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A DSM-5 Primer: Overview and Major Changes

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1 A DSM-5 Primer: Overview and Major Changes
Donald W. Black, MD Professor, Vice Chair for Education Department of Psychiatry University of Iowa Carver College of Medicine Iowa City, IA 52242 2014 Jauch Memorial Educational Symposium May 16, 2014

2 Conflicts Grant support: AstraZeneca National Institute on Aging
Nellie Ball Trust Royalties: American Psychiatric Publishing Oxford University Press UpToDate


4 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.

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

6 The DSM through Time

7 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

8 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 (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)

10 DSM-5: 2013 947 pp.

11 The March to DSM-5

12 Psychiatrists Darrel Regier, MD (l) and David Kupfer, MD (r) appointed in 2006 to lead Task Force that led to DSM-5

13 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. 

14 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.

15 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.

16 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)

17 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.


19 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

20 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

21 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 © American Psychiatric Association.

22 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.

23 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.

24 A Few Words About Coding
(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 (F44.0). The code for dissociative amnesia with dissociative fugue is (F44.1). Specify if: (F44.1) With dissociative fugue: Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical

25 Using DSM-5

26 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”

27 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: (F33.1) Major Depressive Disorder, Recurrent, Moderate; 307.1(F50.01) Anorexia Nervosa, in full remission

28 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: (F20.9) Schizophrenia (principal diagnosis) (F10.20) Alcohol use disorder, severe 305.1 (F17.200) Tobacco use disorder, severe

29 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 neoplasm (F06.2) Psychosis due to malignant lung neoplasm (provisional)

30 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: (F43.10) Posttraumatic stress disorder (reason for visit) (F40.10) Social anxiety disorder (F60.3) Borderline personality disorder

31 Section II: Chapter by Chapter Review

32 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).

33 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. .

34 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

35 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.

36 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.

37 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.

38 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. .

39 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.

40 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. .

41 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.

42 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.

43 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). .

44 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”).

45 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: (F43.10) Posttraumatic Stress Disorder with Panic Attacks © APA

46 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)

47 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. .

48 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. .

49 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. .

50 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

51 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. © APA

52 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.

53 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 © American Psychiatric Association.

54 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.

55 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

56 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.

57 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)

58 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.

59 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).

60 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.

61 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.

62 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.

63 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.

64 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.

65 Thank you!

66 Questions?

67 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: , 1990 Kendler KS, Munoz RA, Murphy G: The development of the Feighner criteria: a historical perspective. Am J Psychiatry 167: , 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: , 1980

68 Department of Psychiatry
The End Donald W. Black, MD Department of Psychiatry University of Iowa

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