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09/06/2013
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DSM-5 OverviewTACE 8
Changes in the Diagnostic and Statistical Manual of Mental Health Disorders
Matthew Markve, Ph.D., CRC
Session Overview
Why 5?
Changes and rationale
Understanding the DSM-5/ICD-10 CM transition
How DSM-5 relates to ICD-9/10-CM codes
Major diagnostic changes in the DSM-5
(Non-comprehensive)
Major criticisms of the changes in the DSM-5
Extra time built in for discussion/questions (South Dakota only)
*APA unless noted refers to the American Psychiatric Association (www.psychiatry.org)
*Source unless noted (www.psychiatry.org/DSM5)
Why do we have to buy another book?
34 years since initial DSM-IV release
High comorbidity within/across chapters
High reliance on (NOS)
Less agreement with studies over time (research disagreement with DSM-IV-x criteria)
RSA
*More remains the same than different (APA mentions continuity)
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Version Definitions
DSM-IV-R: Diagnostic and Statistical Manual of Mental Health Disorders (4th Edition, Text Revision)
DSM-5: DSM 5th Edition
ICD-9-CM: International Classification of Diseases (Ninth Revision, Clinical Modification)
ICD-10-CM: (Tenth Revision, Clinical Modification)
Bluebook: the ICD-10 Classification of Mental and Behavioural Disorders Clinical Descriptions and Diagnostic Guidelines
ICD-10-CM Code Format Rules
Contains:
Categories: First 3 characters (XXX.xxxX)
Subcategories: Each level of subdivision after a category (xxx.XXXx)
Code: Final level of subdivision
Valid codes can contain 3-7 characters (some categories are valid codes)
Codes are not valid unless they reach the maximum level of specificity (simply subcategories or categories prior to this)
http://www.cdc.gov/nchs/icd/icd10cm.htm#10update
ICD 9-CM 10-CM Code Shift
Allows more specific information relevant to ambulatory and managed care
Expanded injury codes
Combines some diagnosis/symptom codes to Reduce number of codes needed to fully describe condition combination of diagnosis/symptom codes
Allows for greater specificity and further expansion
ICD 11 scheduled for 2015 release (not likely to arrive here soon)
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DSM/ICD Versions and Current Use
Valid for current use
Includes Physical Disabilities
MentalHealth Disorders
HIPAACMS use
DSM-IV-R
DSM-5 *
ICD-9-CM *
ICD-10-CM Delayed untilOctober 1, 2014
From http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/Insurance-Implications-of-DSM-5.pdf
RSA Statement on Implementation
RSA Policy Directive PD-13-05:
“The Centers for Medicare and Medicaid Services (CMS) has delayed implementation of the ICD-10 disability codes until October 1, 2014, and the National Center for Health Statistics has stated on its website that the use of the ICD-10 disability codes is not valid until October 1, 2014. As a result of CMS’ delayed implementation of the ICD-10 codes, RSA is delaying the use of the ICD-10 codes and/or the DSM-V codes until such time as we have consulted with CMS on the implementation of the new coding structures including whether CMS will move to DSM-V codes or rely solely on ICD-10 codes. Revised instructions will be issued upon implementation of the ICD-10 and/or DSM-V codes.”
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ICD10Data.com
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DSM-5 Structure Three major sections
Section I: DSM-5 introduction and instructions for use
Section II: Categorical diagnoses section
The core of the document
The core of today’s presentation
Section III: Tentative diagnoses which require additional research prior to inclusion in section II (or elimination).
DSM-5 Features (APA, 2013) “Harmonized” with ICD
Includes crosswalks to ICD-9-CM and (ICD-10) codes
Changed numbering convention (DSM-I, II, III, IV) becomes DSM-5 (5.1, 5.2, 5.3…)
Allows more frequent, minor updates
DSM-5 Major Structural Changes
Chapter organization changed to reflect developmental approach
Disorders more frequently diagnosed in childhood come first.
