a dsm-5 primer: overview and major changes professor, vice chair for education department of...
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A DSM-5 Primer: Overview and Major Changes
Professor, Vice Chair for EducationDepartment of Psychiatry
University of Iowa Carver College of MedicineIowa City, IA 52242
2014 Jauch Memorial Educational SymposiumMay 16, 2014
Donald W. Black, MD
Conflicts
Grant support:• AstraZeneca• National Institute on Aging• Nellie Ball Trust Royalties:
• American Psychiatric Publishing• Oxford University Press• UpToDate
Objectives
• To improve the learners understanding of DSM-5
• To describe the major changes and their rationale.
• To facilitate the transition from DSM-IV to DSM-5.
What the DSM is and is not
• Is for:– Diagnosis and classification– Communication among professionals– Coding/billing– Research
• Is Not:– An inerrant Bible– Static: diagnoses are always evolving– A guide to selection of appropriate treatments
The DSM through Time
The DSM Through Time
• DSM-I (1952) – 132 pages– Mental disorders resulted from a “reaction” of
personality to psychological factors, e.g. manic-depressive reactions.
– Definitions were simple and brief• DSM-II (1968) – 134 pages
– Term “reaction” dropped; users encouraged to record multiple psychiatric diagnoses
DSM-III (1980) – 494 pages• DSM-III was transformative.• Process led by Robert Spitzer,
MD of Columbia University• “Atheoretical” with regard to
etiology.• Introduced:
– diagnostic criteria – multiaxial classification– Diagnostic reliability
Robert Spitzer, MD
DSM-III-R, DSM-IV, and DSM-IV-TR
• DSM-III-R (1987) had few changes (567 pages)• DSM-IV (1994) was much larger (886 pages):
– New disorders introduced (e.g., Acute Stress Disorder, Bipolar II Disorder, Asperger’s Disorder).
• DSM-IV-TR (2000) had text changes (943 pages)
DSM-5: 2013
947 pp.
The March to DSM-5
Psychiatrists Darrel Regier, MD (l) and David Kupfer, MD (r) appointed in 2006 to lead Task Force that led to DSM-5
The March to DSM-5
• Guiding principles:– Priority was given to clinical utility; that is, any
changes had to be useful to clinicians; – Changes had to be guided by research evidence; – DSM-V had to maintain historical continuity with
previous editions; and – No a priori limits on changes proposed by Work
Groups.
The March to DSM-5
• The 13 Work Groups asked to consider ways to:– incorporate dimensional measures.– consider culture/gender issues.
• Field trials organized to assess reliability of the new criteria.
• Many scientific reviews written.• Over 1000 members and consultants involved.• Aimed to be transformative.
First Issue: DSM-V or DSM-5?
• DSM-5 was designed to be a “living” document– Changes made rapidly in response to scientific
advances. • Rapid response was thought best captured by an
Arabic numeral (5), not a Roman numeral (V)– Future changes can be designated as DSM-5.1, DSM-
5.2, etc. • Later quietly dropped because this plan was not
workable.
Multi-Stage Review
• Proposed changes undergo revision with input from APA members and others via 3 Internet postings.
• A Scientific Review Committee created to review the science validating the evidence for revisions.
• A Peer Review process involving hundreds of experts developed to consider clinical/public health risks and benefits of proposed changes.
• Approved by:– APA Assembly (November 2012)– Board of Trustees (December 2012)
Criticism of the DSM-5 Process
• Started early and continued throughout. • Concerns that DSM-5:
– was rushed – lacked transparency– authors were riddled with conflicts of interest– authors did not seek input of APA membership/public
• Focus placed on controversial diagnoses/topics:• Bereavement exclusion • Disruptive Mood Dysregulation Disorder • Autism Spectrum Disorder.
Overview of Major Changes in DSM-5• The organization of diagnostic chapters
follows the developmental lifespan.– Related categories are placed in close proximity.
• New diagnostic classes. Examples:– Obsessive-Compulsive and Related Disorders– Trauma- and Stressor-Related Disorders
• Reformulated diagnostic classes. Examples:– Neurodevelopmental Disorders– Somatic Symptom Disorders
Overview of Major Changes in DSM-5
• New or reformulated diagnoses. Examples:– Autism Spectrum Disorder (ASD)– Disruptive Mood Dysregulation Disorder (DMDD)
• Demise of multiaxial classification– The “five axes” are history.
