Presentation on theme: "+ DSM-5: From Pathological Gambling to Gambling Disorder Heather A. Chapman, Ph.D, NCGCII, BACC Louis Stokes Cleveland VA Medical Center Case Western Reserve."— Presentation transcript:
+ DSM-5: From Pathological Gambling to Gambling Disorder Heather A. Chapman, Ph.D, NCGCII, BACC Louis Stokes Cleveland VA Medical Center Case Western Reserve University School of Medicine
+ DSM-5 Mainly incremental changes from DSM-IV No more Roman numerals Considering online updates in the future (e.g. DSM-5.1) making it a “living document”
+ DSM-5 DSM-5 is now in effect as of 12/31/13. DSM-5 is fully compatible with ICD-9 system now in use by insurance companies and includes ICD-10 codes (to be implemented 10/1/14).
+ Problems with DSM-IV Addressed by DSM-5 High rates of co-morbidity High use of NOS category Concerns about reliability and validity
+ Guiding Principles for Changes to DSM Research evidence should support any addition or substantive modification. Changes should be based on empirical research rather than clinical consensus. Behavioral science Neuroscience Continuity with the current manual should be maintained when possible. Routine clinical practices must be able to implement any changes. 5
+ DSM-5 Structure Section I: Basics/Introduction Section II: Diagnostic Criteria and Codes Section III: Emerging Measures and Models Appendix
+ Section I: Basics Introduction Use of the Manual Cautionary Statement for Forensic Use
+ Section I: Basics: Introduction DSM-5 better reliability than DSM-IV. Research to validate diagnoses continues. The boundaries between many disorder categories are fluid over the life course. DSM-5 accommodates dimensional approaches to mental disorders.
+ NOS/CNEC conditions not elsewhere classified Problem: widespread use of Not Otherwise Specified (NOS) diagnoses. DSM-5 removes the NOS diagnosis. It adds Other Specified Disorder (criteria vary by disorder) Unspecified Disorder (for use when there is insufficient information to be more specific) NOS CNEC (conditions not elsewhere classified) : – Only for 6 months. – Only for specific reasons: 1) Diagnosis unclear (e.g., psychotic disorder CNEC) 2) Clinician not trained to make the dx. 3) Clinician cannot get info (e.g., client uncooperative; records not available). 4) You do not have enough info. 5) Clinicians needs or is required to take more time of direct observation (e.g., 12 months).
+ Two Clusters of Disorders Internalizing group Disorders with prominent anxiety, depressive, and somatic symptoms Externalizing group Disorders with prominent impulsive, disruptive conduct, and substance use symptoms Disorders within these clusters are adjacent in the DSM-5.
+ Organization of Disorders Disorders are organized on developmental and lifespan considerations. DSM-5 begins with diagnoses that manifest early in life, then adolescence and young adulthood, then adulthood and later life.
+ Cultural Issues Culture is considered as it shapes the experience and expression of the symptoms, signs, and behaviors that are criteria for diagnosis. Section III contains a Cultural Formulation. The Appendix contains a Glossary of Cultural Concepts of Distress.
+ Cultural Issues, cont. DSM-5 replaces the construct of the culture-bound syndrome in DSM-IV with 3 concepts: Cultural syndrome: a cluster of invariant symptoms in a specific cultural group Cultural idiom of distress: a way of talking about suffering among people in a cultural group Cultural explanation or perceived cause for symptoms, illness, or distress
+ DSM-5 is Non-Axial DSM-IV axes I, II, and III have been combined. Continue to list relevant medical conditions. The GAF in DSM-IV has been eliminated. Instead, use the World Health Organization Disability Assessment Schedule (WHODAS). The WHODAS-2.0 is on page 747 of the DSM-5 and is also available online.
+ Chart Entry Example of a Diagnosis Major depressive disorder, recurrent, severe; gambling disorder; COPD Anxiety; Insomnia Recent divorce; financial insecurity Function seriously impaired
+ Section I: Basics: Use of the Manual Clinical Case Formulation Making diagnoses requires clinical judgment, not just checking off the symptoms in the criteria. The client’s cultural and social context must be considered. The DSM-5 does not include all possible mental disorders.