Also influenced by genetics/neuroimaging
Organization in line with ICD 11 approach
Section III added
Emerging disorders/further study
DSM multi axial diagnostic system removed
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DSM 5: Diagnostic ChangesNeurodevelopmental Disorders
Schizophrenia Spectrum and Other Psychotic Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma and Stressor-Related Disorders
Dissociative Disorders
Somatic Symptom and Related Disorders
Sleep-Wake Disorders
Disruptive, Impulse-Control, and Conduct Disorders
Substance-Related and Addictive Disorders
Neurocognitive Disorders www.psychiatry.org/DSM5
Neurodevelopmental Disorders
Intellectual Disability (replaces MR)
Cognitive Capacity
Adaptive Functioning (determines severity)
Placed at front of Section II due to early developmental impact and diagnosis
Neurodevelopmental Disorders
Communication Disorders
Language disorder:
combines speech sound disorder (formerly phonological disorder) and childhood-onset fluency disorder (formerly stuttering)
Social Communication Disorder introduced:
One example of the attempt to eliminate (NOS), particularly around autism. To qualify for SCD an individual must have social communication issues but in absence of the “restricted repetitive behaviors, interests, and activities” found in autism spectrum disorder.
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Autism Spectrum Disorder (ASD)
“New, more accurate, and medically and scientifically useful way of diagnosing individuals with autism-related disorders”
Eliminates: Autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified.
Individuals concerned with loss of identity/disorder classification (especially Asperger's population)
http://www.dsm5.org/Documents/Autism%20Spectrum%20Disorder%20Fact%20Sheet.pdf
Autism Spectrum Disorder (ASD)
Huerta, et al. (2012) found 91% of children with DSM-IV diagnoses on the spectrum meet the DSM-5 ASD criteria
“Anyone diagnosed with one…should still meet the criteria for ASD in DSM-5 or another, more accurate DSM diagnosis.”
Social communication/interaction deficits AND restricted repetitive behaviors/interests/activities required components
Attention-Deficit/Hyperactivity Disorder Retains same 18 symptoms
Retains:
Inattention domain
Hyperactivity/impulsivity domain
DSM-5 changes:
Added examples and specifiers
Children/Older Adolescents/Adults
Requires ‘several’ symptoms in each setting
Symptoms now present before age 12 instead of age 7 (research illustrated no benefit to younger threshold)
Allows for comorbid diagnosis with ASD
Recognizes significant number continue to show symptoms into adulthood
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Specific Learning Disorder Combines DSM-IV’s reading disorder, mathematics
disorder, disorder of written expression, and learning disorder not otherwise specified.
Supersedes with coded specifies for deficit types in each area.
315.00 (F81.0) With impairment in reading
315.2 (F81.81) With impairment in written expression
315.1 (F81.2) With impairment in mathematics
*multiple areas of impairment require individual codes for each
Motor Disorders
Tic criteria have been standardized across all disorders in neurodevelopment chapter
“Tic disorders are characterized by the presence of motor or vocal tics, which are sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations.”
Schizophrenia Symptom threshold requirement has been raised from
one to at least two.
Diagnostic subtypes have been eliminated
Used to be dictated by predominant subtype on evaluation, but symptoms often changed (limited diagnostic stability, decreased validity, low reliability)
Some subtypes are now specifiers
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Schizophrenia Spectrum and Other Psychotic Disorders
Schizoaffective Disorder: Now requires a major mood episode (depressive or manic) for the majority of disorder’s total duration after the criteria for (Schizophrenia part A) are met
Delusional Disorder:
Removed requirement that delusions must be non-bizarre
No longer separates delusional disorder from shared delusional disorder
Requires symptoms not better explained by OCD or body dysmorphic disorder
Schizophrenia Spectrum and Other Psychotic Disorders
Catatonia:
DSM-IV: Required 2 of 5 symptom clusters within psychotic/mood disorder context and one cluster if context was general medical
DSM-5: All contexts require three catatonic symptoms(from 12 total)
Allows catatonia to be used as:
Specifier for depressive/bipolar/psychotic disorders
Separate diagnosis in context of another medical condition
Other specified diagnosis
Bipolar and Related Disorders
Bipolar Disorder:
Added an emphasis on change in activity and energy in addition to ‘mood’
Removed ‘Bipolar I disorder, mixed episode’
Replaced with specifier ‘with mixed features’
Addition of Other Specified Bipolar and Related Disorder
Allows diagnosis for individuals who fall short of hypomania criteria (duration or too few symptoms for full bipolar II)
Addition of Anxious Distress Specifier
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Depressive Disorders ‘Streamlined’ like bipolar
Addition of new disorders:
Premenstrual dysphoric disorder
Formerly in DSM-IV appendix for further study
Disruptive mood dysregulation disorder
Response to overdiagnosis of children-18 with bipolar disorder in children
Exhibit persistent irritability and inability to control behavior
Depressive Disorders Added ‘with mixed features’ specifier to major
depressive disorder.