• Demise of NOS categories (replaced by “other specified” or “unspecified”)
• New dimensional scales in Section III
Changes in Specific DSM Disorder Numbers
(net difference = -15)
DSM-IV DSM-5
Specific Mental Disorders* 172 157
*NOS (DSM-IV) and Other Specified/Unspecified (DSM-5) conditions are counted separately.
Copyright © 2013. American Psychiatric Association.
The Multiaxial System Scrapped• Introduced in DSM-III: Axes I – V.• Criticized from the outset:
– Artificial separation of axes I/II – Personality disorders and MR became further
marginalized (e.g., “Axis II disorders”)– Axes III/IV never used consistently– Axis V (GAF) had low reliability
• Insurance companies cynically misused Axes II and V to deny care.
• No other diagnostic system has used axes.
A Few Words About Coding
• The official coding system in the US is the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) released by WHO in 1978 and not DSM-5. – It was expected that DSM-5 and its new
counterpart - ICD-10-CM - would become available at the same time (May 2013), so that both would employ the same new codes.
• Because implementation of ICD-10-CM is delayed to October 2015, DSM-5 presents both ICD-9-CM and ICD-10-CM codes.
A Few Words About Coding
• 300.12 (F44.0) Dissociative Amnesia
• A. An inability to recall important autobiographical information, usually of a traumatic or• stressful nature, that is inconsistent with ordinary forgetting.• Note: Dissociative amnesia most often consists of localized or selective amnesia for a• specific event or events; or generalized amnesia for identity and life history.• B. The symptoms cause clinically significant distress or impairment in social, occupational,• or other important areas of functioning.• C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol• or other drug of abuse, a medication) or a neurological or other medical condition• (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/• traumatic brain injury, other neurological condition).• D. The disturbance is not better explained by dissociative identity disorder, posttraumatic• stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive• disorder.• Coding note: The code for dissociative amnesia without dissociative fugue is 300.12• (F44.0). The code for dissociative amnesia with dissociative fugue is 300.13 (F44.1).• Specify if:• 300.13 (F44.1) With dissociative fugue: Apparently purposeful travel or bewildered• wandering that is associated with amnesia for identity or for other important autobiographical
Using DSM-5
Learning to Make DSM Diagnoses
• Learn the various psychiatric diagnostic classes and the major diagnoses
• Recognize the typical patient who fits these criteria
• Learn to diagnose patients with atypical presentations– Used to be “NOS”– In DSM-5 “other specified” and “unspecified”
When There Is More Than One Diagnosis
• Start with diagnosis that is the focus of attention at visit– If there is more than one, indicate “principal diagnosis”
or “reason for visit” in parentheses– The clinician may indicate diagnostic uncertainty by
writing “(Provisional)” following the diagnosis.• If there is a past diagnosis that is no longer active,
list as “in full remission”Example: 296.32 (F33.1) Major Depressive Disorder, Recurrent, Moderate; 307.1(F50.01) Anorexia Nervosa, in full remission
Example 1
A 25-year-old man is brought to the emergency room by family members for bizarre behavior including making threats of harm, muttering obscenities, and talking to himself. His bizarre behavior appears motivated by paranoid delusions. Family members report that he drinks nearly daily to intoxication and that he smokes cigarettes nearly nonstop. He has had several prior hospitalizations for similar reasons and has been diagnosed with schizophrenia. • His DSM-5 diagnoses are:
295.90 (F20.9) Schizophrenia (principal diagnosis)303.90 (F10.20) Alcohol use disorder, severe305.1 (F17.200) Tobacco use disorder, severe
Example 2
A 65-year-old man is brought to the clinic by his worried spouse. She reports that he has been diagnosed with lung cancer, which his doctors believe has metastasized to his brain. He hears “voices” that tell him not to trust family members. He has become very suspicious and has threated family members who he believes are planning to kill him. There is no psychiatric history. • His DSM-5 diagnoses are:
162.9 (C34.90) Malignant lung neoplasm293.81 (F06.2) Psychosis due to malignant lung neoplasm (provisional)
Example 3
A 27-year-old woman presents to the clinic for treatment of intrusive thoughts about a recent rape and recurrent nightmares. Prior to her recent symptoms, she reports having experienced overwhelming anxiety in social situations. She also reports a history of deliberate self-harm by cutting, relationship difficulties, and abandonment fears. • Her DSM-5 diagnoses are:
309.81 (F43.10) Posttraumatic stress disorder (reason for visit)300.23 (F40.10) Social anxiety disorder301.83 (F60.3) Borderline personality disorder
Section II: Chapter by Chapter Review
Neurodevelopmental Disorders
• MR replaced by Intellectual Disability (Intellectual developmental disorder).