+ Definition of a Mental Disorder A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. There is usually significant distress or disability in social or occupational activities.
+ Definition of a Mental Disorder The diagnosis of a mental disorder should have clinical utility; it should help clinicians to determine prognosis and treatment plan. The diagnosis of a mental disorder is not equivalent to a need for treatment.
+ Definition of a Mental Disorder Diagnoses are made on the basis of The clinical interview DSM-5 text descriptions DSM-5 criteria Clinician judgment
+ Steps in Making a Diagnosis Administer cross-cutting assessments Administer WHODAS 2.0 Conduct clinical interview Determine whether a diagnostic threshold is met Consider subtypes and/or specifiers Consider contextual information, disorder text, distress, clinician judgment Apply codes and develop a treatment plan
+ Section I: Basics: Cautionary Statement for Forensic Use of DSM-5 The diagnosis of a mental disorder does not imply that the person meets legal criteria for the presence of a mental disorder or a specific legal standard for competence, criminal responsibility, disability, etc. Having a diagnosis does not imply that the person is (or was) unable to control his or her behavior at a particular time.
+ Section II: Diagnostic Criteria and Codes Highlights of Specific Disorder Revisions
+ Neurodevelopmental Disorders Autism Spectrum Disorder (ASD) replaces DSM-IV’s Autistic Disorder, Asperger’s Disorder, Pervasive Developmental Disorder, etc. Rationale: Clinicians had applied the criteria for these disorders inconsistently and incorrectly. There was not enough data to justify continuing to separate these disorders.
+ Intellectual Disability The term “Intellectual Disability” replaces “Mental Retardation.” DSM-5 places greater emphasis on adaptive functioning deficits rather than IQ scores alone.
+ Attention-Deficit/Hyperactivity Disorder Age of onset was raised from 7 years to 12 years. The symptom threshold for adults was reduced to five symptoms. Specific Learning Disorder Now presented as a single disorder, with specifiers for deficits in reading, writing, and mathematics.
+ Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Elimination of special treatment of bizarre delusions and special hallucinations in Criterion A. At least one of two required symptoms to meet Criterion A must be delusions, hallucinations, or disorganized speech. Specific subtypes were deleted due to poor reliability and validity. Schizoaffective Disorder Now based on the lifetime (rather than the episodic) duration of the illness. Catatonia Now exists as a specifier for many mental disorders.
+ Bipolar and Related Disorders Mania and Hypomania Criterion A now includes increased energy/activity as a required symptom. “Mixed episode” is replaced with a “with mixed features” specifier. “With anxious distress” was added as a specifier for bipolar and depressive disorders.
+ Depressive Disorders The bereavement exclusion was eliminated from major depressive episode (MDE). In some people, a major loss can lead to a MDE. Disruptive Mood Dysregulation Disorder (DMDD) was added. For children with extreme behavioral dyscontrol but persistent rather than episodic irritability. This should decrease the number of children diagnosed with bipolar disorder. Dysthymic Disorder was renamed Persistent Depressive Disorder.
+ Anxiety Disorders DSM-5 has four chapters to cover the anxiety disorders covered by two chapters in DSM-IV. Anxiety Disorders Obsessive-Compulsive & Related Disorders Trauma- & Stressor-Related Disorders Dissociative Disorders Anxiety Disorders Panic attacks was added as a specifier for any mental disorder. Panic attacks can occur in many mental disorders.
+ Obsessive-Compulsive & Related Disorders Hoarding Disorder was added. Excoriation (Skin-Picking) Disorder was added. Body Dysmorphic Disorder (BDD) was moved from the chapter on somatic disorders to the chapter on OCD & Related disorders. A “delusional” specifier was added for both OCD and BDD.
