DSM-5 Major Changes and Important aspects for School Psychologists

Dr Maxine Hawkins maxinehawkins1@hotmail.com

Aims:DSMDevelopment of DSM- 5 Principles guiding DSM-5 processMajor Changes Points for ConsiderationAutismSummary of Changes

DSM 5

DSMManual developed by the American

Psychiatric AssociationUsed by clinicians and researchers to

classify and diagnose mental disorders. Although Australian health services

use the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD), the diagnostic system used by most Australian researchers and practitioners is DSM.

There have been five revisions of the DSM since it was first released in 1952, with the last major revision, DSM-IV, published in 1994. A 19-year period will have elapsed between the introduction of DSM-IV (1994) and the DSM-5 (2013).

Timeline of DSM-5

1999-2001 Development of Research Agenda

2002-2007 APA/WHO/NIMH DSM-5/ICD-11 Research Planning

conferences2006 Appointment of DSM-5 Taskforce2007 Appointment of Workgroups2007-2011 Literature Review and Data Re-

analysis2010-2011 1st phase Field Trials ended July

20112011-2012 2nd phase Field Trials began Fall

2011 July 2012 Final Draft of DSM-5 for APA

review May 2013 Publication Date of DSM-5

Critique of DSM-5

McLaren (2010) held that it does not matter if the language in the DSM-5 is updated. It is of no account if categories are reshuffled, broadened, blurred, or loosened; the faults are conceptual, not operational, a case of old wine in new bottles. The DSM-5 Task Force has spent some 3 million hours so far (600 people at 10 hours per week for 10 years), and the biggest jobs are still to come. It has been 3 million wasted hours, just as all those psychoanalytic textbooks and conferences, plus the therapeutic hours on the analyst’s couch, were wasted. It is the wrong model.

Principles guiding DSM-5 process

Clinical utility Research Evidence Recommendations to be

grounded in empirical evidence Changes to the DSM-5 in the future must be

made in light of maintaining continuity with previous editions for this reason the DSM-5 is not using Roman numeral V but rather 5, later editions or revision would be DSM-5.1

No limitations on the number of changes that may occur over time with the new DSM-5

The DSM-5 will continue to exist as a living, evolving document that can be updated and reinterpreted over time

Issues with DSMSocial processes have a significant impact on the

DSM classification -cultural trends.

Eg of social influence on DSM is the changing status of homosexuality across editions. Homosexuality was a diagnosed mental disorder in DSM-I and early printings of DSM-II. Political lobby in the early 1970s led to it being removed in later printings of DSM-II. In DSM-III, homosexuality appeared in the form of ‘ego-dystonic homosexuality’ (the person’s sexual arousal pattern causes them distress), and in DSM-III-R, homosexuality was removed altogether.

The DSM project is commonly criticised for being unduly influenced by commercial interests, particularly large pharmaceutical companies.

Changes in DSM-5

The multi-axial system of documenting a diagnosis has been removed, so that the former Axes I (clinical disorders), II (personality disorders) and III (general medical conditions) psychosocial and contextual factors (formerly Axis IV) and global assessment of functioning (formerly Axis V).

The chapter order has been restructured based on the relatedness of disorders to one another in terms of similarities in underlying vulnerabilities and symptom characteristics. This change will align the DSM-5 more closely with the ICD.

Grouping of Diagnostic Categories

The DSM-5 groups are:

1. Neurodevelopmental disorders

2. Schizophrenia Spectrum & other Psychotic Disorders

3. Bipolar Disorders

4. Depressive Disorders

5. Anxiety Disorders

6. Obsessive Compulsive & Related Disorders

7. Trauma and Stress-Related Disorders

8. Dissociative Disorders

9. Somatic Symptom & Related Disorders

10. Feeding and Eating Disorders

11. Elimination Disorders

12. Sleep-Wake Disorders

13. Sexual Dysfunctions

14. Gender Dysphoria

15. Disruptive, Impulse-Control Disorders & Conduct Disorders

16. Substance Abuse-Related Disorders

17. Neurocognitive Disorders

18. Personality Disorders

19. Paraphillic Disorders

20. Other Mental Disorders

21. Medication-Inducted Movement Disorders

22. Other Conditions That may be a Focus of Clinical Attention

Obvious Changes in DSM-5 The diagnostic groups have been reshuffled There is a dimensional component to the categories (mild, moderate, severe). The goal has been to have the categories more

sensitive to gender and cultural differences Diagnostic codes will change from numeric to

alphanumeric e.g., Obsessive Compulsive Disorder will change from 300.3 to F42

Terminology“general medical condition” is replaced in

“another medical condition”Mental retardation (used in DSM-IV) –

intellectual disability is the term used among medial, educational and other professionals. US federal statue replaced the term.