In cases where symptoms of mania are present but insufficient to meet criteria for manic episode
Two month bereavement exclusion removed from DSM-5
Grief duration found to be longer
Bereavement can precipitate major depressive episode
Bereavement related major depression more likely to occur in individuals with history of past depressive episodes
Anxiety Disorders OCD/PTSD removed from anxiety disorders chapter
Obsessive-compulsive and related disorders get own chapter (next)
PTSD and acute stress disorder included in trauma/stressor related disorders (after OCD chapter)
Illustrates how DSM-5 chapters are ordered in their relation to similar disorders
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Anxiety Disorders Agoraphobia, Specific Phobia, and Social Anxiety
Disorder
Removed requirement that adults recognize anxiety is excessive/unreasonable
Added requirement that anxiety is out of proportion to actual threat
6-month requirement now extends to adults as well as under 18
Anxiety Disorders Panic Attack
Removed confusing terminology describing different types of attacks and added ‘expected or unexpected’
Panic Disorder and Agoraphobia
Previously linked (with or without agoraphobia)
Now separate diagnoses (requiring separate coding if conditions for both are met)
Selective Mutism: moved into anxiety disorder section due to link with anxiety. Criteria unchanged.
Anxiety Disorders Social Anxiety Disorder
Formerly known as Social Phobia
Generalized specifier (social situations) replaced with performance specific specifier (public speaking)
Separation Anxiety Disorder: Like selective mutism, moved out of early development chapter (also had onset before 18 requirement removed)
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Obsessive-Compulsive and Related Disorders New chapter
Clinical utility
Relation to surrounding chapters
Includes trichotillomainia (moved from impulse-control disorders)
Removed “with poor insight” specifier for OCD in favor of
Good or fair insight (recognizes beliefs are definitely or probably not true…or that they may or may not be true)
Poor insight (thinks beliefs are probably true)
Absent insight/delusional (completely convinced)
Obsessive-Compulsive and Related Disorders Body Dysmorphic Disorder:
Added “with muscle dysmorphia”
Preoccupied with small build or insufficient muscularity
Delusional variant removed
Formerly delusional disorder, somatic type, and body dysmorphic disorder
Now simply body dysmorphic disorder with the good/fair, poor, or absent insight/delusional beliefs specifier
Obsessive-Compulsive and Related Disorders Hoarding Disorder
New diagnosis
Previously symptom of OCD
Data didn’t back hording as a variant within OCD, but instead warranted a new diagnosis
“Persistent difficulty discarding or parting with possessions due to a perceived need to save the items and distress associated with discarding them.”
