Exploring and Understanding DSM-5. Neal Adams, MD, MPH, Deputy Director, CiMH Victor Kogler, Executive Director, ADPI

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1 Exploring and Understanding DSM-5 Neal Adams, MD, MPH, Deputy Director, CiMH Victor Kogler, Executive Director, ADPI 1

2 Disclosure Information Exploring and Understanding: DSM-5 Neal Adams, MD, MPH Victor Kogler Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to disclose. Neal Adams, MD, MPH Victor Kogler I have no financial relationships to disclose -and I will not discuss off label use and/or investigational use in my presentation 2

3 Learning Objectives Identify major changes from DSM IV to DSM-5 Describe the strengths and potential limitations of DSM-5 Understand DSM-5 approach to diagnosis of substance use disorders 3

4 Agenda History of the DSM and diagnosing Definition of a Mental Disorder Changes Manual s Structure Removal of Axes Diagnosing Coding Subtypes and Specifiers Dimensional Approach 4 Assessing on a Spectrum Biological Markers Removal of NOS Change to Medical Condition Cross-Cutting Measures/Assessment Measures Substance Use Disorders

5 History of the DSM

6 History of the DSM

7 History of the DSM

8 History of the DSM

9 History of the DSM

10 History of DSM 5 TIME LINE 1999 Planning started 2002 A Research Agenda for DSM-5 published conferences Nominations for DSM-5 Task Force and 13 Associated Work Groups Review and Revision of Diagnostic Criteria DSM5.org launched Field Trials started in Academic Medical Centers Field Trials in community based clinics and individual practitioners offices Draft Diagnostic Criteria Published online APA Board of Trustees approved final draft criteria 10

11 History of the DSM

12 Manual s New Structure DSM-5 Classification and Preface Section I: DSM-5 Basics Section II: Essential Elements: Diagnostic Criteria and Codes Section III: Emerging Measures and Appendix Index

13 Definition of a Mental Disorder A syndrome Significant dysfunction in an individual cognition emotion regulation behavior Reflect dysfunction psychological biological developmental process 13

14 Definition of a Mental Disorder Significant distress or disability social occupation other important activities Not an expectable or culturally sanctioned response to stressor or loss Not a culturally deviant behavior Not conflict between individual and society 14

15 Manual s New Structure DSM-5 Classification and Preface Section I: DSM-5 Basics Section II: Essential Elements: Diagnostic Criteria and Codes Section III: Emerging Measures and Models Appendix Index 15

16 Removal of Axes Axial System I clinical disorder II personality d/o, mental retardation III general medical condition IV psychosocial and environmental problems V GAF Axes are eliminated 16

17 Diagnosis in DSM-5 without 5-Axis system Where is the information in a DSM-5 diagnosis? Former Axis I Clinical Disorder This is the psychiatric diagnosis Former Axis II Personality D/O This is now a psychiatric diagnosis Mental Retardation This is now under Intellectual Disabilities, a psychiatric diagnosis Former Axis III General Medical Condition This is a medical diagnosis, also charted

18 DSM-5 what about Axis IV and V? Former Axis IV Psychosocial and Environmental Problems Psychosocial stressors are found in an expanded list of V- codes in ICD-9. In the forthcoming ICD -10, Z codes will replace V-codes. They can be used in the patient s record to provide information and circumstances that may affect care. Former Axis V GAF The GAF is replaced by the WHO-DAS

19 Diagnosing Mental Health, Health Problems and Psychosocial Stressors Psychosocial Stressors V - codes ICD 9 Z - codes ICD 10 19

20 Measuring Disability Diagnosing disability and functioning levels WHODAS

21 Changes to Chapters New Disorders Social (Pragmatic) Communication Disorder Disruptive Mood Dysregulation Disorder Persistent Depressive Disorder Premenstrual Dysphoric Disorder Hoarding Disorder Excoriation (Skin Picking) Disorder Binge Eating

22 Changes to Chapters 22 chapters One chapter kept the same name: Personality Disorders

23 Changes to Chapters 6 chapters with new names but identical or similar diagnoses: DSM IV DSM 5 Schizophrenia and Other Psychotic Disorders Somatoform Disorders Eating Disorders Sleep Disorders Substance-Related Disorders Delirium, Dementia, and Amnestic and Other Cognitive Disorders Schizophrenia Spectrum and Other Psychotic Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorders Sleep-Wake Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders

24 Changes to Chapters 15 chapters with significant changes Neurodevelopmental Disorders Bipolar and Related Disorders Depressive Chapters Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Dissociative Disorders Elimination Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse-Control and Conduct 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

25 Coding Criteria new or different Codes the same ICD-10 25

26 Subtypes and Specifiers Provide increase specificity when diagnosing Found in Classification Section Most subtypes and specifiers cannot be coded using ICD-9 or ICD-10 Some subtypes or codes are available in ICD-10, will be able to use that after October Write the subtype or specifier next to diagnosis, if no code available 26

27 Subtypes and Specifiers The Difference Subtypes Diagnostic subgroups Can only fall into one subgroup at at time All the possible subgroups are listed Specifiers More than one specifier may be given at a time. Allows for defining more homogeneous subgroupings Individuals with the same disorder sharing features convey information relevant to management of the disorder 27

28 Subtypes and Specifiers Specify Whether Subtypes Examples: Specify whether: With depressed mood With anxiety With mixed anxiety and depressed mood With disturbance of conduct With mixed disturbance of emotions and conduct Unspecified Specifiers Specify or Specify if Examples: Specify symptom type Specify current severity 28

29 Subtypes and Specifiers Disorder Subtypes Specifiers Anorexia Nervosa Specify whether: Restricting type Bingeeating/purgi ng type Specify if: In remission, In partial remission, In full remission Specify current severity: mild, moderate, severe, extreme 29

30 Subtypes and Specifiers Disorder Subtypes Specifiers Alcohol Use Disorder Opioid Intoxication Tobacco Use Disorder In early remission, in sustained remission In a controlled environment With perceptual disturbances Current severity: mild, moderate or severe With perceptual disturbances With use disorder mild With use disorder, moderate or severe Without use disorder On maintenance therapy, in a controlled environment Current severity 30

31 Subtypes and Specifiers Disorder Subtypes Specifiers Illness anxiety disorder Care seeking type Care avoidant type 31

32 Developmental Approach Chapters arranged by developmental level Order of Chapters Diagnoses within Chapters 32

33 Capturing the Complexity of the Human Experience in a Mental Health Evaluation Severity Ratings Tailored to disorders: Alcohol Use Disorder Severity (total of 11 criteria) Screening Tools 2-3= mild; 4-5= moderate; 6 or more=severe Example: mild moderate severe extreme ratings in anorexia nervosa based on body mass index (BMI) Cultural Assessments Potential impact of differences in interviewer: client cultural, religious, or linguistic background (e.g. odd vs. psychotic belief)

34 Assessing on a Spectrum A dimensional approach Assess severity No line between normal and disordered Disorders are on a spectrum Measure degree of acuteness Examples Autism Spectrum Disorder Substance Use Disorder 34

35 Assessing on a Spectrum Benefits More info = more insight Reduced use of NOS Informative and helpful for treatment planning Don t have to fit precisely into a category Research Hypothesizing and testing 35

36 Biological Markers Objective tests versus patients reports Examples: polysomnography Hypocretin deficiency 36

37 NOS Replaced by Other Specified Unspecified Examples: Unspecified Eating Disorder Other Opioid-Induced Disorders 37

38 Medical Condition General Medical Condition is replaced by Another Medical Condition 38

39 Assessment Measures Cross-Cutting Measures Clinician-Rated Dimensions of Psychosis Symptom Severity World Health Organization Disability Assessment Schedule 2.0 Cultural Formulation Interview 39

40 Cross-Cutting Symptom Measures Assesses mental health domains across psychiatric diagnoses Purpose Identify additional areas of inquiry that may have significant impact on treatment and prognosis Useful to track changes in symptoms over time 40

41 Instruments APA website: In Manual: Adult Pages Child Pages

42 Instruments Level 1 Cross-Cutting Symptom Measures DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure Adult DSM-5 Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure Child Age 6 17 DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure Child Age Level 2 Cross-Cutting Symptom Measures For Adults For Parents of Children Ages 6 17 For Children Ages For specific disorders depression, sleep disorders, somatic symptoms, anger, anxiety, etc. 42

43 Who completes assessment? Version DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure Adult DSM-5 Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure Child Age 6 17 DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure Child Age Who Completes Adult Knowledgeable adult informants if individual impaired (example - adult with dementia) Parent or Guardian Child age