+ Trauma- & Stressor-Related Disorders Posttraumatic Stress Disorder The stressor criterion (A) is now more explicit. Criterion A2 (subjective reaction) is eliminated. The symptom clusters were enlarged from 3 to 4. Separate criteria were added for children age 6 and younger. Reactive attachment disorder was separated into RAD and disinhibited social engagement disorder.
+ Feeding and Eating Disorders Binge Eating Disorder (BED) is new. The diagnosis of Anorexia Nervosa no longer requires amenorrhea as a diagnostic criterion.
+ Sleep-Wake Disorders Primary Insomnia renamed Insomnia Disorder. Rapid Eye Movement Sleep Behavior Disorder and Restless Legs Syndrome elevated to the main body of the manual. Subtypes expanded for Circadian Rhythm Sleep Disorders.
+ Disruptive, Impulse-Control, and Conduct Disorders Conduct Disorder Added a specifier “with limited prosocial emotions.” Intermittent Explosive Disorder Provides more specific criteria to define outbursts. Trichotillomania was moved from the Impulse-Control Disorder chapter in DSM-IV to the Obsessive-Compulsive and Related Disorders chapter in DSM-5.
+ Neurocognitive Disorders The word dementia was eliminated; the new term is Major Neurocognitive Disorder. The word “Dementia” was linked to old age diseases and clinicians tended to be pessimistic about its prognosis. Mild Neurocognitive Disorder is new. This condition exists and treatment can help. Neurocognitive decline is not inevitable.
+ Adjustment Disorders The chapter “Adjustment Disorders” in DSM-IV was incorporated into the chapter on Trauma- and Stressor- Related Disorders in DSM-5. Criterion B-1 was rephrased as “marked distress that is out of proportion to the severity or intensity of the stressor.” Symptoms are in response to an identifiable stressor.
+ Personality Disorders All 10 PDs in DSM-IV remain intact in DSM-5. Note that “Axis II” in DSM-IV no longer exists. Section III of the DSM-5 contains an alternate, trait-based approach to assessing personality. It helps with the diagnosis of people who meet the core criteria for a PD but do not meet the criteria for a specific type of PD.
+ Alternate Model for PDs PDs are characterized by impairments in personality functioning and pathological personality traits. General Criteria for Personality Disorder Specific Personality Disorders Antisocial, Avoidant, Borderline, Narcissistic, Obsessive- Compulsive, and Schizotypal.
+ Alternate Model for PDs Proposed Diagnostic Criteria Impairment in personality functioning. Identity Self-direction Empathy Intimacy Pathological personality trait domains. Negative affectivity; detachment; antagonism; disinhibition; psychoticism.
+ Paraphilic Disorders Emphasizes paraphilic disorders rather than paraphilias. Paraphilias that do not involve non-consenting victims are not necessarily indicative of a mental disorder. To have a paraphilic disorder requires distress, impairment, or abuse of a non-consenting victim.
+ Substance-Related and Addictive Disorders Substance Use Disorder (SUD) Substance abuse and substance dependence are combined into a single disorder. Severity can be rated as mild, moderate, or severe. Craving was added as a new criterion for SUD. Legal consequences was removed as a criterion.
+ Substance-Related & Addictive Disorders No “abuse” or “dependence”; now “use.” Chapter reorganized by substance. 10 classes of drugs: Alcohol; Caffeine; Cannabis; Hallucinogens; Inhalants; Opioids; Sedatives, hypnotics & anxiolytics; Stimulants; Tobacco; Other. Two groups of disorders: (a) Substance use disorders, (b) Substance-induced disorders. 43 p. 481
+ Substance use disorder: continued use of substance despite significant substance-related problems. 4 sets of criteria: Impaired control (4 criteria). Social impairment (3 criteria). Risky use (2 criteria). Pharmacological criteria (2 criteria: tolerance & withdrawal). 44 Substance-Related & Addictive Disorders
+ Substance-Related and Addictive Disorders Cannabis withdrawal is a new disorder. Caffeine withdrawal is a new disorder.