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Obsessive-Compulsive and Related Disorders Trichotillomania (Hair-Pulling Disorder)
Excoriation (Skin-Picking) Disorder: New addition
Former specifiers moved into new chapter and disorders:
Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
Symptoms develop soon after intoxication, withdrawal or exposure
Obsessive-Compulsive and Related Disorder Due to Another Medical Condition
(OCD best explained as direct pathophysiological result of another medical condition)
Other Specified and Unspecified Obsessive-Compulsive and Related Disorders
Catch-all category including everything from Body-focused repetitive behavior (other than hair pulling/skin picking) to ‘obsessional jealousy’ and other ‘unspecified’ disorders
Trauma and Stressor Related Disorders Acute Stress Disorder:
Now requires more elaboration on how traumatic events were experienced (directly, witnessed, indirectly)
Removed DSM-IV requirement that the “person’s response involved intense fear, helplessness, or horror”
Posttraumatic Stress Disorder:
Significant change in criteria
Same elaboration now required as in acute stress disorder (directly, witnessed, indirectly)
Also removed subjective experience language similar to acute stress disorder
Three symptom clusters expanded to four through division of avoidance/numbing into ‘avoidance’ and ‘persistent negative alterations in cognitions and mood’
Lowered diagnostic thresholds for children and adolescents
Added separate criteria for age 6 and below
Trauma and Stressor Related Disorders
Reactive Attachment Disorder:
Split into two disorders
Reactive Attachment Disorder
Lack of/incompletely formed preferred attachment to caregivers
Disinhibited Social Engagement Disorder
May have established/secured attachments
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Dissociative Disorders Depersonalization/Derealization Disorder
Formerly depersonalization disorder, now with the inclusion of derealization!
Dissociative fugue no longer a disorder, but now a specifier of dissociative amnesia
Dissociative Identity Disorder
Criteria A expanded:
“Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.”
Criteria B expanded to include gaps in recall for everyday events in addition to traumatic experiences
Somatic Symptom and Related Disorders
Formerly somatoform disorders
DSM-5 lowered the number of disorders/subcategories due to high overlap (problematic use) between DSM-IV somatoform disorders
Removed: somatization disorder, hypochondriasis, pain disorder (now specifier: somatic symptom disorder with predominant pain) and undifferentiated somatoform disorder
DSM-5: High likelihood that a individuals would meet the criteria of a separate somatic symptom disorder
Somatic Symptom Disorder: Merges somatization disorder and undifferentiated somatoform disorder
Eliminates ‘long and complex symptom count’ in favor of ‘one or more somatic symptoms’ but adds the requirement ‘that are distressing or result in significant disruption of daily life’
Somatic Symptom and Related Disorders
Reduced emphasis on medically unexplained symptoms
Eliminated where unable to determine source of unexplained symptoms
Retained in conversion disorder and pseudocyesis where “it is possible to demonstrate definitively in such disorders that the symptoms are not consistent with medical pathophysiology”
Psychological Factors Affecting Other Medical Conditions: new disorder
Adversely impacting an existing medical condition by increasing risk of suffering, death or disability
Few DSM-5 examples: (anxiety-impacting asthma, denying need to treat acute chest pain, insulin manipulation by person with diabetes in an attempt to lose weight)
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Somatic Symptom and Related Disorders
Factitious Disorder: Moved to this chapter
Falsification of medical or psychological signs/symptoms
Factitious Disorder Imposed on Another replaces Factitious Disorder by Proxy
Conversion Disorder (Functional Neurological Symptom Disorder)
Altered voluntary motor/sensory function with incompatible neurological or medical condition causing clinically significant distress or impairment
Greater emphasis on importance of neurological examination
Sleep-Wake Disorders Sleep disorders related to another mental disorder or
related to a general medical condition have been removed
Pertinent information derived from removed sleep disorders have been integrated into DSM-5 sleep-wake disorders
Requirements subsequently raised to specify coexisting conditions
Breathing-Related Sleep Disorders divided into three disorders:
Obstructive sleep apnea hypopnea
Central sleep apnea
Sleep-related hypoventilation
Sleep-Wake Disorders Circadian Rhythm Sleep-Wake Disorders expanded to
include the following specifiers:
Advanced sleep phase syndrome
Irregular sleep-wake type
Non-24-hour sleep-wake type
Rapid Eye Movement Sleep Behavior Disorder (new):
