Introduction to the New DSM-5 Manual

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Core slides from my presentation about the new DSM diagnostic system. The full presentation has more zing but I removed some to streamline and to whet the appetite.

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Introduction to the New DSM-5 Manual

  1. 1. DSM 5.0 (Just in Time or Too Late) Laurence P. Karper, M.D. Vice-Chair, Department of Psychiatry
  2. 2. 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
  3. 3. 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)
  4. 4. DSM Editions Page Count 1200 DSM-5 1000 DSM-IV DSM-IV-R 800 600 DSM-III DSM-III-R 400 200 DSM-II DSM-I 0 1950 1960 1970 1980 1990 2000 2010
  5. 5. For More Information • http://www.psychiatry.org/dsm5 – Assessment Measures – Extensive Fact Sheets – Videos of Thought Leaders – News Articles
  6. 6. Where is the Mind in DSM-5? Does not appear in the “Glossary of Technical Terms” or the Index
  7. 7. 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.
  8. 8. 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.
  9. 9. Disturbance of Behavior Social Deviance Mental Disorder Stress Response
  10. 10. 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 wellfounded and corresponds accurately to the real world.
  11. 11. 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.
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Common Diagnoses DSM-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
  19. 19. 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
  20. 20. NOS Diagnoses DSM-IV-TR Mood Disorder NOS Depressive Disorder NOS DSM-5 296.90 Unspecified Bipolar and Related Disorder 296.89 311 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
  21. 21. A Way Out State Trait Anger Sadness Anxiety Pain Lethargy Irritable Aggressive Depressive Anxious Somatic Lethargic Unstable
  22. 22. How States Become Traits Increasing Threat Adaptive Response Rest Vigilance Freeze Flight Fight Hyperarousal Continuum Rest Crying Resistance Defiance Aggression Dissociative Continuum Rest Avoidance Compliance Numbing Fainting Brain Areas Neocortex Subcortex Limbic Midbrain Brainstem Abstract Concrete Emotional Reactive Reflexive CALM AROUSAL ALARM FEAR TERROR Cognition Mental State Perry B: Infant Mental Health Journal, Vol. 16, No.4, 1995.
  23. 23. 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
  24. 24. Categorical Assessment
  25. 25. Dimensional vs. Categorical
  26. 26. 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
  27. 27. Personality Domains & Facets Domains Facets Negative Affect Emotional Lability, Anxiousness, Separation Insecurity Detachment Withdrawal, Anhedonia, Intimacy Avoidance Antagonism Manipulativeness, Deceitfulness, Grandiosity Disinhibition 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.
  28. 28. 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.
  29. 29. 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
  30. 30. 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

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