National Council for Behavioral Health Overview of the DSM-5 Changes Steve M. Jenkins, Ph.D. July 30, 2013
Overview Development How was it developed? Controversies I heard that Organization Three Sections Developmental lifespan approach Functional Changes (Adams & Faye) Non-axial system & ICD 9, 10, 11 Specified & unspecified disorders Other descriptors Diagnostic Changes Highlights to some major changes Minimal changes to others Section III 1
How was it developed? 1999: Development began APA coordinated a series of conferences with the WHO, the WPA, and NIMH to evaluate the strengths and weaknesses of the DSM-IV- TR based upon the most recent research 2002: A Research Agenda for DSM-V monograph Over the next six years, the APA worked with numerous major mental health related organizations in over 13 international conferences 2
How was it developed (cont.) 2006: APA appointed a chair and vice chair of the DSM-5 task force 2007: 28 task force members Research scientists from a variety of disciplines (i.e.,clinical care, biology, genetics, statistics, epidemiology, public health, consumer advocacy). 130 work group members & 400 work group advisors joined the team 2010: APA created a website dedicated to the development of the DSM-5 Preliminary drafts including all proposed changes and all diagnostic criteria were posted Tens of thousands of public comments and criticisms were collected and reviewed by committee members for consideration in revision 2013: After six years of final revision, DSM-5 Released 3
Controversies! Not everyone agreed on the changes? Really? APA lacked transparency Requiring DSM-5 task force members to sign a nondisclosure agreement Some members of the task force have direct ties to the pharmaceutical industry Ulterior motives? Lack of validity? The overall number of diagnoses and lower thresholds are problematic Research driven Not perfect but neither were any of the previous versions Easy to express public opinion in the information age Like it or not, it is here to stay Approved for immediate use by Medicare and Medicaid Services *Specific diagnostic controversies discussed in the course 4
Organization of the DSM-5 Three sections Section I: Introduction and how to use the updated manual Section II: Chapters that outline the categorical diagnoses Section III: Assessment measures, cultural formulations, alternative PD Model, conditions that require further research, glossary and Indices Organization of psychological disorders Some disorders are now in new, more comprehensive categories Others have been clustered separately in different chapters Approximately the same number of disorders as the DSM-IV-TR, but reordered based on scientific and clinical advances over the last two decades Three new chapters, for a total of 20 Disorders grouped together based upon underlying vulnerabilities and symptoms characteristics, rather than categorically 5
A Few Examples of Organizational Changes Depressive Disorders / Bipolar and Related Disorders Anxiety Disorders / Trauma- and Stressor-related Disorders Substance Related and Addictive Disorders / Gambling Disorder 6
Developmental Lifespan Approach Section II: Chapters progress according to disorders typically diagnosed in: Childhood (e.g., neurodevelopmental disorders) Adolescence and young adulthood (e.g., depressive and anxiety disorders) Later in life (e.g., neurocognitive disorders) The developmental approach is also found within the individual chapters themselves whenever possible Ex: Trauma- and Stressor-Related Disorders Reactive Attachment & Disinhibited Social Engagement Disorders PTSD Designed to assist you in considering development of disorders beginning with genetic influences, and how they can continue to develop and change over an individual s lifespan 7
Diagnostic Changes A few highlights 8
Autism Spectrum Disorders In the chapter on Neurodevelopmental Disorders The ASD category now covers what research suggests is a single condition that exists on a spectrum Autistic Disorder (Autism), Asperger s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder NOS Diagnosis must include both deficits in social communication/social interaction, AND restricted, repetitive behaviors, interests, and activities Specifiers include: With or without accompanying intellectual impairment With or without accompanying language impairment Associated with known medical or genetic conditions or environmental factor Associated with another neurodevelopmental, mental, or behavioral disorder With catatonia 9
Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder Body Dysmorphic Disorder (new!) Hording Disorder (new!) Trichotillomania (Hair-Pulling Disorder) Excoriation (Skin-Picking) Disorder Substance/Medication-Induced Obsessive-Compulsive and Related Disorder Obsessive-Compulsive and Related Disorder Due to a Another Medical Condition Other Specified Obsessive-Compulsive and Related Disorder Unspecified Obsessive-Compulsive and Related Disorder 10
Personality Disorders The clusters, titles, and basic criteria for the ten personality disorders listed in the DSM-IV-TR have remained essentially the same in section II of the DSM-5 Finally something stays the same! Or does it...? Section III of the DSM-5 includes another entire chapter for an alternate model for personality disorders 11
Section III of the DSM-5 A few brief highlights 12
Alternative DSM-5 Model for Personality Disorders A new hybrid categorical-dimensional model Included in the Emerging Models chapter (more research is needed before it could be fully adopted) Antisocial Avoidant Borderline Narcissistic Obsessive-Compulsive Schizotypal Personality Disorder - Trait Specified (PD-TS: One or more traits of negative affectivity, detachment, antagonism, disinhibition, psychoticism) 13
Why the New PD Model? This new conceptualization is designed to address: Significant overlap among personality disorder diagnoses Lack of specificity in certain personality disorder diagnoses Lack of research for diagnostic thresholds that are loosely related to impairment The extensive use of PD NOS diagnosis (often not clinically useful) Includes 3 tables to help you identify the level of impairment, and differentiate between domains 14
Cultural Formation Addresses the importance of cultural competence is in diagnosis and treatment The Cultural Formulation Interview (CFI) A set of 16 questions that you can use ascertain the impact an individual s culture may have on clinical symptoms Five broad categories: Cultural identity of the individual Cultural conceptualizations of distress Psychosocial stressors and cultural features of vulnerability and resilience Cultural features of the relationships between the individual and the clinician Overall cultural assessment Glossary (limited) of cultural concepts of distress & descriptions some culturally bound syndromes 15
Applause! Thank you for your time 16