Intellectual development disorder was placed in parenthesies to reflect the WHO classification system (ICD11 will not be adopted for several years, so ID was chosen as the current preferred term with the bridge term for the future in parentheses.

Communication DisorderLanguage disorder (which combines

DSM-IV expressive and mixed receptive-expressive language disorders),

Speech Sound Disorder (a new name for phonological disorder)

Childhood-onset Fluency Disorder (a new name for stuttering)

Social (pragmatic) Communication Disorder a new condition for persistent difficulties in social uses of verbal and nonverbal communication.

Attention-Deficit/Hyperactivity Disorder

Same 18 symptoms are used divided into 2 symptom domains (inattention and hyperactivity/impulsivity) of which at least 6 symptoms in 1 domain are required.

1) the cross-situational requirement has been strengthened to “several” symptoms in each setting;

2) the onset criterion has been changed from “symptoms that caused impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”

3) a comorbid diagnosis with ASD is now allowed; and

4) a symptom threshold change (adults), to reflect their evidence of clinically significant ADHD impairment, with the cutoff for ADHD of five symptoms, instead of six required for younger persons, both for inattention and for hyperactivity and impulsivity.

5) Now in neurodevelopmental disorders chapter to reflect brain developmental correlates.

Specific Learning Disorder

Combines the DSM-IV diagnoses of 1) reading disorder, 2) mathematics disorder, 3) disorder of written expression, 4) learning disorder not otherwise specified.

Learning deficits in the areas of reading, written expression, and mathematics commonly occur together, coded specifiers for the deficit types in each area are included.The text acknowledges that specific types of reading deficits are described internationally in various ways as dyslexia.

Bipolar and related disorders

Bipolar is now a free standing category

Taken out of the mood disorder category

Depressive Disorders

Dysthymia now called Chronic Depressive Disorder D03

Added Prementrual Dysphoric Disorder D04

Added Mixed Anxiety/Depression D05

Disruptive Mood Dysregulation Disorder

To address concerns about potential over diagnosis and overtreatment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is included for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol.

Disruptive Mood Dysregulation Disorder Chronic persistent irritability. Irritability has 2 prominent clinical manifestations,

1)temper outburst (in response to frustration and can be verbal or behavioural). They must occur frequently (ie average 2 -2 times a week) over at least 1 year in at least two settings (ie home, school) and they must be developmentally inappropriate.

The second manifestation of severe irritability consists of chronic, persistently irritable or angry mood that is present between the severe temper outburst. This irritable or angry mood must be characteristic of the child, being present most of the day, nearly every day and noticeable by others in the child’s environment.

Diagnosis not make before age of 6 or over18 yrs.

Critique Disruptive Mood Dysregulation Disorder

Society for Humanistic Psychology (2011) stated Children and adolescents will be particularly susceptible to receiving a diagnosis of Disruptive Mood Dysregulation Disorder or Attenuated Psychosis Syndrome.

The British Psychological Society (2011) stated diagnoses such as Disruptive Mood Dysregulation Disorder presented in DSM-5 are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgments, with little confirmatory physical 'signs' or evidence of biological causation. They stated that the criteria used for this diagnosis in the DSM-5 are not value-free, but rather reflect current normative social expectations.

Anxiety Disorders

No longer has PTSD in this category

No longer has OCD in this category

Social Phobia now called Social Anxiety Disorder E04

Obsessive-Compulsive and Related Disorders

OCD is now a stand alone category Body Dysmorphic Disorder listed under OCD as F01 Added Hoarding under category of OCD as

F02 Trichotillomania now called Hair-Pulling

Disorder is listed under OCD as F03 Skin Picking Disorder moved under OCD as

F04

Trauma and Stressor Related Disorders

Trauma related disorders are now a stand alone categoryReactive Attachment Disorder is now listed here G00 Added Disinhibited Social Engagement Disorder G01Added PSTD in Preschool Children G03Acute Stress Disorder is now listed here G04PTSD is now listed here G05Adjustment Disorders are now listed here G06

Somatic Symptom Disorder

Replaced Somatiform Disorders with this category

Eliminated the following: Somatization Disorder; Pain Disorder; and Hypochondriasis

Added Complex Somatic Symptom Disorder J00 Added Simple Somatic Symptom Disorder J01 Added Illness Anxiety Disorder J02 Conversion Disorder renamed Functional Neurological Disorder J03

Concerns about DSM-5

Revisions will promote Inaccurate diagnosesDiagnostic inflationPrescribing of unnecessary &

potentially harmful medication.