- Emphasis now on adaptive functioning not IQ.
• Autism Spectrum Disorder consolidates 5 conditions: - Autistic Disorder, Rett’s Disorder, Childhood Disintegrative
Disorder, Asperger’s Disorder and Pervasive Developmental Disorder NOS).
- Specifiers can be used to describe variants of ASD (e.g., the former diagnosis of Asperger’s can now be diagnosed as autism spectrum disorder, without intellectual impairment and without structural language impairment).
Neurodevelopmental Disorders:Attention-Deficit/Hyperactivity Disorder
• Age of onset raised from before 7 years to before 12 years.
– Large-scale studies showed that onset is often not identified until after age 7 years.
• Symptom threshold for adults age 17 years and older was reduced to five symptoms (from 6).
– The reduction in symptom threshold was based on longitudinal studies showing that patients have fewer ADHD symptoms in adulthood than in childhood.
.
Schizophrenia Spectrum and Other Psychotic Disorders
• Disorders arranged from least to most severe• Schizotypal PD included (criteria in PD chapter)• Schizoaffective Disorder now specifies that mood
symptoms are present for a “majority of the total duration of the illness”
• Schizophrenia subtypes dropped• Shared Psychotic Disorder deleted
Schizophrenia Spectrum and Other Psychotic Disorders: Schizophrenia
• Deletion of specific subtypes (paranoid, disorganized, catatonic, undifferentiated, residual)
– DSM-IV subtypes had poor reliability and validity. They failed to differentiate from one another based on treatment response and course.
Schizophrenia Spectrum and Other Psychotic Disorders: Schizoaffective Disorder
• In DSM-5 schizoaffective disorder is now based on lifetime duration of illness in which mood and psychotic symptoms occur.
– DSM-IV criteria had poor reliability because the language regarding the duration of illness was ambiguous.
Mood Disorders
• Now divided into 2 chapters.• Bipolar and Related Disorders
– Mixed episode dropped; replaced by specifier– Emphasis on “increased energy/activity” as a
defining feature of mania and hypomania• Depressive Disorders, now include:
– Disruptive Mood Dysregulation Disorder (DMDD)– Premenstrual Dysphoric Disorder – Bereavement exclusion for MDD dropped.
Bipolar and Related Disorders: Mania and Hypomania
• Inclusion of “increased energy/activity” as a Criterion A symptom of mania and hypomania
– This makes explicit the requirement of increased energy/activity in order to diagnose bipolar I or II disorder (not required in DSM-IV); this may improve the specificity of the diagnosis.
.
Bipolar and Related Disorders: Mania and Hypomania
• “Mixed episode” is replaced with a “with mixed features” specifier for manic, hypomanic, and major depressive episodes
– DSM-IV criteria excluded a sizeable population of individuals with subthreshold mixed states who did not meet full criteria for major depression and mania.
Depressive Disorders: Disruptive Mood Dysregulation Disorder (DMDD)
• New to DSM-5:
– DMDD provides a diagnosis for children with extreme behavioral dyscontrol but persistent, rather than episodic, irritability.
– This diagnosis addresses the alarming increase in pediatric bipolar diagnoses in the past 20 years, due to the incorrect characterization of non-episodic irritability as mania.
– May reduce the likelihood of such children being inappropriately prescribed antipsychotic medication.
.
Depressive Disorders: MDE Bereavement Exclusion
• In DSM-5: DSM-IV Criterion E (bereavement) eliminated from major depressive episode
– For some, a major loss – including the loss of a loved one – can lead to MDE or exacerbate pre-existing depression. There is little difference between depression associated with bereavement and depression associated with other stressors.
