DSM-5: Practical Overview of Changes

Faculty

Michael B. First, MD

Professor of Clinical PsychiatryColumbia UniversityNew York, New YorkAttending Physician

New York-Presbyterian HospitalNew York, New York

Faculty Disclosure

• Dr. First receives royalties from DSM-related publications

Learning Objectives

• Review the new organization structure of the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5)

• Explain the rationale, implications, and manifestations of the incorporation of a more dimensional approach to DSM-5

• Describe the background and practical implications of the forthcoming changeover from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM codes

• Discuss the changes being made throughout the DSM-5, including their rationale and practical implications

• Identify the controversies surrounding some of the changes, including their pros and cons

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.

Value of Making a DSM Diagnosis

• Well-defined and reliable terminology facilitates communication among clinicians, administrators, lawyers, patients, and families

– Provides convenient short-hand when describing psychiatric presentations

• Assigning DSM diagnosis provides direct access to psychiatric literature about treatment, prognosis, etc

– Journal articles, practice guidelines, textbooks for the past 33 years have been geared to DSM definitions of mental disorders

• Facilitates assignment of diagnostic code for payment

Limitations of Making a DSM Diagnosis

• Most treatment decisions are geared to symptoms regardless of diagnosis (eg, psychosis)

• Diagnostic heterogeneity limits predictive power of diagnoses

• Diagnoses are not informative about etiology or pathophysiology

• High rates of NOS limit clinical utility in terms of communication and access to the literature

NOS = not otherwise specified.

Why a DSM-5 Is Needed

• Longest gap between DSMs ever

– DSM-IV criteria sets reflect research base circa 1993 (20-year gap)

– Text reflects research base circa 1999 (14-year gap)

• Need to coordinate with ICD-11 (to be published in 2017)

• Potential for DSM-5 to update definitions to reflect most recent research findings and to address identified weaknesses

Will DSM-5 Be More “Etiological” and/or Based on Objective Measures?

• The simple answer: No

• Genetics, neuroimaging, biological markers, etc will NOT be included in definitions of disorders in DSM-5/ICD-11

– Exception: polysomnography in sleep disorders and hypocretin in narcolepsy

• Problem is lack of diagnostic specificity on an individual patient level

– Tests able to identify clear differences between groups but not between individuals because of within group variability (ie, some non-affected people will have abnormal value on test that is higher than “affected” individuals)

Changes in Diagnostic Groupings (“Metastructure”)

• DSM-IV diagnostic classes mostly based on shared symptom presentation (eg, anxiety disorders)

• DSM-5 regrouping of disorders reflects 20 years of research on how the brain functions and interactions between genes and environment

– Groupings are based on putative common underlying factors (eg, internalizing vs externalizing) and underlying vulnerabilities

• Ordering of diagnostic groupings also reflects relationships among disorders

– eg, bipolar disorders following schizophrenia spectrum

DSM-5 “Metastructure”

DSM- 5

• Neurodevelopmental Disorders

– Includes Intellectual Disability, Global Developmental Delay, Autism Spectrum Disorder, Learning Disorders, Communication Disorders (including Social Pragmatic Communication Disorder), ADHD, Motor Disorders (Tics, Stereotyped Movement, Coordination)

• Schizophrenia Spectrum and Other Psychotic Disorders

– Includes Schizophrenia, Schizotypal PD, Schizoaffective, Brief Psychotic, Delusional Disorder, Substance-induced Psychotic Disorder, Psychotic Disorder due to AMC, Catatonia Associated with Another Mental Disorder, Catatonia due to AMC

DSM-IV

• Childhood Disorders

– Mental Retardation, Learning Disorders, Communication, PDD, Tic Disorders, part of Disruptive Behavior

• Schizophrenia and Other Psychotic Disorders

– Schizotypal in PD

ADHD = attention-deficit/hyperactivity disorder; AMC = another medical condition; PD = personality disorder; PDD = pervasive developmental disorder.

DSM-5 “Metastructure” (continued)

DSM-5

• Bipolar and Related Disorders

– Includes Bipolar I, Bipolar II, Cyclothymic, Substance-Induced Bipolar, Bipolar due to AMC

• Depressive Disorders

– Includes MDD, Chronic Persistent Depressive Disorder, Disruptive Mood Dysregulation Disorder, Premenstrual DysphoricDisorder, Substance-induced, due to AMC

DSM-IV

• Mood Disorders

MDD = major depressive disorder.

