIVE DISORDERS  ⃝�PREMENSTRUAL DYSPHORIC DISORDER

◦ 5 of4+7 symptoms appear in final week before onset of most menses, then improve (lability, irritability, anxiety, depressive, etc. )

⃝�SUBSTANCE/MEDICATION-INDUCED DEPRESSIVE DISORDER◦ Removed Criterion A2:elevated, expansive or irritable mood

⃝�OTHER SPECIFIED DEPRESSIVE DISORDER◦ Lists a few examples

⃝�UNSPECIFIED DEPRESSIVE DISORDER◦ e.g. insufficient information

ANXIETY DISORDERS⃝�“The anxiety must be out of proportion to the

actual danger or threat in the situation”

⃝�This chapter no longer includes OCD and PTSD◦ DSM 5 creates new chapters for OCD and PTSD

⃝�Chapter is arranged developmentally. ◦ Sequenced by age of onset◦ Now includes Separation Anxiety and ◦ Selective Mutism

ANXIETY DISORDERS⃝�Panic Attacks and Agoraphobia are “unlinked” in

DSM- 5

⃝�DSM- IV terminology describing different types of Panic Attacks replaced in DSM-5 with the terms “expected” or “unexpected” panic attack

⃝�Social Anxiety Disorder :◦ “Generalized” specifier in DSM-IV has been

deleted◦ Replaced with “performance only” specifier

OBSESSIVE COMPULSIVE AND RELATED DISORDERS⃝�New chapter created for DSM 5

⃝�Rationale for this chapter grouping:◦ Increasing evidence that these disorders are related to

each other

⃝�New disorders in chapter :◦ Hoarding disorder◦ Excoriation (skin picking) disorder◦ Substance /Medication–induced OCD◦ OCD due to another medical condition

OBSESSIVE COMPULSIVE AND RELATED DISORDERS⃝�Trichotillomania, now termed trichotillomania

disorder (hair pulling), moved to OCD chapter◦ No longer classified as an impulse control disorder.

⃝�Specifiers listed for each OCD disorder◦ Specifier “with poor insight” in DSM- IV has been

expanded in DSM- 5◦ New Specifiers are

1. “with good or fair insight”2. “with poor insight”3. “with absent insight/delusional beliefs”

◦ Intent of these specifiers is to improve differential diagnoses

OBSESSIVE COMPULSIVE AND RELATED DISORDERS⃝�Body Dysmorphic Disorder

◦ A criterion added: “Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others”

⃝�Hoarding Disorder added to DSM-5 ◦ Due to evidence that it is not a variant of OCD; ◦ Evidence that it is a separate diagnosis

⃝�Excoriation Disorder added to DSM-5◦ Based on strong evidence of diagnostic validity and clinical

utility

OTHER SPECIFIED AND UNSPECIFIED OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

DSM-5 includes conditions in this chapter such as:

⃝�Body-focused repetitive behavior disorder ◦ - other than excoriation and trichotillomania

i.e. nail biting, lip chewing

⃝�Obsessional jealousy

TRAUMA- AND STRESSOR-RELATED DISORDERSNew chapter in DSM-5 brings together anxiety disorders that are preceded by a distressing or traumatic event:

⃝�Reactive Attachment Disorder⃝�Disinhibited Social Engagement Disorder (new)⃝�PTSD (includes PTSD for children 6 years and younger)⃝�Acute Stress Disorder⃝�Adjustment Disorders

Disinhibited Social Engagement Disorder:

“The essential feature of disorder is a pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers. This behavior violates the social boundaries of the culture.” DSM-5, p. 269

TRAUMA- AND STRESSOR-RELATED DISORDERSAcute Stress Disorder ⃝�Stressor criterion in DSM -5 is changed:

◦ Criterion requires being explicit whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly.

◦ DSM-IV Criterion A2 regarding reaction to the event- “the person’s response involved intense fear, helplessness, or horror” –has been eliminated

TRAUMA- AND STRESSOR-RELATED DISORDERSChanges in PTSD Criteria⃝�Four symptom clusters, rather than three:

◦ Re-experiencing◦ Avoidance◦ Persistent negative alterations in mood and cognition◦ Arousal: describes behavioral symptoms

⃝�DSM-5 more clearly defines what constitutes a traumatic event:

◦ Sexual assault is specifically included◦ Recurring exposure, that could apply to first

responders

DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS

Oppositional Defiant Disorder⃝�Criteria exhibited “with at least one individual who

is not a sibling”⃝�“Spiteful or vindictive twice in 6 months”⃝�Severity: Mild, moderate, severe ⃝�<5years most days for 6 months; >5 years, weekly

Conduct Disorder ⃝�Adds specifier “With limited prosocial emotions”⃝�Persistently in 12 months (2 of 4)

◦ Lack of Remorse/ guilt ◦ Callous—lack of empathy◦ Unconcerned about performance◦ Shallow or deficient affect

DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS

Intermittent Explosive Disorder⃝�Verbal aggression 2x weekly for 3 months⃝�Destruction or assault: 3x in 12 months⃝�6 years +⃝�Not premeditated

AntiSocial Personality Disorder (criteria in PD chapter) “Dual coded”

⃝�Pyromania⃝�Kleptomania⃝�Other DICCD ⃝�Unspecified DICCD