+ Severity levels: – Mild (2-3 symptoms) – Moderate (4-5 symptoms) – Severe (> 6 symptoms) Remission: – Early vs Sustained; – Maintenance therapy – Controlled environment 46 Substance-Related & Addictive Disorders Example: Moderate Valium use disorder; Mild alcohol use disorder; Secobarbital withdrawal.
+ New language: “All drugs that are taken in excess have in common direct activation of the brain reward system…. Individuals with lower levels of self-control, which may reflect impairments of brain inhibitory mechanisms, may be particularly predisposed to develop substance use disorders, suggesting that the roots of substance use disorders for some persons can be seen in behaviors long before the onset of actual substance use itself.” (p. 481) 47 Substance-Related & Addictive Disorders
+ “This chapter also includes gambling disorder, reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse, and produce some behavioral symptoms that appear comparable to those produced by the substance use disorders.” (p. 481) 48 Substance-Related & Addictive Disorders
+ Non-Substance-Related and Addictive Disorders “Pathological Gambling” in DSM-IV was renamed “Gambling Disorder” and moved from the Impulse Control Disorders chapter to the chapter in DSM-5 called Substance-Related and Addictive Disorders. Internet Gaming Disorder is included in Chapter 3 as a “condition for further study.” No other behavioral addictions are mentioned even hypersexuality
+ is preoccupied with gambling needs to gamble with increasing amounts of money for desired excitement repeated unsuccessful efforts to control, cut back, or stop restless or irritable when attempting to cut down or stop gambling gambles as a way of escaping from problems or of relieving a dysphoric mood "chasing" lies to conceal the extent of involvement with gambling has committed illegal acts, to finance gambling has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling relies on others to provide money to relieve a desperate financial situation caused by gambling ODADAS Advanced Training Pathological Gambling: DSM-IV
+ is preoccupied with gambling needs to gamble with increasing amounts of money for desired excitement repeated unsuccessful efforts to control, cut back, or stop restless or irritable when attempting to cut down or stop gambling gambles as a way of escaping from problems or of relieving a dysphoric mood "chasing" lies to conceal the extent of involvement with gambling has committed illegal acts, to finance gambling has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling relies on others to provide money to relieve a desperate financial situation caused by gambling ODADAS Advanced Training Gambling Disorder: DSM-5
+ DSM-5 Gambling Disorder ODADAS Advanced Training Specifiers Specify ifEpisodic: meeting criteria at more than one point, symptoms subsiding between periods of gambling disorder for at least several months Persistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple years Specify ifIn early remission: after full criteria met, none of the criteria have been met for at least 2 months but for less than 12 months In sustained remission: after criteria met, none of the criteria have been met during a period of 12 or more months Specify current severity level Mild: 4-5 criteria Moderate: 6-7 criteria Severe: 8-9 criteria
+ Windsor Items literature review and focus groups and testing Have you frequently gambled with larger amounts of money than you intended to or for longer periods of time than you intended to? Did you make excuses or think of reasons to justify your gambling, such as “I will win money, or I need to calm down”? Did your gambling cause you to feel depressed, for example, sad, anxious, withdrawn, tearful? Did your gambling cause you to disregard the worth or value of money? Has your gambling caused you to have negative feelings about your self-worth or your outlook on life? Has your gambling caused you to lose interest in things that used to be important to you, such as relationships, work, hobbies, family activities, friends, etc.? Did you feel that you were in control when you gambled? Have you gambled to fill a void or emptiness in your life? Did you continue to gamble despite having lost your life savings or house due to gambling? (DSM-III-R) Have you been secretive about your gambling and tried to hide the evidence of your gambling? Did you believe it was possible to win more than you lose? ODADAS Advanced Training