DSM-5 “Metastructure” (continued)

DSM-5

• Anxiety Disorders– Includes Separation Anxiety, Selective

Mutism, Social Anxiety, Specific Phobia, Panic, Agoraphobia, GAD, Substance-induced Anxiety, Anxiety due to AMC

• Obsessive-Compulsive and Related Disorders

– Includes OCD, BDD, Hoarding, Trichotillomania, Excoriation Disorder, Substance-induced, due to AMC

• Trauma- and Stress-Related Disorders

– Includes PTSD, Acute Stress, Reactive Attachment, Disinhibited Social Engagement Disorder, Adjustment Disorders

DSM-IV

• Anxiety Disorders– Separation Anxiety within Childhood

– Reactive Attachment within Childhood

– Trichotillomania within Impulse Control

• Adjustment Disorders

BDD = body dysmorphic disorder; GAD = generalized anxiety disorder; OCD = obsessive-

compulsive disorder; PTSD = posttraumatic stress disorder.

DSM-5 “Metastructure” (continued)

DSM-5• Dissociative Disorders

– Includes Depersonalization/ Derealization, Dissociative Amnesia, DID

• Somatic Symptom Disorders– Includes Somatic Symptom Disorder

Illness Anxiety, Conversion Disorder, Factitious Disorder, PFAMC

• Feeding and Eating Disorders– Includes Anorexia, Bulimia, Binge-

Eating Disorder, Avoidant/Restrictive Food Intake, Pica, Rumination Disorder

• Elimination Disorders– Includes Enuresis, Encopresis

DSM-IV• Dissociative Disorders

• Somatoform Disorders

• Factitious Disorders

• Feeding Disorders

• Eating Disorders

• Elimination Disorders

– Formerly in Childhood

DID = dissociative identity disorder; PFAMC = psychological factors affecting medical condition.

DSM-5 “Metastructure” (continued)

DSM-5• Sleep/Wake Disorders

– Includes several new disorders from ICSD including REM Sleep Behavior, Restless Leg Syndrome

• Sexual Dysfunctions

– Includes Male Hypoactive Sexual Desire Disorder, Erectile Disorder, Early Ejaculation, Delayed Ejaculation, Female Sexual Interest/Arousal Disorder, Female Orgasmic Disorder Genito-Pelvic Pain/Penetration Disorder

• Gender Dysphoria

DSM-IV

• Sleep Disorders

• Sexual Dysfunctions (within Sexual Disorders)

• Gender Identity Disorder (within Sexual Disorders)

ICSD = International Classification of Sleep Disorders; REM = rapid eye movement.

DSM-5 “Metastructure” (continued)

DSM-5• Disruptive, Impulse Control,

and Conduct Disorders

– Includes ODD, Conduct Disorder, Antisocial PD, Pyromania, Kleptomania, IED

• Substance Use and Addictive Disorders

– Includes Substance Use, Substance-Induced, Intoxication, Withdrawal, Gambling Disorder

DSM-IV• Disruptive Behavior

– ODD, Conduct (in Childhood)

• Impulse Control Disorder

– Pyromania, Kleptomania, IED

• Antisocial PD

– In personality disorders

• Substance-Related Disorders

– Pathological Gambling in Impulse Control Disorders

IED = intermittent explosive disorder; ODD = oppositional defiant disorder.

DSM-5 “Metastructure” (continued)

DSM-5

• Neurocognitive Disorders

– Includes Delirium, Major Neurocognitive Disorder, Mild Neurocognitive Disorder

• Personality Disorders

• Paraphilias

DSM-IV

• Delirium, Dementia, Amnesticand Other Cognitive Disorders

• Personality Disorders

• Paraphilias (within Sexual Disorder)

DSM-5 and Dimensions

“We have decided that one, if not the major, difference between DSM-IV and DSM-5 will be the more prominent

use of dimensional measures in DSM-5”

Regier DA, et al. Am J Psychiatry. 2009;166(6):645-650.

