The future of the DSM

1. The future of the DSM • Next revision of the DSM will likely see major changes like we have never seen before. • Focus of NIMH research in the future will be on underlying genetic/neurobiological causes that are common among psychological disorders. This is known as the Research Domain Criteria (RDoC) project.

2. The future of the DSM • “In brief, the RDoC is to define basic dimensions of functioning (such as fear circuitry or working memory) to be studied across multiple units of analysis, from genes to neural circuits to behaviors, cutting across disorders as traditionally defined. The intent is to translate rapid progress in basic neurobiological and behavioral research to an improved integrative understanding of psychopathology and the development of new and/or optimally matched treatments for mental disorders.” source: NIMH website

3. DSM-5 – Important Section • There is a section in DSM-5 titled: • Highlights of Changes from DSM-IV to DSM-5 (p. 809)

4. DSM-5 – Multiaxial System is Gone • AXIS I, II, and III – gone. • DSM-5 recognizes that separating things out in terms of AXIS I, II, and III really served no purpose because of the overlap of I, II, and III. Separating out could actually be misleading.

5. DSM-5 – Multiaxial System is Gone • AXIS IV is gone. Instead of writing out social problems, environmental problems, etc., the list of V codes (p. 715) has been expanded significantly to cover anything that would have gone under AXIS IV • Very important to have a solid working knowledge of V codes

6. DSM-5 – Multiaxial System is Gone • AXIS V – gone. • For many of the disorders in DSM-5 severity rating specifiers have been added • These specifiers are much better in helping to explain the severity of specific disorders, rather than trying to explain overall functioning via the AXIS V, GAF, which was not reliable across clinicians

7. A very brief case study • Leroy is 40-years-old. He just lost his job, which has caused a financial strain. He is experiencing marital distress. Leroy has been depressed off and on for 10 years. He is considering suicide, and has attempted suicide in the past. He worries constantly, and he cannot concentrate. He drinks a 6 pack every night.

8. DSM-5 Diagnosis – Case Study - The Way It Should Be Done • 296.33 Major Depressive Disorder, Recurrent, Severe • 303.90 Alcohol Use Disorder, Severe • 300.02 Generalized Anxiety Disorder • V61.10 Relationship Distress With Spouse or Intimate Partner • V60.2 Low Income • V15.59 Personal History of Self-Harm

9. DSM-5 Diagnosis • The primary diagnosis (listed first) will be the most acute condition that requires the most intensive professional services.

10. DSM-5 ICD-9 Codes • Note: The ICD-9 codes in the DSM-5 will be used until October 1, 2014. After this time, the ICD-10 codes will be used. • The ICD-10 codes are in gray and in parenthesis after each ICD-9 code. • For example: • 301.22 (F21) Schizotypal Personality Disorder

11. DSM-5 – no more NOS categories • With DSM-5, the NOS categories are no more. • DSM-5 includes for each group of related disorders “Other Specified” and “Unspecified” categories • Other Specified category – the clinician can specify why the person does not meet the full diagnostic criteria for a disorder • Unspecified category – the clinician does not specify why the full diagnostic criteria is not met for a disorder

12. DSM-5 – Other Specified and Unspecified Category Examples • 300.3 Other Specified Obsessive-Compulsive and Related Disorder, Body-focused repetitive behavior disorder (nail and lip biting) • Will likely use Other Specified category most often • 300.3 Unspecified Obsessive-Compulsive and Related Disorder • Will likely use Unspecified category less often; when the category is used, it is often in emergency settings, when there is not enough time for full assessment

13. Neurodevelopmental Disorders • Intellectual Disability • no longer called Mental Retardation • Severity no longer determined by IQ, but rather adaptive functioning

14. Neurodevelopmental Disorders • Communication Disorders • Language Disorder – combines what was called Expressive and Mixed Receptive-Expressive Language Disorders • Speech Sound Disorder – fka Phonological Disorder • Childhood-onset Fluency Disorder – fka Stuttering • Social (pragmatic) Communication Disorder – a new disorder; difficulties in social uses of verbal/nonverbal communication

15. Neurodevelopmental Disorders • Autism Spectrum Disorder • A new DSM-5 diagnosis • Encompasses several DSM-IV diagnoses: • Autism • Asperger’s • Childhood Disintegrative Disorder • Rett’s Disorder • Pervasive Developmental Disorder NOS • Deficits in two core domains: • 1. social communication and social interaction • 2. restrictive, repetitive patterns of behavior, interests, and activities