+ Windsor Items literature review and focus groups and testing 1. How often have you spent a lot of time thinking about past gambling experiences, planning your next gambling activity, or thinking of ways to get money to gamble? 2. How often have you needed to gamble with larger amounts of money or with larger bets in order to obtain the same feeling of excitement? 3. How often have you tried to control, cut back, or stop gambling several times and were unsuccessful? For example, setting a money or time limit for yourself and then going over it. 4. How often have you felt restless or irritable when you tried to cut down or stop gambling? 5. How often did you feel that your gambling was a way of avoiding or escaping from personal problems or a way of relieving uncomfortable emotions, such as feelings of nervousness, helplessness, guilt, anxiety or sadness? 6. After you lost money gambling how often did you return another day to get even or try to win back your losses? 7. How often have you lied to family members, therapists, or others to hide your gambling from them? 8. How often have you committed any illegal acts such as forgery, fraud, theft, or embezzlement to get money to gamble or to pay gambling debts? 9. How often have you risked or lost a relationship with someone important to you, or a job, or career opportunity because of gambling? 10. How often have you relied on others to pay your gambling debts or to pay your bills when you had financial problems caused by your gambling? Not in the past 12 months once a few times many times ODADAS Advanced Training
+ DSM-5 Changes Rationale The Criterion of “Illegal Acts” It does not appear to be a decisive symptom for most people with gambling problems (American Psychiatric Association, 2010) Individuals who commit illegal acts as a result of their gambling already reach the threshold of five or more symptoms and, therefore, this symptom does not improve the precision of the diagnostic code for identifying most individuals with pathological gambling/gambling disorder. ODADAS Advanced Training
+ Other Conditions That May Be A Focus of Clinical Attention The list of “V-Code” and other conditions was expanded to 134 separate conditions. Examples Relational Problems Abuse and Neglect Educational and Occupational Problems Phase of Life Problem Malingering
+ V codes CodeCondition V15.41Personal history (past history) of physical abuse in childhood V15.41Personal history (past history) of sexual abuse in childhood V15.41Personal history (past history) of spouse or partner violence, Physical V15.41Personal history (past history) of spouse or partner violence, Sexual V15.42Personal history (past history) of neglect in childhood V15.42Personal history (past history) of psychological abuse in childhood V15.42Personal history (past history) of spouse or partner psychological abuse V15.42Personal history (past history) of spouse or partner neglect V15.49Other personal history of psychological trauma V15.59Personal history of self-harm
+ V codes CodeCondition V15.81Nonadherence to medical treatment V15.89Other personal risk factors V40.31Wandering associated with a mental disorder V60.0Homelessness V60.1Inadequate housing V60.2Extreme poverty V60.2Insufficient social insurance or welfare support V60.2Lack of adequate food or safe drinking water V60.2Low income V60.3Problem related to living alone
+ V codes CodeCondition V60.6Problem related to living in a residential institution V60.89Discord with neighbor, lodger, or landlord V60.9Unspecified housing or economic problem V61.03Disruption of family by separation or divorce V61.10Relationship distress with spouse or intimate partner V61.11Encounter for mental health services for victim of spouse or partner psychological abuse V61.11Encounter for mental health services for victim of spouse or partner neglect V61.11Encounter for mental health services for victim of spouse or partner violence, Physical V61.11Encounter for mental health services for victim of spouse or partner violence, Sexual V61.12Encounter for mental health services for perpetrator of spouse or partner psychological abuse V61.12Encounter for mental health services for perpetrator of spouse or partner neglect
+ V codes CodeCondition V61.12Encounter for mental health services for perpetrator of spouse or partner violence, Physical V61.12Encounter for mental health services for perpetrator of spouse or partner violence, Sexual V61.20Parent-child relational problem V61.21Encounter for mental health services for victim of child neglect by parent V61.21Encounter for mental health services for victim of nonparental child neglect V61.21Encounter for mental health services for victim of child abuse by parent V61.21Encounter for mental health services for victim of nonparental child abuse V61.21Encounter for mental health services for victim of child psychological abuse by parent V61.21Encounter for mental health services for victim of nonparental child psychological abuse V61.21Encounter for mental health services for victim of child sexual abuse by parent V61.21Encounter for mental health services for victim of nonparental child sexual abuse