Dimensions vs Categories

• Although most patient data is dimensional (eg, blood pressure, laboratory values, severity of depression), all classification systems in medicine are categorical (eg, hypertension, MDD) reflecting nature of medical decisions

• Dimensions most useful for

– Documenting subthreshold symptoms

– Indicating and monitoring of disorder severity

– Communicating dimensional nature of syndromes

DSM-5 Moves Toward Dimensionality

• Combining categories with lower and higher severities into single broad categories with dimensional severity indicators

– Autistic Disorder (more severe) and Asperger’s disorder (less severe) combined into Autism Spectrum Disorder

– Substance Dependence (more severe) and Substance Abuse (less severe) combined into Substance Use Disorder

DSM-5 Moves Toward Dimensionality(continued)

• Reconceptualization of Neurocognitive Disorders on a dimensional continuum

– Major Neurocognitive Disorder: significant cognitive decline that interferes with independence in everyday activities

– Mild Neurocognitive Disorder: modest cognitive decline that does not interfere with capacity for independence but requires greater effort, compensatory strategies, or accommodation

DSM-5 Moves Toward Dimensionality(continued)

• Original plan for radical change in classification of personality disorders to a trait model dividing personality into 5 domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism

• Ultimately rejected because of concerns about complexity, validity, reliability, and clinical utility

• Placed in Section III (“Emerging Measures and Models”)

DSM-5 Moves Toward Dimensionality(continued)

• Original plan to include cross-cutting symptom measures, a disability scale, plus 150+ disorder severity measures as an official part of DSM-5

• With 2 exceptions (severity of intellectual disability, autism spectrum disorder), all were relegated to Section III

– Only 3 of these measures included in print version of DSM-5; remainder available for free in the on-line supplement (www.psych.org/dsm5)

– Although dimensions of psychosis symptom severity appear in Section III, severity ratings for psychotic disorders in Section II entails their use

Concerns About Adding Dimensional Measures to DSM-5

• No evidence that adding dimensions improves patient management or outcome

• No evidence for feasibility of use of dimensions in typical psychiatric settings

• None of proposed DSM-5 dimensions are codable and thus information cannot be indicated to payers

• Many are extremely complex (eg, 8 dimensions for psychosis, each rated 0 to 4)

• Could be co-opted by insurers to limit care (see GAF, Axis II)

GAF = Global Assessment of Functioning.

When Does DSM-5 Become “Official”?

• Answer: Never

– The only official coding system is ICD-9-CM (until October 1, 2015, when it will be ICD-10-CM)

– DSM-5 can be used immediately and will produce legal codes now (and after October 1, 2015)

– For most clinicians, its use is voluntary. One can meet legal requirements by using ICD-9-CM/ICD-10-CM codes

– Some institutions may require use of DSM-5 and may establish a mandatory implementation date

– Generally advantageous to use DSM-5 in order to maintain effective communication with the vast majority of clinicians who will be using it

DSM / ICD / ICD-CM Timeline

1975 1979 1980 1987 1992 1994 2000 5/2013 10/2015 2017

ICD-9-CM ICD-10-CM

DSM-III DSM-III-R DSM-IV

ICD-10

DSM-IV-TR DSM-5

ICD-11ICD-9

APA = American Psychiatric Association; NCHS = National Center for Health Statistics; WHO = World Health Organization.

WHO

NCHS

APA

Multiaxial System and DSM-5

• Multiaxial System eliminated in DSM-5

– Axis I (clinical disorders), Axis II (personality and mental retardation), and Axis III (medical conditions) listed together without separate designation

– Axis IV (psychosocial and environmental stressors) can be coded along with disorders using codes from “Other Conditions That May Be a Focus of Clinical Attention”

– Axis V (GAF) eliminated completely, “replaced” by optional WHO-DAS

WHO-DAS = WHO Disability Assessment Schedule.

