DSM 5.0(Just in Time or Too Late)

Laurence P. Karper, M.D.Vice-Chair, Department of

Psychiatry

What I’m not Going to Do

• I will not discuss subspecialty areas that require focused review and attention– Neurodevelopmental Disorders– Neurocognitive Disorders– Childhood-Onset Disorders

• I am only touching upon other areas without clinical relevance to general inpatient or outpatient practice or that merit more in-depth treatment (e.g. Somatic Symptoms and Related Disorders, Trauma- and Stressor-Related Disorders, etc.)

• I will not focus on ICD 10, Forensic, or Insurance Issues

Insurance Considerations

• Not the focus of this presentation• DSM-5 is fully compatible with ICD-9 and 10

but the transition to ICD-10-CM is very complicated and will need further delineation

• Crosswalks are currently available for your delectation

• Since the codes are what drives insurance use them and list the name separately (e.g. hoarding disorder vs. OCD; both 300.3)

DSM Editions Page Count

1950 1960 1970 1980 1990 2000 20100

200

400

600

800

1000

1200

DSM-IDSM-II

DSM-III DSM-III-R

DSM-IV

DSM-IV-R

DSM-5

For More Information

• http://www.psychiatry.org/dsm5– Assessment Measures– Extensive Fact Sheets– Videos of Thought Leaders– News Articles

Where is the Mind in DSM-5?

Does not appear in the “Glossary of Technical Terms” or the Index

Definition of a Mental Disorder

A mental disorder is 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…. 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.

Who/What is Disordered?

“All drugs that are taken in excess have in common direct activation of the brain reward system…. They produce such an intense activation of the reward system that normal activities may be neglected. …[The] roots of substance use disorders for some persons can be seen in behaviors long before the onset of actual substance use itself.” DSM-5, p. 481.

Disturbance of Behavior

SocialDeviance

Stress Response

Mental Disorder

The Primacy of Reliability

• A measure is said to have a high reliability if it produces similar results under consistent conditions.

• Validity is the extent to which a concept, conclusion, or measurement is well-founded and corresponds accurately to the real world.

Multiaxial System: Deleted

• “DSM-5 has moved to a non-axial documentation of diagnosis.” p.16

• Never needed in DSM-IV-TR• GAF dropped due to “conceptual lack of clarity” and

“questionable psychometrics in routine practice.” Instead WHODAS 2.0 is to be used

• The principal diagnosis (reason for visit) is listed first• In the case of mental disorders due to another medical

condition “ICD coding rules requires that the etiological medical condition be listed first.” p.23

• The phrase “general medical condition” is replaced in DSM-5 with “another medical condition” where relevant across all disorders.

Changes: Schizophrenia• Removal of subtypes of schizophrenia (dimensional measures)• Two changes were made to DSM-IV Criterion A for schizophrenia. The first

change is the elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing). In DSM-IV, only one such symptom was needed to meet the diagnostic requirement for Criterion A, instead of two of the other listed symptoms. This special attribution removed due to the non-specificity of Schneiderian symptoms and the poor reliability in distinguishing bizarre from non-bizarre delusions. Therefore, in DSM-5, two Criterion A symptoms are required for any diagnosis of schizophrenia. The second change is the addition of a requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech. At least one of these core “positive symptoms” is necessary for a reliable diagnosis of schizophrenia

Changes: Bipolar Disorders

• Bipolar disorders now include both changes in mood and changes in activity or energy

• Mixed Type is Deleted• Specifiers “with mixed features” and “anxious

distress” are added

Changes: Depressive Disorders

• Premenstrual Dysphoric Disorder (625.4) is promoted from Appendix B

• Dysthymia is replace by Persistent Depressive Disorder (dysthymia) (300.4)

• Specifiers “with mixed features” and “anxious distress” are added

• Bereavement exclusion omitted

Changes: Substance Use Disorders• Note Substance-Specific Issues– No Withdrawal for PCP, Hallucinogens– No Caffeine Use Disorder

• Severity Modifier is Key– Mild: 2-3 Symptoms– Moderate: 4-5 Symptoms– Severe: >5 Symptoms

• If medications are taken under appropriate medical supervision Tolerance/Withdrawal are not used for diagnosis

Substance-Related Use Disorders

• Use of larger amounts or over a longer period than was intended

• Persistent desire of unsuccessful efforts to cut down or control

• A great deal of time spent to obtain or recover from use

• Craving, or a strong desire or urge to use• Failure to fulfill major role obligations