44 World Health Organization Disability Assessment Schedule 2.0 WHODAS 2.0 Assesses disability in adults (18 + years old) 36 items 6 domains 1. Understanding and communicating 2. Getting around 3. Self-care 4. Getting along with people 5. Life activities (household, work, and /or school activities) 6. Participating in society 44

45 World Health Organization Disability Assessment Schedule 2.0 WHODAS 2.0 Administered Self Proxy-administered version is also available when adult is unable to complete the version (dementia) 5 point scale 1. None 2. Mild 3. Moderate 4. Severe 5. Extreme 45

46 World Health Organization Disability Assessment Schedule 2.0 WHODAS 2.0 Scoring Simple: Hand scoring by adding up the numbers Get a total score which indicates the degree of functional limitations Complex Done by computer Accounts for multiple level of difficulty for each questions Differentially weighs each item and level of severity Available at: 46

47 Substance-Related and Addictive Disorders 47

48 Two Groups of Substance-related Disorders 1. Substance Use Disorders (SUDs) 2. Substance-Induced Disorders Intoxication Withdrawal Other substance/medication-induced mental disorders

49 Substance Use Disorders 10 classes of substances Other (or unknown) Substance-Related Disorders 49

50 Alcohol

51 Images courtesy of Wikipedia

52 Cannabis Cannibis sativa Images courtesy of Wikipedia

53 PCP & Hallucinogens Amanita muscaria Images courtesy of Wikipedia

54 Inhalants Images courtesy of Wikipedia

55 Opioids Opium Poppy

56 Sedative, Hypnotic, Anxiolytic Valerian Image courtesy of Wikipedia

57 Images courtesy of Wikipedia Stimulants Coca plant

58 Tobacco Nicotiana tabacum Image courtesy of Joachim Müllerchen

59 Criteria for Substance Use Disorder 2 or more of the 11 diagnostic criteria in the past 12- months Impaired Control 1. Using more or using for a longer period than was intended 2. Persistent desire or unsuccessful effort to cut down or control substance use 3. A great deal of time is spend in activities necessary to obtain use or recover for the effects of substance 4. Cravings, or a strong desire or urge to use substance 59

60 Criteria for Substance Use Disorder Social Impairment 5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of substance 7. Important social, occupational or recreational activities are given up or reduced because of alcohol use 60

61 Criteria for Substance Use Disorder Risky Use 8. Recurrent substance use in situations in which it is physically hazardous. 9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance. 61

62 Criteria for Substance Use Disorder Pharmacological Criteria 10. Tolerance A need for increased amounts to achieve intoxication or desired effects Diminished effect with continued use of the same amount of substance 11. Withdrawal The characteristic withdraw syndrome for substance A substance or a closely related substance is taken to relieve or avoid withdrawal symptoms 62

63 Severity Measures 0-1 criteria: No Diagnosis 2-3 criteria: Mild Substance Use Disorder 4-5 criteria: Moderate Substance Use Disorder 6 or more: Severe Substance Use Disorder 63

64 SUDs Specifiers Specify Specify Specify if Specify if Specify current severity The particular substance (hallucinogen, inhalant, stimulant) In early remission: All full criteria met previous, none met for at least 3 months, but for less than 12 months In sustained remission: All full criteria met previous, none met for 12 months or longer In a controlled environment: If in environment where access to substance is restricted On maintenance therapy: Taking a prescription agonist, never met criteria for SUD with agonist (nicotine, methadone, buprenorphine, other) (except tolerance or withdrawal) Mild: presence of 2-3 symptoms Moderate: presence of 4-5 symptoms Severe: presence of 6 or more symptoms

65 Substance-Induced Disorders Alcohol Caffeine Cannabis Intoxication Hallucinogen Phencyclidine (PCP) Inhalant Opioid Alcohol Caffeine Cannabis Opioid Withdrawal none none Sedative, Hypnotic or Anxiolytic Sedative, Hypnotic or Anxiolytic Stimulant Other (or Unknown) Substance Stimulant Tobacco Other (or Unknown) Substance

66 Intoxication Criteria A. Recent ingestion of substance B. Clinically significant problematic behavior or psychological changes (specific to the substance) that developed during or shortly after ingestion C. Two (or more) signs or symptoms (specific to the substance) developing within a time frame which is specific to substance (differs for each substance). D. Not attributable to another medical condition, mental disorder or intoxication with another substance.