Multiaxial System and DSM-5 (continued)

• Eliminated because of

– Concerns that use of multiaxial system put psychiatry at odds with rest of medicine, which does not use a multiaxial system (although perhaps medicine would benefit from its use)

– Concerns that placement of personality disorders on separate axis encouraged differential insurance coverage

Case Example: DSM-IV vs DSM-5

• 35-year-old homeless male with 13-year history of schizophrenia, type 2 diabetes, and recurrent hospitalizations for exacerbation of psychotic symptoms is brought to emergency room by police because of violent behavior related to hearing voices

• He also has a childhood history of conduct disorder with a pattern of antisocial behavior that has persisted into adulthood

DSM-IV Coding Using Multiaxial System

• Axis I: 295.30 Schizophrenia, Paranoid Type

• Axis II: 301.7 Antisocial Personality Disorder

• Axis III: 250.00 diabetes, type 2

• Axis IV: Homelessness

• Axis V: GAF = 25

DSM-5 Coding

• DSM-5: 295.90 Schizophrenia, multiple episodes, currently in acute episode, delusions present and severe, hallucinations present and severe, absent disorganized speech, abnormal psychomotor behavior and negative symptoms; 250.00 diabetes, type 2; 301.7 Antisocial Personality Disorder; V60.0 homelessness

WHO-DAS

• World Health Organization Disability Assessment Schedule 2.0

• Included in Section III; no evidence for its validity or clinical utility in mental health settings

• 36-item measure that assesses disability in adults age 18 years and older

• Self-report; if individual is impaired, knowledgeable informant can complete the proxy-administered version

WHO-DAS (continued)

• Individual asked to rate how much difficulty he or she has had in specific areas of functioning over the past 30 days

• 6 domains assessed:

– Understanding and communicating

– Getting around

– Self-care

– Getting along with people

– Life activities

– Participation in society

WHO-DAS (continued)

• Examples of items

– From Participation in Society domain: “In the past 30 days, how much of a problem did you have joining in community activities (for example, festivities, religious, or other activities) in the same way as anyone else can?”

– From Self-care domain: “In the past 30 days, how much of a problem did you have washing your whole body?”

– From Getting Around domain: “In the past 30 days, how much of a problem did you have standing for long periods, such as 30 minutes?”

Need for NOS Categories

• To cover the many presentations that do not fit into the precise diagnostic boundaries of the specific DSM-5disorders

• To cover situations in which the clinician does not have sufficient information to make a specific DSM-5diagnosis (eg, emergency room settings)

• To cover situations in which the clinician is uncertain whether a psychiatric presentation is primary, substance-induced, or due to AMC

Problem with NOS Categories

• Primary goal of DSM is to facilitate communication

• NOS categories communicate that the presentation is predominated by a particular symptom (eg, Psychotic Disorder NOS, Depressive Disorder NOS) but provides no other diagnostic information

NOS Split into 2 Categories in DSM-5

______ Disorder NOS

Other Specified _____ Disorder

Unspecified

_____ Disorder

Other Specified _____ Disorder

• For presentations in which the clinician has fully characterized the presentation but does not meet full criteria for existing disorders or for syndromes not included in the DSM-5

• Clinician writes in the reason why criteria are not met, eg, “Other Specified Bipolar Disorder, Short-duration hypomanic episodes (2-3 days) and major depressive episodes,” “Other Specified Feeding or Eating Disorder, Night Eating Syndrome”

Other Specified _____ Disorder (continued)

• Many Other Specified categories provide a numbered list of examples

– “Examples of presentations that can be specified using the ‘other specified’ designation include the following”

• Clinician can also write in the reason if not included among examples

• Problem: provides quasi-legitimacy with potential forensic implications to categories which are not accepted in DSM-5 as valid categories (eg, Attenuated Psychosis Syndrome listed as example)

Autism Spectrum Disorder

• Combined 5 DSM-IV categories: Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder, Rett’s Disorder, and Pervasive Developmental Disorder NOS

• Reflects dimensional nature of autism

• Evidence that Asperger’s is simply milder form of Autism rather than distinct condition (eg, relatives of Asperger’s have increased risk of both Asperger’s and Autistic Disorder)

Autism Spectrum Disorder (continued)

• Persistent deficits in social communication and social interaction (ALL)

– Deficits in social-emotional reciprocity

– Deficits in non-verbal communication

– Deficits in developing and maintaining relationships

• Restricted repetitive behaviors or interests (2 of 4)– Stereotyped behavior or speech

– Need for sameness and routines

– Abnormal fixations or restricted interests

– Hyper- or hypo-reactivity to sensory input

• Spectrum of severity provided (“ranging from…”)

Autism Spectrum Disorder Controversies

• Loss of Asperger’s as a distinct category– Rare example of destigmatized category (“Aspies” who

claim Einstein had Asperger’s)

– Concern about being put into same boat as more ill Autistic patients

• Increase in requirement in social communications domain (2 of 4 in DSM-IV vs 3 of 3 in DSM-5) led to concern about false negatives

• Note added– “Individuals with a well-established DSM-IV diagnosis of

autistic disorder, Asperger’s disorder, or pervasive developmental disorder NOS should be given the diagnosis of autism spectrum disorder.”