Depressive Disorders: MDE Bereavement Exclusion
• DSM-IV MDE:Criterion E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Anxiety Disorders• In DSM-5: Reformulation of DSM-IV anxiety
disorders by creating new chapters for OCD and trauma-based disorders.
– Data suggest differences in the heritability, risk, course, and treatment response among fear-based anxiety disorders (e.g., phobias); disorders of obsessions or compulsions (e.g., OCD); and trauma-related anxiety disorders (e.g., PTSD).
.
Anxiety Disorders• Moved to other chapters:
- Obsessive-Compulsive Disorder - Acute Stress Disorder - Posttraumatic Stress Disorder
• Separation Anxiety Disorder, Selective Mutism added.• Panic Disorder and Agoraphobia are “unlinked.”• Panic attack specifier may apply to any disorder (“with panic attack”).
Panic Attacks Specifier
• Now a specifier for any mental disorder
– Panic attacks can predict the onset, severity and course of mental disorders, including anxiety disorders, bipolar disorder, depression, psychosis, substance use disorders, and personality disorders.
Example: 309.81 (F43.10) Posttraumatic Stress Disorder with Panic Attacks
© 2013. APA
Obsessive-Compulsive and Related Disorders
• New chapter - acknowledges the existence of the obsessive-compulsive spectrum.• Includes:
- Obsessive-compulsive Disorder - Body Dysmorphic Disorder (from Somatoform chapter)- Hoarding Disorder (new)- Trichotillomania (Hair-pulling Disorder)- Excoriation (Skin-Picking) Disorder (new)
Obsessive-Compulsive and Related Disorders: Hoarding Disorder
• New to DSM-5:
– Clinically significant hoarding is common and appears clinically valid. It can have direct and indirect consequences on the health and safety of patients as well as that of others.
.
Obsessive-Compulsive and Related Disorders: Body Dysmorphic Disorder
• Now classified as an OCD-related disorder rather than as a somatoform disorder
– Based on symptoms, family studies, and treatment studies, BDD appears related to OCD.
.
Obsessive-Compulsive and Related Disorders: Excoriation (Skin-Picking) Disorder
• New to DSM-5:
– Based on studies showing that it is common, and related to OCD based on symptoms, family studies, and treatment studies.
.
Trauma and Stressor-Related Disorders
• New to DSM-5: chapter brings together disorders that develop in response to stressful or traumatic events:
- Reactive Attachment Disorder (from CH chapter)- Disinhibited Social Engagement Disorder (new)- Acute Stress Disorder (from Anxiety chapter)- Posttraumatic Stress Disorder (from Anxiety chapter)- Adjustment Disorders
Trauma and Stressor-Related Disorders: PTSD
Separate criteria are now available for PTSD occurring in preschool-age children (i.e., 6 years and younger)
Rationale: DSM-IV criteria for PTSD were not developmentally sensitive to very young children. Numerous studies indicate that children exposed to trauma develop PTSD yet did not meet threshold for PTSD in DSM-IV.
© 2013. APA
Somatic Symptom and Related Disorders
• Somatic Symptom Disorder replaces Somatization Disorder, Hypochondriasis, Pain Disorder, and Undifferentiated Somatic Disorder.• Illness Anxiety Disorder (new) for individuals with high health-related anxiety.• Conversion Disorder no longer requires a psychological stressor.
Somatic Symptom Disorder • Replaces somatoform disorder, undifferentiated
somatoform disorder, hypochondriasis, and the pain disorders
– Rationale: DSM-IV’s somatoform disorders have been shown to be rarely used in most clinics and across numerous countries, due in part to criteria and terminology that are confusing, unreliable, and not valid. SSD is projected to cover the majority of patients previously diagnosed with these disorders.
Copyright © 2013. American Psychiatric Association.
Feeding and Eating Disorders
• Feeding Disorders (Pica, Rumination Disorder) now included with the Eating Disorders
- All involve disturbed eating behaviors.
• Amenorrhea dropped for Anorexia Nervosa.• Bulimia – fewer binge/purge cycles needed (1 weekly for 3 months).• Binge Eating Disorder is new.