+ V codes CodeCondition V61.22Encounter for mental health services for perpetrator of parental child neglect V61.22Encounter for mental health services for perpetrator of parental child abuse V61.22Encounter for mental health services for perpetrator of parental child psychological abuse V61.22Encounter for mental health services for perpetrator of parental child sexual abuse V61.29Child affected by parental relationship distress V61.5Problems related to multiparity V61.7Problems related to unwanted pregnancy V61.8High expressed emotion level within family V61.8Sibling relational problem V61.8Upbringing away from parents V62.21Problem related to current military deployment status
+ V codes CodeCondition V62.22Exposure to disaster, war, or other hostilities V62.22Personal history of military deployment V62.29Other problem related to employment V62.3Academic or educational problem V62.4Acculturation difficulty V62.4Social exclusion or rejection V62.4Target of (perceived) adverse discrimination or persecution V62.5Conviction in civil or criminal proceedings without imprisonment V62.5Imprisonment or other incarceration V62.5Problems related to other legal circumstances V62.5Problems related to release from prison V62.82Uncomplicated bereavement
+ V codes CodeCondition V62.83Encounter for mental health services for perpetrator of nonspousal adult abuse V62.83Encounter for mental health services for perpetrator of nonparental child neglect V62.83Encounter for mental health services for perpetrator of nonparental child abuse V62.83Encounter for mental health services for perpetrator of nonparental child psychological abuse V62.83Encounter for mental health services for perpetrator of nonparental child sexual abuse V62.89Borderline intellectual functioning V62.89Discord with social service provider, including probation officer, case manager, or social services worker V62.89Other problem related to psychosocial circumstances V62.89Phase of life problem V62.89Religious or spiritual problem V62.89Victim of crime
+ V codes CodeCondition V62.89Victim of terrorism or torture V62.9Unspecified problem related to social environment V62.9Unspecified problem related to unspecified psychosocial circumstances V63.8Unavailability or inaccessibility of other helping agencies V63.9Unavailability or inaccessibility of health care facilities V65.2Malingering V65.40Other counseling or consultation V65.49Encounter for mental health services for victim of nonspousal adult abuse V65.49Sex counseling V69.9Problem related to lifestyle V71.01Adult antisocial behavior V71.02Child or adolescent antisocial behavior
+ Section III: Emerging Measures and Models Optional Assessment Measures Level 1 Cross-Cutting Symptom Measure To measure depression, anger, mania, anxiety, etc. To screen for important symptoms; self-administered by patient; brief (1-3 questions per symptom domain). Level 2 Cross-Cutting Symptom Measure To be done when a Level 1 item is endorsed at the level of “mild” or greater.
+ Emerging Measures, cont. Diagnosis-Specific Severity Measures To document the severity of a specific disorder. Some are clinician-rated, some are patient-rated.
+ Emerging Measures, cont. WHO Disability Assessment Schedule 2.0 Replaces the GAF Scale in DSM-IV Is recommended but not required. Has 36 self-administered questions. Cultural Formulation Outline for Cultural Formulation Cultural Formulation Interview
+ Conditions for Further Study Attenuated Psychosis Syndrome Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Suicidal Behavior Disorder Non-suicidal Self-Injury
+ Suicidal Behavior Disorder A suicide attempt within the past 24 months. The act is not non-suicidal self-injury. Suicidal ideation does not qualify.
+ Nonsuicidal Self-Injury In the last year the person has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body... with the expectation that the injury will lead to only minor or moderate physical harm (i.e. there is no suicidal intent). Five additional criteria.
+ For More Information
+ References American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Association. Jones, K. D. (2013, March). Understanding the DSM-5 and the ICD. Workshop sponsored by the American Psychological Association. Nock, M. K. (2013, October). Teaching about psychopathology: Implications of DSM-5. Workshop sponsored by Harvard University and Macmillan Higher Education. Thienhaus, O. J. (2013, October). DSM-5: What You Need To Know To Transition From DSM-IV. Workshop sponsored by the American Psychiatric Association and the Arizona Psychiatric Society. Flagstaff, AZ.