Schizophrenia Changes

• Diagnosis narrowed by excluding cases that met criteria for DSM-IV Schizophrenia

– Cases of disorganized or catatonic behavior AND negative symptoms (in DSM-5, delusions, hallucinations, or disorganized speech are required)

– Cases of bizarre delusions or certain kinds of auditory hallucinations (eg, running commentary) without other symptoms (in DSM-5, need 2 out of 5)

Schizophrenia Changes (continued)

• Subtypes, some dating back to turn of the century, are eliminated

– Paranoid Schizophrenia

– Catatonic Schizophrenia

– Disorganized Schizophrenia

– Undifferentiated Schizophrenia

– Residual Schizophrenia

• Not actually “types;” patients often change types over time

• Catatonia still can be indicated as a specifier

Severity Profile of Current Schizophrenia Symptoms

• Severity rated by quantitative assessment or primary symptoms of psychosis (ie, delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms)

• Rated for current severity (at its most severe point in the past 7 days) on a 5-point scale from 0 (not present) to 4 (present and severe)

• Each psychotic disorder (including substance-induced and psychotic disorder due to AMC) include these specifiers

Examples: Current Severity Rating for Delusion and Disorganized Speech

Domain Absent EquivocalPresent but

MildPresent and

ModeratePresent and

Severe

II. Delusions

0 1 = severity or duration not sufficient to be considered psychosis

2 = little pressure to act upon delusional beliefs, not very bothered by delusions

3 = some pressure to act upon beliefs, or is somewhat bothered by beliefs

4 = severe pressure to act upon beliefs, or is very bothered by beliefs

III. Disorganized Speech

0 1 = severity or duration not sufficient to be considered dis-organization

2 = some difficulty following speech

3 = speech often difficult to follow

4 = speech almost impossible to follow

Bipolar and Related Disorders

• Reduction of false positives

– Criterion A for mania and hypomania will require both mood disturbance (euphoric, elevated, or irritable mood) plus increase in activity or energy

– Mood disturbance must be present for most of the day, nearly every day during 4-day period (for hypomania) or 7-day period (for mania)

Elimination of Mixed Episode

• “With Mixed Features” specifier available for Manic, Hypomanic, and Major Depressive Episodes

– Manic or Hypomanic Episode with Mixed Features: 3+ depressive symptoms for majority of days

– Major Depressive Episode with Mixed Features: 3+ manic symptoms for majority of days (however, if full criteria for manic met, then Manic Episode with Mixed Features)

“Anxious Distress” Specifier

• Anxiety comorbidity associated with worse outcome (eg, increased suicidality, more difficult to manage)

• Anxious symptoms for majority of days: feeling keyed up, restless, difficulty concentrating, fear that something awful might happen, fear of losing control

• Severity:

– Mild = 2 Sxs

– Moderate = 3

– Moderate-Severe = 4-5

– Severe = 4-5 with motor agitation

Disruptive Mood Dysregulation Disorder

• Intended to provide diagnostic home for children with severe frequent temper outbursts on top of a baseline of angry, irritable mood

• Because of irritability and mood reactivity, misdiagnosed as juvenile bipolar disorder and inappropriately treated

• Since 95% also meet criteria for ODD, comorbid diagnosis not given

Disruptive Mood DysregulationDisorder Controversies

• Pros:

– Meet clinical need for children who require treatment; only applicable DSM-IV category was ODD; does not capture the severity of this condition

– Provides visible alternative to juvenile bipolar

• Cons:

– Replacing one category that encourages antipsychotic use with another that is likely to (“mood dysregulation”)