Critique of DSM-5

The British Psychological Society (2011) put out a major critique of the DSM-5. Their concern: clients and general public are negatively affected by “medicalization of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.”

ACA’s Concerns about DSM-5

A major concern for professional counselors is proposed definition of mental disorders. The language suggested implies that all mental disorders have a biological component. An example of mental disorders that do not necessarily have a biological basis is the severe anxiety an individual may face upon losing a job. This is an environmental issue, according to ACA, not necessarily a problem rooted in biology. The trauma faced by an earthquake victim or the grief following the death of a loved one are other examples of mental conditions that might lead an individual to seek therapy, yet would not qualify under the proposed definition emphasizing a biological basis.

AutismDSM-IV – 4 subtypes of autism

classified under the label of ‘pervasive developmental disorders’

Autistic disorderAsperger’s disorderChildhood disintegrative disorderPervasive developmental disorder-not

otherwise specified and

Autism Spectrum Disorder One central diagnosisThe diagnosis of ASD will be

accompanied by an indication of the severity level of presenting symptoms (3-point scale)

DSM-IV - triad of symptom categories 1) impaired social reciprocity;2) impaired language/communication 3) restricted and repetitive pattern of

interests/activities.

DSM V - two symptom categories 1) Social communication deficits

(combining social and communication deficits)

2) Restricted/repetitive behaviours.

Behaviours listed under ‘social communication deficits’ and repetive behaviours’ overlap partially with those in the DSM-IV with 2 changes: ‘language impairment/delay’ is no longer included in DSM-5 and ‘unusual sensitivity to sensory stimuli’ a clinical feature of autism that was not in the previous classification, is now listed within the repetitive behaviour category.

Both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present.

DSM -5 ASD

Presence of all 3 symptoms in the social communication deficits category and at least 2 out of 4 listed in the repetitive behaviours category.

Onset in early developmental period The criterion of onset before 36

months used in the DSM-IV is replaced with the ‘open’ definition in DSM-5. “Symptoms must be present in the early developmental period, but may not fully manifest until social demands exceed limited capacities”.

Dual If the child presents with

additional symptoms that are sufficient to meet criteria for other disorders, it is possible to assign a double diagnosis under the DSM-5 (e.g., ASD + ADHD). This was not the case under the DSM-IV.

Differential Diagnosis The DSM-5 also introduces a new diagnostic label within the category of ‘Language Impairments’: ‘Social Communication Disorder’. The diagnostic features partially overlap with that of ASD, as children diagnosed with social communication disorder are required to have an “impairment of pragmatics” and impairment in the “social uses of verbal and nonverbal communication”. However, the presence of fixated interests and repetitive behaviours is an exclusionary criterion. Therefore, the occurrence of repetitive behaviours will be essential for the differential diagnosis of ASD.

Rational for changesEmpirical data (Ozonoff, 2012). Longitudinal research –subtypes are inconsistent

over timeDifferences in social and cognitive abilities between

subgroups are better characterised in terms of a continuum (Daniels et al., 2011; Prior et al., 1998).

Reliability -diagnostic subtypes of in DSM-IV was poor across sites (Asperger’s disorder at one site and autistic disorder at another; Lord et al., 2012).

Little evidence for differences between autistic disorder and Asperger’s disorder at the phenotypic and genotypic level (Frith, 2004; Macintosh & Dissanayake, 2004).

The relevance assigned to the presence of repetitive behaviours and the elimination of the language-related criteria is based on recent studies documenting that repetitive behaviours, including abnormal sensory responses, emerge early in the development of children with ASD and, unlike language difficulties, are a distinctive feature of ASD (Ben-Sasson et al., 2009). Finally, introduction of the new diagnostic category of ‘Social Communication Disorder’ is motivated by evidence that some children might present with impairments in the social use of communication without having repetitive/restricted behaviours (Rapin & Allen, 1983).