16. Neurodevelopmental Disorders • ADHD • Under DSM-5 must see symptoms prior to age 12 (used to be age 7 under DSM-IV) • For adults (17 and older), only have to meet 5 symptoms of inattention and/or hyperactivity/impulsivity • For children, threshold is higher, must meet 6 criteria

17. Neurodevelopmental Disorders • Specific Learning Disorder • Used to be separate learning disorders (Reading, Disorder of Written Expression, etc.) under DSM-IV • Under DSM-5, the diagnosis is Specific Learning Disorder, and then there are specifiers for each type • Example: 315.00 Specific Learning Disorder, with impairment in reading (reading rate)

18. Schizophrenia Spectrum and Other Psychotic Disorders • In DSM-5, the subtypes of Schizophrenia have been eliminated (e.g., Schizophrenia, Paranoid Type) • They were eliminated because of low reliability and poor validity • The subtypes have been replaced with the Clinician-Rated Dimensions of Psychosis Symptom Severity (p. 743) to help gauge the degree of types and severity of symptoms – see handout

19. Schizophrenia Spectrum and Other Psychotic Disorders • Catatonia - rather than being a subtype of Schizophrenia as seen under DSM-IV, Catanonia is now its own diagnosis. • Example: • 295.70 Schizoaffective Disorder, Depressive Type • 293.89 Catatonia Associated with Schizoaffective Disorder

20. Depressive Disorders • There was significant concern that Bipolar D/O was being over diagnosed in children • For this reason, a new diagnosis, Disruptive Mood Dysregulation Disorder was created. • cannot diagnose over age 18 • Persistent irritability • Frequent episodes of extreme lack of behavioral control

21. Depressive Disorders • Premenstrual Dysphoric D/O is new to DSM-5 • Persistent problems with mood around the time of menses

22. Depressive Disorders • No longer a diagnosis of Dysthymia, the diagnosis is now called: Persistent Depressive Disorder (Dysthymia) • The disorder encompasses what was called Dysthymia under DSM-IV • Disorder also includes Chronic Major Depressive Disorder, never a break in depressive symptoms of at least two months • Note: If a break in depressive symptoms for at least 2 months, then diagnose MDD, Recurrent

23. Depressive Disorders • On p. 161 of DSM-5, there is a lengthy footnote describing how to distinguish characteristics of Bereavement and MDD • If Bereavement, then there are a couple of diagnostic possibilities: • 309.89 Other Specified Trauma- and Stressor-Related Disorder, Persistent Complex Bereavement Disorder or • V62.82 Uncomplicated Bereavement

24. Anxiety Disorders • Anxiety Disorders under DSM-5 no longer includes the following: • OCD – has been moved to Obsessive-Compulsive and Related Disorders • PTSD and Acute Stress Disorder – have been moved to Trauma and Stressor-Related Disorders

25. Anxiety Disorders • Now included under Anxiety Disorders in DSM-5: • Separation Anxiety Disorder • Wording has been modified to better fit when SAD occurs in adulthood • Wording removed that you must be under 18 • Selective Mutism

26. Anxiety Disorders • Panic Attacks • Panic attacks can now be listed as a potential specifier for all psychological disorders • Example: PTSD with Panic Attacks

27. Anxiety Disorders • Under DSM-5, no longer the following diagnoses: • Panic Disorder with Agoraphobia • Panic Disorder without Agoraphobia • Agoraphobia without a history of Panic Disorder • Under DSM-5, the diagnoses are now: • 300.01 Panic Disorder • 300.22 Agoraphobia • Note: you could have one diagnosis without the other

28. Obsessive-Compulsive and Related Disorders • This new section in DSM-5 includes the following newly created disorders: • Hoarding Disorder • Excoriation (skin-picking) Disorder • Substance/Medication-induced Obsessive-Compulsive and Related Disorder • Obsessive-Compulsive and Related Disorder due to Another Medical Condition • Trichotillomania (hair-pulling disorder) – moved from Impulse Control Disorders in DSM-IV; the term in parentheses has been added in DSM-5