– Limited empirical support, all from a single research center

Premenstrual Dysphoric Disorder

• “Promoted” from appendix where it has lived since DSM-III-R (1987)

– Marked affective lability, irritability or anger or interpersonal conflicts, depressed mood or anxiety in week before onset of menses, improve after onset, minimal or absent in week post-menses

– Additional symptoms (eg, lethargy, appetite, sleep changes) for a total of 5

– Must be present for most cycles in previous year

– Not merely exacerbation of existing disorder

– Must cause clinically significant distress

– Should be confirmed by prospective daily ratings for 2 cycles

Premenstrual Dysphoric Disorder (continued)

• Most controversial diagnosis in DSM-III-R and DSM-IV

– Benefits of recognition and treatment vs stigmatizing women

• Little controversy in DSM-5; perhaps due to FDA-approved treatments

FDA = US Food and Drug Administration.

Hoarding Disorder

• Hoarding occurs in 2% to 5% of the population and can lead to substantial distress and disability, as well as serious public health consequences

• Most cases do not meet criteria for OCD or OCPD

– Difficulty parting with possessions due to perceived need to save them and distress associated with act of discarding them

– Results in cluttered active living areas, compromising their intended use

OCPD = obsessive-compulsive personality disorder.

New Eating/Feeding Disorders

• Avoidant/Restrictive Food Intake Disorder

– Eating or feeding disturbance leading to persistent failure to meet energy or nutritional needs

– Examples include lack of interest in eating or food, avoidance of foods based on sensory characteristics, concerns about aversive consequences

• Binge-Eating Disorder (formerly in appendix)

– Binge eating without compensatory behavior

– Accompanied by other symptoms such as eating until uncomfortably full or when not hungry and feeling disgusted, guilty, or depressed

– Once a week for 3 months

Substance-Related and Addictive Disorders

DSM-5 Substance Use (2 of 11)

• Larger amounts taken than intended

• Persistent desire to cut down or control use

• Great deal of time to obtain, use, or recover

• Craving or strong desire to use

• Failure to fulfill role obligations

• Use despite social/interpersonal problems

• Activities given up or reduced

• Use where physically hazardous

• Use despite physical/psychological problem

• Tolerance

• Withdrawal

DSM-IV Dependence/Abuse

• Dependence (3)

• Dependence (4)

• Dependence (5)

• Not in DSM-IV

• Abuse (1)

• Abuse (4)

• Dependence (6)

• Abuse (2)

• Dependence (7)

• Dependence (1)

• Dependence (2)

Neurocognitive Disorders

• Major Neurocognitive Disorder

– Subsumes DSM-IV dementia and amnestic disorder

– Evidence of significant cognitive decline based on concern of individual, informant, or clinician AND substantial impairment in cognitive performance preferably documented by neuropsychological testing

– Severe enough to interfere with independence

– At a minimum, requires assistance with complex ADLs

ADLs = activities of daily living.

Neurocognitive Disorders (continued)

• Mild Neurocognitive Disorder

– Evidence of modest cognitive decline based on concern of individual, informant, or clinician AND modest impairment in cognitive performance preferably documented by neuropsychological testing

– NOT severe enough to interfere with capacity for independence

– Complex ADLs preserved but may require greater effort or compensatory strategies

Diagnosing Neurocognitive Disorders

• Determine whether cognitive impairment is major (“significant”) or mild (“modest”)

• Determine etiological factor

• Determine level of certainty regarding etiology, ie, “probable” or “possible” (only applies to some etiological causes)

• Indicate if “with behavioral disturbance,” eg, psychotic symptoms, mood disturbance, agitation, apathy, or other behavioral symptoms

Living Document: DSM-5.x

• Rather than revising the entire DSM at certain intervals, sections will be revised and updated depending on scientific advances

– For example, if biomarker is found for a diagnosis of Alzheimer’s disease, then that section only might be revised

• Might reduce profusion of small changes that are inevitable with current method (ie, temptation for workgroup members to leave their mark)

Summary

• DSM-5 revision characterized by many small changes reflecting new empirical evidence rather than paradigm shift

• Most significant change is reorganization of disorder groupings

• Original plan to add dimensions not implemented; instead dimensional measures included in Section III

Q&A Session