Criticisms ASD Too narrow

McPartland and colleagues (2012) found that the DSM-5 criteria missed 40 per cent of individuals who would meet the DSM-IV criteria. Other studies found the percentage of cases that would be missed by the DSM-5 to be lower, but still substantial: 32% in Worley & Matson, 2012; 12% in Frazier et al., 2012; 9% in Huerta et al. (2012) ; 7% in Mazefsky et al. (2013); 37% in Taheri & Perry, 2012; 22% in Wilson et al. (2013); and 23% in Gibbs et al. (2012) – this latter study including an Australian sample.

While the different results of these studies are likely to reflect different methodologies, the overall picture emerging from this literature is that fewer individuals will meet criteria for autism under the new diagnostic system.

ASD DSM 5A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history:Deficits in social-emotional reciprocityDeficits in nonverbal communicative behaviours used for social interactionDeficits in developing, maintaining and understanding relationshipsB. Restricted, repetitive patterns of behaviour, interests or activities as manifested by at least two of the following, currently or by history:Stereotyped or repetitive motor movements, use of objects, or speechInsistence on sameness, inflexible adherence to routines, or ritualised patterns of verbal or nonverbal behaviourHighly restricted, fixated interests that are abnormal in intensity or focusHyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environmentC. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life)D. Symptoms cause clinically significant impairment in social, occupational or other important areas of current functioningE. These disturbances are not better explained by intellectual disability (intellectual developmental disorder), or global developmental delay.

Summary of key changes to specific disorders

Binge eating disorderThis is now officially recognised as a disorder, as in the DSM-IV it was in an appendix as a condition requiring further study. The inclusion as a disorder is intended to better represent the symptoms and behaviours of people with this condition.Disruptive mood dysregulation disorderThis has been included as a disorder to diagnose children who exhibit persistent irritability and frequent episodes of behaviour outbursts three or more times a week for more than a year. The diagnosis is intended to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children.

Summary of key changes to specific disorders

Posttraumatic stress disorder (PTSD)A new chapter in the DSM-5 on Trauma- and Stressor-Related Disorders. The DSM-5 pays more attention to the behavioural symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. PTSD criteria are also more developmentally sensitive for children and adolescents. Removal of bereavement exclusionThe exclusion criterion in the DSM-IV that applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one has been removed and replaced by several notes within the text delineating the differences between grief and depression. This reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one

Summary of key changes to specific disorders

Excoriation (skin-picking) disorderThis is a new disorder for the DSM-5 that will be included in the Obsessive-Compulsive and Related Disorders chapter. Hoarding disorderThis is a new disorder for the DMS-5 and is supported by extensive scientific research on the disorder. The diagnostic criteria will help to identify people with persistent difficulty discarding or parting with possessions, regardless of their actual value. The behaviour usually has harmful effects for a hoarder and family members, including emotional, physical, social, financial and even legal impacts. Pedophilic disorderThe disorder name has been revised from pedophilia in the DSM-IV to pedophilic disorder in the DMS-5, but the criteria for this disorder remain unchanged from those in the DSM-IV.

Substance use disorderThis new disorder in the DSM-5 combines the DSM-IV categories of substance abuse and substance dependence. In this one overarching disorder, the criteria have not only been combined, but strengthened. Previous substance abuse criteria required only one symptom while the DSM-5’s mild substance use disorder requires two to three symptoms.

Personality disordersThe 10 personality disorders included in the DSM-IV remain in DSM-5, although changes had been proposed. The categorical model and criteria have been maintained, but new trait-specific methodology has been included in a separate area of Section 3 to encourage further study on how this could be used to diagnose personality disorders in clinical practice.

Specific learning disorderThe criteria for this disorder in the DSM-IV have been broadened to represent distinct disorders which interfere with the acquisition and use of one or more of the following academic skills: oral language, reading, written language or mathematics.

SummaryMany changes and clinicians will take

a while to adjust. Lot of consultation and lot of criticism DSM 5 appBreak it down into chapters and look

at one a week in a study group. Clinical interview based on DSM 5 is

the gold standard and a common language.

Good Luck !!!

Websites on DSM-5

Official APA DSM-5 site: www.dsm5.org

DSM-5 on: www.coping.us