Overview of DSM-5. With a Focus on Adult Disorders. Gordon Clark, MD

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1 Overview of DSM-5 With a Focus on Adult Disorders Gordon Clark, MD Sources include: 1. DSM-5: An Update D Kupfer & D Regier, ACP Annual Meeting, 2/21-22/13, Kauai 2. Master Course, DSM-5: What You Need To Know, APA Annual Meeting, 5/18/13, San Francisco 3. APA Train the Trainers General Talking Points & power point presentation 4. Psychiatric News articles 5. DSM-5 Highlights: Change from Roman to Arabic numeral system to have the manual be more amenable to updates in psychiatry and neuroscience (e.g., DSM-5.1), and, therefore, more of a living document Upcoming ICD-10-CM codes are in parentheses after the current ICD-9-CM codes. Elimination of multi-axial system. GAF no longer recommended because it 1) mixes disparate concepts (symptom severity, disability, suicidality) and 2) has inter-rater reliability problems (there were also problems with gaming the system) Reordering of chapters that loosely follows a developmental pattern and that groups disorders with overlapping features/symptoms Major changes to diagnoses and diagnostic criteria in Section II include the following: - To maintain greater concordance with the official International Classification of Diseases (ICD) coding system, NOS diagnoses have been changed to Other specified or Unspecified (e.g., re latter, in ER, not enough time to clarify duration & number of symptoms). - With anxious distress has been added as a specifier for bipolar and depressive disorders (specify current severity: mild, moderate, moderatesevere, or severe) - DSM-IV Sexual and Gender Identity Disorders now broken out into distinct chapters: Sexual Dysfuntion, Gender Dysphoria, and Paraphilic Disorders - Two chapters added to DSM-5 that are not mental disorders but which may be a focus of clinical attention include: Medication-Induced

2 Movement Disorders and Other Adverse Effects of Medication, the latter including Antidepressant Discontinuation Syndrome. - Other Conditions That May Be a Focus of Clinical Attention are usually V codes or factors that may formerly were listed in Axis IV. Neurodevelopment Disorders - Consolidation of autism, Asperger s, and pervasive developmental disorder into Autism Spectrum Disorder - ADHD has been added to the chapter, Neurodevelopmental Disorders, and the age of onset has been raised from 7 to 12. The threshold for diagnosis in adults has been reduced from 6 to 5 symptoms. Subtypes have been changed to current presentation specifier Schizophrenia - Schizophrenia subtypes have been eliminated and catatonia is now a specifier for multiple disorders. Bipolar and Related Disorders - DSM-IV Mood Disorders are now divided into Bipolar and Related Disorders and Depressive Disorders. - Mixed Episode has been replaced with mixed features specifier for depression as well as bipolar disorder. - Drug induced mania/hypomania lasting beyond the duration of the physiological effects of the drug is now diagnosed as bipolar disorder. Depressive Disorders - Elimination of the bereavement exclusion for major depression - Dysthymic Disorder is now subsumed under the diagnosis of Persistent Depressive Disorder. - PMDD has been added to the Depressive Disorders chapter. Anxiety Disorders - Social Phobia is now Social Anxiety Disorder. - Agoraphobia is now a separate diagnosis from panic disorder, recognizing that many patients with agoraphobia don t have panic attacks. When agoraphobia and panic disorder appear together, both codes should be used. Obsessive-Compulsive and Related Disorders - OCD has been removed from the Anxiety Disorders chapter, and is now in a chapter on Obsessive-Compulsive and Related Disorders. - Body Dysmorphic Disorder (BDD) is now classified as an OCD-related disorder rather than as a somatic disorder - Hoarding Disorder & Excoriation Disorder have been added to this chapter.