Substance-Related Use Disorders

• Use despite social or interpersonal problems• Social, occupational, or recreational activities

given up or reduced• Use in situations that are physically hazardous• Use despite persistent or recurrent physical or

psychological problems• Tolerance• Withdrawal

Common DiagnosesDSM-IV-TR DSM-5

Bipolar Disorder, Mixed Type

296.60 Bipolar Disorder, Manic with mixed features, with anxious distress

296.40

Alcohol Abuse 305.00 Alcohol Use Disorder, Mild 305.00

Alcohol Dependence 303.90 Alcohol Use Disorder, Severe 303.90

Alcohol-Induced Mood Disorder

291.89 Alcohol-Induced Depressive Disorder

291.89

Cocaine-Induced Mood Disorder

292.84 Cocaine-Induced Bipolar and Related Disorder

292.84

Amphetamine-Induced Psychotic Disorder

292.9 Amphetamine-Induced Psychotic Disorder

292.9

Polysubstance Dependence 304.80 List Each Disorder Separately

Not Otherwise Specified: Deleted

• Other Specified Disorder– Used to communicate the atypical nature of the

situation– For example: “other specified depressive disorder,

depressive episode with insufficient symptoms.”• Unspecified Disorder– Used when the criteria are not met for a specific

disorder and no determination further is necessary

NOS DiagnosesDSM-IV-TR DSM-5

Mood Disorder NOS 296.90 Unspecified Bipolar and Related Disorder

296.89

Depressive Disorder NOS 311 Unspecified Depressive Disorder

311

Anxiety Disorder NOS 300.00 Unspecified Anxiety Disorder

300.00

Psychosis NOS 298.9 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

298.9

Personality Disorder NOS 301.9 Unspecified Personality Disorder

301.9

A Way Out

State TraitAnger Aggressive

Sadness DepressiveAnxiety Anxious

Pain SomaticLethargy LethargicIrritable Unstable

How States Become Traits

Adaptive Response

Rest Vigilance Freeze Flight Fight

Hyperarousal Continuum Rest Crying Resistance Defiance Aggression

DissociativeContinuum Rest Avoidance Compliance Numbing Fainting

Brain Areas Neocortex Subcortex Limbic Midbrain BrainstemCognition Abstract Concrete Emotional Reactive ReflexiveMental State CALM AROUSAL ALARM FEAR TERROR

Increasing Threat

Perry B: Infant Mental Health Journal, Vol. 16, No.4, 1995.

DSM-IV-TR: Categorical Method

• “The naming of categories is the traditional method of organizing and transmitting information in everyday life and has been the fundamental approach used in all systems of medical diagnosis.” p. xxxi

• “…[I]t is possible that the increasing research on, and familiarity with, dimensional systems may eventually result in their greater acceptance both as a method of conveying clinical information and as a research tool.” p. xxxii

Categorical Assessment

Dimensional vs. Categorical

DSM-5: A Dimensional Approach To Diagnosis Begins

• “…[T]he once plausible goal of identifying homogeneous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality…. The historical aspiration of achieving diagnostic homogeneity by progressive subtyping with disorder categories no longer is sensible….” DSM-5, p. 12

Personality Domains & FacetsDomains Facets

Negative Affect

Emotional Lability, Anxiousness, Separation Insecurity

Detachment Withdrawal, Anhedonia, Intimacy AvoidanceAntagonism Manipulativeness, Deceitfulness, GrandiosityDisinhibition Irresponsibility, Impulsivity, Distractibility Psychoticism Unusual Beliefs & Experiences, Eccentricity, Perceptual

Dysregulation

Krueger, R. F., Derringer, J., Markon, K. E., Watson, D., & Skodol, A. E. (2012). Initial construction of a maladaptive personality trait model and inventory for DSM-5. Psychological Medicine, 42, 1879-1890.

Borderline Personality Disorder

• Negative Affect– Emotional Lability– Anxiousness– Separation Insecurity

• Disinhibition– Distractibility – Irresponsibility– Impulsivity

Hopwood, Thomas, et al., Journal of Abnormal Psychology 2012, 1-9.

Cross-Cutting Symptoms Measures• Level 1– Self-Rated, 23 Questions on 5 point scale (0-4)– Rating of 2 (mild) or greater (except for substance

use, suicidal ideation, and psychosis where a 1 or greater) suggests need for additional inquiry (level 2)

• Level 2– Self-Rated, Separate Scales for Depression, Anger,

Mania, Anxiety, Somatic Symptoms, Sleep Disturbance, Repetative Thoughts, Behaviors, Substance Use

– Clininician-Rated, Non-Suicidal Self-Injury and Psychosis

Self-Reflection

• Cosmetic Changes Reflecting a Putative Revolution in Thought

• Cross-Cutting Symptoms Measures• Personality Domains & Facet Measures• Caring for the Psyche as Psychiatric Treatment