29. Trauma and Stessor-Related Disorders • PTSD – diagnostic thresholds have been lowered for children • Separate criteria in the DSM-5 have been added for children age 6 and under • These criteria are better descriptions of how PTSD presents in childhood (e.g., reliving events during play)

30. Trauma and Stessor-Related Disorders • Under DSM-IV, there were two subtypes of Reactive Attachment Disorder. • Under DSM-V, these subtypes are now considered separate disorders: • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder

31. Dissociative Disorders • Under DSM-IV, Dissociate Fugue was a separate diagnose, but under DSM-5, it is considered a specifier of the disorder, Dissociative Amnesia

32. Somatic Symptom and Related Disorders • In DSM-5, there is no longer the following diagnoses: • Somatization disorder • Hypochondriasis • Pain Disorder • Undifferentiated Somatoform Disorder • New to DSM-5: • Somatic Symptom Disorder – most with Somatization D/O will now fall here • Illness Anxiety Disorder – most with Hypochondriasis will now fall here

33. Feeding and Eating Disorders • Disorders that fell under Feeding and Eating Disorders of Infancy and Early Childhood, now fall under this category in DSM-5 – for example, Pica and Rumination Disorder • New disorder: Avoidant/Restrictive Food Intake Disorder – used to be called Feeding Disorder of Infancy or Early Childhood

34. Feeding and Eating Disorders • Anorexia Nervosa • Criteria for amenorrhea, 3 missed menstrual cycles has been removed • Bulimia Nervosa • Criteria for bingeing and compensatory behavior has been reduced from 2 x’s to 1 x weekly • Binge-eating Disorder – a new disorder

35. Sleep Wake Disorder • Two new disorders: • Rapid Eye Movement Sleep Behavior Disorder • Restless Leg Syndrome

36. Sexual Dysfunctions • Females • Sexual Desire Disorder and Sexual Arousal Disorder in DSM-IV have been combined in DSM-5: • Female sexual interest/arousal disorder • Vagnisimus and Dyspareunia have been combined in DSM-5: • Genito-pelvic pain/penetration disorder

37. Disruptive, Impulse-Control, and Conduct Disorders • This is a new category to DSM-5 • The following DSM-IV diagnoses now fall under this DSM-5 category: • Oppositional Defiant Disorder • Conduct Disorder • Disruptive Behavior Disorder NOS • Intermittent Explosive Disorder – must be at least age 6 has been added • Pyromania • Kleptomania

38. Disruptive, Impulse-Control, and Conduct Disorders • Conduct Disorder – a specifier has been added called “Limited Prosocial Norms”; under this specifier, you can get more specific: • Lack of remorse or guilt • Callous – lack of empathy • Unconcerned about performance • Shallow or deficient affect These specifiers make it look more like a mini-version of Antisocial Personality Disorder

39. Substance-Related and Addictive Behaviors • Gambling Disorder – new to this category • Cannabis Withdrawal – new disorder • Caffeine Withdrawal – new disorder • Polysubstance Dependence – deleted from DSM-5; now diagnose each substance disorder separately

40. Substance-Related and Addictive Behaviors • No longer separate diagnoses for Substance Abuse and Substance Dependence. • Everything is now considered a Substance Use Disorder • Substance Use Disorder criteria/specifiers include the following: • Intoxication • Withdrawal • Substance-Induced Disorders

41. Neurocognitive Disorders • Major Neurocognitive Disorder – new disorder • Previous DSM-IV diagnoses of Dementia and Amnestic Disorder now fall under this diagnosis • Mild Neurocognitive Disorder – new disorder for less disabling syndromes

42. Personality Disorders • No changes in criteria for Personality Disorders from DSM-IV to DSM-5

43. Personality Disorders • DSM-5 presents an alternative approach to diagnosing Personality Disorders for further study • Due to the approaches thoroughness, I would STRONGLY encourage you to look at this section of DSM-5 (p. 761) prior to diagnosing any client with a personality disorder • The assessment measures the following: • Level of personality functioning • Pathological personality traits • Pervasiveness and stability of traits • Possible alternative explanations for personality pathology

44. New Useful Tools in DSM-5 • FREE assessment measures for psychological disorders that can be found online (www.psychiatry.org/dsm5) • See p. 733 in DSM-5 for more information • Forms to be used when trying to assess the cultural variables in relation to psychological disorders • See p. 749 in DSM-5