67 Intoxication Specifiers Specify if Specify Perceptual disturbances (Cannabis, Opioid, Amphetaminetype substance, Cocaine, other or unspecified stimulant) Specific intoxicant (Amphetamine-type substance, Cocaine, other or unspecified stimulant)

68 Withdrawal Criteria A. Due to cessation of or reduction in, heavy and prolonged use of substance-specific problematic behavioral changes B. Symptoms that develop within a time frame specific to the substance, after cessation or reduction of use the substance C. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning D. Symptoms not due to another medical condition or mental disorder

69 Withdrawal Specifiers Specify if With perceptual disturbances (Alcohol; Sedative, Hypnotic, or Anxiolytic) Specify The specific substance that causes the withdrawal syndrome (Hallucinogen, PCD; Amphetamine-type substance, Cocaine or other or unspecified stimulant)

70 new Cannabis Withdrawal irritability, anger, or aggression nervousness or anxiety sleep difficulty (e.g., insomnia, disturbing dreams) decreased appetite or weight loss Restlessness depressed mood at least one of the following physical symptoms: stomach pain shakiness/chills sweating fever chills headache 70

71 new Caffeine Withdrawal Daily Use of Caffeine 3 or more headache marked fatigue or drowsiness dysphoric or depressed mood, or irritability difficulty concentrating flu like symptoms clinically significant distress or impairment in social, occupational or other important areas of functioning not due to the direct physiological effects of a general medical condition 71

72 Other Substance/Medication-Induced Mental Disorders DSM-IV Substance-Induced Psychotic Disorder Substance-Induced Mood Disorder Substance-Induced Mood Disorder Substance-Induced Anxiety Disorder Substance-Induced Anxiety Disorder with Obsessive-Compulsive Symptoms. Substance-Induced Sleep Disorder Substance-Induced Sexual Dysfunction Substance Intoxication Delirium and Substance Withdrawal Delirium Substance-Induced Persisting Dementia Substance-Induced Sleep-Wake Disorder DSM-5 Substance-Induced Psychotic Disorder Substance-Induced Bipolar Disorder Substance-Induced Depressive Disorder Substance-Induced Anxiety Disorder Substance-Induced Obsessive-Compulsive or Related Disorders Substance-Induced Sleep-Wake Disorder Substance-Induced Sexual Dysfunction Substance-Induced Delirium Substance-Induced Neurocognitive Disorder Substance-Induced Sleep-Wake Disorder

73 Common Features of Substance Induced Mental Disorders The disorder represents a clinically significant symptomatic presentation of a relevant mental disorder There is evidence from the history, physical exam or lab work of The disorder developed during or within one month of substance intoxication, withdrawal or taking medications The involved substance/medication is capable of producing the mental disorder

74 Common Features of Substance Induced Mental Disorders The disorder is not better explained by an independent mental disorder (one that is not substance- or medication induced) The disorder does not occur exclusively during the course of a delirium The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

75 Behavioral Addictions Gambling Disorder Brain reward system is activated Other Behavioral Addiction Research is not clear Internet gaming (conditions for further study) Sex addiction Exercise addiction Shopping addiction

76 Gambling Disorder Symptoms Persistent and recurrent problematic gambling behavior lead gin to clinically significant impairment or distress, as indicated by the individual exhibiting 4 (or more) of the following in a 12- month period: 1. Needs to gamble with increasing amount of money in order to achieve the desired excitement 2. Is restless or irritable when attempting to cut down or stop 3. Has made repeated unsuccessful efforts to control, cut back, or stop 4. Is often preoccupied with gambling 5. Often gambles when feeling distresses

77 Gambling Disorder 6. After losing money gambling, often returns another day to get even 7. Lies to conceal the extent of involvement with gambling 8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling 9. Relies on other to provide money to relieve desperate financial situations caused by gambling 10.Behavior is not explained by a manic episode

78 Gambling Disorder - specifiers Specify If Episodic: meeting criteria at more than one time point, symptoms subsiding between periods of gambling disorder for at least several months Persistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple years Specify if In early remission: after full criteria met, none of the criteria have been met for at least 2 months but for less than 12 months In sustained remission: after criteria met, none of the criteria have been meet during a period of 12 or more months Specify current severity level Mild: 4-5 criteria Moderate: 6-7 criteria Severe: 8-9 criteria

79 DSM 5 Impact on Treatment No more abuse/dependence dichotomy Severity Specifiers potentially clarify treatment 79

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