Repeated episodes of arousal as a result of REM sleep
Can involve loud, profane vocalizations
Can involve complex muscle movements (punching, hitting, kicking)
Restless Leg Syndrome (new):
Sensorimotor, neurological sleep disorder
Desire to move legs or arms, generally associated with uncomfortable sensations
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Disruptive, Impulse-Control, and Conduct Disorders New DSM chapter including disorders characterized by
problems in emotional and behavioral self-control
Antisocial Personality Disorder is listed in both this chapter and the chapter on personality disorders due to close affiliation with conduct disorders
Includes items from DSM-IV chapters on impulse-control disorders not otherwise specified (intermittent explosive disorder, pyromania, kleptomania) and disorders usually first diagnosed in infancy, childhood or adolescence (oppositional defiance disorder, conduct disorder)
Disruptive, Impulse-Control, and Conduct Disorders Oppositional Defiant Disorder:
The 8 symptoms found in IV have been grouped into three groups of symptoms, however the threshold remains 4 symptoms :
Angry/irritable mood
Argumentative/defiant behavior
Vindictiveness
The requirement that criteria are not met for conduct disorder has been removed
Clarification has been provided on the frequency threshold required to qualify for a disorder
Severity has been added to the criteria reflecting number of settings where symptoms are present
Mild: One setting (home, school, work, peers)
Moderate: Two
Severe: Symptoms are present in three or more settings
Disruptive, Impulse-Control, and Conduct Disorders Conduct Disorder:
Added specifier ‘with limited prosocial emotions’ (indicating likely more severe form of disorder)
Requires at least two characteristics displayed persistently over a year and across multiple relationships and settings
Lack of remorse or guilt (excludes remorse when ‘caught’)
Callous-lack of empathy
Unconcerned about performance
Shallow or deficient affect
Intermittent Explosive Disorder
Verbal aggression can now satisfy criteria A1 (in addition to physical outbursts)
Frequency thresholds established/clarified:
Verbal or physical aggression (without physical injury) twice weekly on average over three months (or)
Three outbursts involving damage/destruction of property/physical assault in a year
Must be at least six years of age
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Substance-Related and Addictive Disorders DSM-5 drops distinction between substance abuse and
dependence and combines criteria into one list
Recurrent legal problems dropped as criteria
Craving/strong desire/urge to use added as criteria
The criteria thresholds from DSM-IV for abuse (one) and dependence (three) have been removed and replaced with a threshold of two criteria for a substance use disorder diagnosis
Gambling Disorder (new)
Similar criteria to other chapter disorders
Increasing amounts of money to achieve excitement (tolerance)
Restless/irritable attempting to cut down (withdrawal)
Specifiers:
Episodic or persistent
Early or sustained remission
Mild (4-5), Moderate (6-7) or Severe (8-9 criteria met)
Neurocognitive Disorders Delirium: Now includes disturbance development over a
short period of time (hours to a few days) and is a change from baseline attention/awareness
Major and Mild Neurocognitive Disorder (NCD) (new)
Dementia and amnestic disorder gone, now classified under major NCD
Mild NCD now recognized by DSM (who admit that the distinction between major and mild is somewhat arbitrary)
Major “significant cognitive decline”
Mild “modest cognitive decline”
Specifiers for both Major and Mild NCD include Alzheimer’s, frontotemporal lobar degeneration, Lewybody, vascular disease, TBI, substance/medication use, HIV infection, prion disease, Parkinson’s, Huntington’s, other, multiple and unspecified
Both also include the specifier with or without behavioral disturbance
Major also requires current severity (mild, moderate, severe)
DSM-5 Controversies Global issues
Criticism of potential conflicts of interest in panels (many disclosed prior work with drug companies)
Lack of transparency in development phase
Validity issues (document itself provides reliability)
Criticism that the new structure and approach is too centered on biological causes
Criticism that the new structure doesn’t go far enough with a biological approach (NIMH Director highly critical, forming own Research Domain Criteria (RDoC))
Created to generate money for APA (DSM-IV-TR was fine)
Committee engaging in “nomenclatural exploration”
Disorder Specific Issues
Changes in _____ have impacted potential assistance through loss of disorder diagnosis (Loss of Asperger’s designation/self identification)
Changes in _____ have broadened the pool to include individuals who don’t require pharmacological interventions (bereavement exclusion removal)