3 - Insight specifiers (good or fair insight, poor insight, or absent insight/delusional beliefs) have been added to diagnostic criteria for OCD, BDD, and Hoarding Disorder. Trauma- & Stressor-Related Disorders - PTSD has been moved from the Anxiety Disorders to Trauma- and Stressor-Related Disorders, and PTSD now includes 4 symptom clusters: re-experiencing, avoidance, persistent negative alterations in cognitions & mood ( numbing ), and arousal (i.e., avoidance and numbing now split). - For a PTSD diagnosis, cases involving actual or threatened death must have been violent or accidental, and not a natural death. - Adjustment Disorders are now included in this chapter, as well, but are otherwise unchanged. Somatic Symptom and Related Disorders - Both Somatization Disorder and Hypochondriasis with somatic symptoms are now included in Somatic Symptom Disorder, and Hypochondriasis without somatic symptoms is now Illness Anxiety Disorder. - A key new criterion has been added to Conversion Disorder : incompatibility between the symptom and recognized neurological or medical conditions. - Factitious Disorder includes Factitious Disorder Imposed on Self & Factitious Disorder Imposed on Another (previously Factitious Disorder by Proxy). Feeding and Eating Disorders - For Anorexia Nervosa, 1) refusal, viewed as pejorative, has been eliminated, 2) the 85% threshold has been eliminated, and 3) the amenorrhea criterion has been eliminated. - Binge Eating Disorder (BED), with binge eating occurring at least once a week for 3 months, has been elevated to the main body of the manual from DSM-IV s Appendix. Sleep-Wake Disorders - Primary Insomnia has been renamed Insomnia Disorder to avoid the differentiation of primary and secondary insomnia, and to highlight that insomnia disorder typically coexists with other medical & psychiatric disorders, with each disorder exacerbating the other and with each requiring specific clinical attention. Sleep difficulty occurs at least 3 times per week for at least 3 months Sexual Dysfunctions - Vaginismus and dyspareunia are merged into genito-pelvic pain/penetration disorder (GPPPD)

4 Gender Dysphoria - Gender Identity Disorder changed to Gender Dysphoria Substance-Related and Addictive Disorders - Substance Abuse and Substance Dependence now consolidated into Substance Use Disorder, with severity continuum of mild, moderate, or severe - Legal consequences criterion removed and craving criterion added to Substance Use Disorder - Tolerance and Withdrawal criteria are not counted if the substance is prescribed by a physician - Gambling Disorder has been moved from the Impulse-Control Disorders chapter in DSM-IV to this chapter in DSM-5 Neurocognitive Disorders - Neurocognitive Disorders replaces Delirium, Dementia, and Amnestic and Geriatric Cognitive Disorders. Mild Neurocognitive Disorder has been added to this chapter to reflect the movement within the Alzheimer s community toward earlier diagnosis & treatment. Mild Cognitive Disorder is differentiated from Major by 1) a single cognitive domain is impaired and 2) independence is preserved Personality Disorders - Personality Disorders unchanged in DSM-5, but 1) Axis II is eliminated and 2) an Alternative model is presented in Section III. Paraphillic Disorders - Paraphilic Disorders (unlike paraphilias which may occur among consenting adults) must cause either significant distress or impairment, or involve a victim. Section III includes: Assessment Measures - Cross-Cutting Symptom Measures - referred to as cross-cutting because it calls attention to symptoms relevant to most, if not all, psychiatric disorders (e.g., mood, anxiety, sleep disturbance, substance use, suicidal ideation/suicide attempts) - Diagnosis-Specific Severity Measures - Word Health Organization Disability Assessment Schedule (WHODAS) Alternative DSM-5 Model for Personality Disorders - This uses a Level of Personality Functioning Scale (LPFS) has a continuum of 5 levels (0, little to no impairment) to 5 (extreme impairment) addressing 1) two Self domains, Identity & Selfdirection and 2) two Interpersonal domains, Empathy & Intimacy

5 - According to the DSM-5 Alternative Model, personality disorders are characterized by impairments in personality functioning and pathological personality traits. The personality disorder diagnoses that may be derived from this model include: Antisocial, Avoidant, Borderline, Narcissistic, Obsessive-Complusive, and Schizotypal. The remaining 4 of the original 10 DSM-IV personality disorder diagnoses are eliminated under the new model: Dependent, Histrionic, Paranoid, and Schizoid. Conditions for Further Study, e.g.: - Attenuated Psychosis Syndrome (early intervention can lead to secondary prevention) - Caffeine Use Disorder - Internet Gaming Disorder The APA is working with insurers. However, there may be delays for insurers to 1) update their coding systems and 2) remove the multi-axial system from their forms and computer systems - Place all mental and other medical disorders on a single list with corresponding ICD code - In place of Axis IV, use DSM-5 s V/Z/T codes - WHODAS 2.0 is provided for disability rating (formerly Axis V), but no replacement for the GAF has yet been approved Code corrections (F63.3) Trichotillomania (F63.2) Kleptomania

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