Disruptive, Impulse Control, and Conduct Disorders
• New chapter for individuals with problems of self-regulation and replaces ICD NEC chapter.• Disorders include:
- Oppositional Defiant Disorder (from CH chapter)- Conduct Disorder (from CH chapter)- Intermittent Explosive Disorder - ASPD (criteria in PD chapter)- Pyromania- Kleptomania
• Pathological Gambling moved to SUDs chapter as Gambling Disorder
Substance-Related and Addictive Disorders: Substance Use Disorder
• In DSM-5: Merges substance abuse with substance dependence into a single substance use disorder.
– Dependence is a misunderstood term that actually refers to normal patterns of withdrawal that can occur from the proper use of medications. Further, clinicians had trouble distinguishing between abuse and dependence.
• New disorders: Caffeine Withdrawal and Cannabis Withdrawal.
Substance-Related and Addictive Disorders: Substance Use Disorder
– Research studies indicate DSM-IV substance abuse and dependence criteria represent a singular phenomenon but encompassing different levels of severity.
• Mild SUD (2-3/11 criteria)
• Moderate (4-5/11 criteria)
• Severe (6+/11 criteria)
Substance-Related and Addictive Disorders: Gambling Disorder
• In DSM-5: Pathological gambling has been renamed gambling disorder.– The term “pathological” was considered pejorative.
Further, research had shown gambling disorder to have many similarities with substance use disorders in terms of symptoms, family history, treatment response and neurobiology.
Neurocognitive Disorders
• In DSM-5: The term “dementia” subsumed under the new diagnosis Major Neurocognitive Disorder. • Mild Neurocognitive Disorder is new. Included as a less severe level of cognitive impairment. • DSM-IV etiologic subtypes now independent disorders (e.g., major neurocognitive disorder due to Alzheimer’s disease).
Neurocognitive Disorders• Why use the term major neurocognitive disorder
rather than dementia?
– The term dementia is usually associated with neurodegenerative conditions occurring in older populations, but major NCD refers to a broad range of possible etiologies that can occur even in young adults, such as major NCD due to traumatic brain injury or HIV infection.
Neurocognitive Disorders: Mild NCD
• New to DSM-5:
– Patients with mild NCD are frequently seen in clinics and in research settings, and there is widespread consensus that these populations can benefit from diagnosis and treatment. The clinical utility of such a diagnosis also is supported in the literature.
– In the past this was widely referred to as “mild cognitive impairment” and was not coded in DSM-IV.
Personality Disorders
• The PD’s are unchanged from DSM-IV-TR and include the 3 clusters and 10 disorders.• A hybrid categorical-dimensional scheme developed by the work group was rejected by the Board of Trustees as unworkable.
- The proposed categorical-dimensional scheme is included in Section III.
Critique of DSM-5• Most changes are positive and non-
controversial; few are problematic.• Some changes were overdue (e.g., SZ
subtypes, abuse/dependence), while others are of little interest to most (e.g., Somatic Symptom Disorders).
• Important to examine inter-rater reliability, but the true test is to compare criteria sets (DSM-IV vs. DSM-5), which was not done.
• The BOT made correct calls with regard to the PD chapter.
Wrap-up• The DSM is important to psychiatrists and
other mental health professionals.• DSM-5 was 14 years in the making and
involved a cast of 1000s.• Controversy accompanying DSM-5 was not
unique nor the time involved.• The “Holy Grail” of classification is the
inclusion of genetic/biologic markers, but we are not there.
Thank you!
Questions?
References• American Psychiatric Association: Diagnostic and Statistical Manual of
Mental Disorders, 5th Edition. Washington, DC, American Psychiatric Association, 2013
• Black DW, Grant JE: DSM-5 Guidebook: The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington DC: American Psychiatric Publishing, 2014
• Frances A, Pincus HA, Widiger TA, et al.: DSM-IV: work in progress. Am J Psychiatry 147:1439-1448, 1990
• Kendler KS, Munoz RA, Murphy G: The development of the Feighner criteria: a historical perspective. Am J Psychiatry 167:134-142, 2010
• Reiger D, Narrow W, Kuhl E, et al. (eds.): The Conceptual Evolution of DSM-5. Arlington, VA: American Psychiatric Press, 2011
• Spitzer RL, Williams JB, Skodol AE: DSM-III: the major achievements and an overview. Am J Psychiatry 137:151-164, 1980
