Presentation on theme: "DSM-5: From Pathological Gambling to Gambling Disorder"— Presentation transcript:
1 DSM-5: From Pathological Gambling to Gambling Disorder Heather A. Chapman, Ph.D, NCGCII, BACCLouis Stokes Cleveland VA Medical CenterCase Western Reserve University School of Medicine
2 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”
3 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).
4 Problems with DSM-IV Addressed by DSM-5 High rates of co-morbidityHigh use of NOS categoryConcerns about reliability and validity
5 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 scienceNeuroscienceContinuity with the current manual should be maintained when possible.Routine clinical practices must be able to implement any changes.
6 DSM-5 Structure Section I: Basics/Introduction Section II: Diagnostic Criteria and CodesSection III: Emerging Measures and ModelsAppendix
7 Section I: Basics Introduction Use of the Manual Cautionary Statement for Forensic Use
8 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.
9 NOS/CNEC conditions not elsewhere classified Problem: widespread use of Not Otherwise Specified (NOS) diagnoses.DSM-5 removes the NOS diagnosis. It addsOther 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:Diagnosis unclear (e.g., psychotic disorder CNEC)Clinician not trained to make the dx.Clinician cannot get info (e.g., client uncooperative; records not available).You do not have enough info.Clinicians needs or is required to take more time of direct observation (e.g., 12 months).
11 Two Clusters of Disorders Internalizing groupDisorders with prominent anxiety, depressive, and somatic symptomsExternalizing groupDisorders with prominent impulsive, disruptive conduct, and substance use symptomsDisorders within these clusters are adjacent in the DSM-5.
12 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.
13 Cultural IssuesCulture 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.DSM-IV had a list of culture-bound syndromes.
14 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 groupCultural idiom of distress: a way of talking about suffering among people in a cultural groupCultural explanation or perceived cause for symptoms, illness, or distress
15 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.
16 Chart Entry Example of a Diagnosis Major depressive disorder, recurrent, severe; gambling disorder; COPDAnxiety; InsomniaRecent divorce; financial insecurityFunction seriously impaired
17 Section I: Basics: Use of the Manual Clinical Case FormulationMaking 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.
18 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.A mental disorder is a disturbanceThat reflects a dysfunctionIn psychological or biological or developmental processes
19 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.There is no need to make a diagnosis unless it interferes with the patient’s functioning.Some patients may not want treatment for their mental disorder.Eg. A patient who has hallucinations may choose to live with them.
20 Definition of a Mental Disorder Diagnoses are made on the basis ofThe clinical interviewDSM-5 text descriptionsDSM-5 criteriaClinician judgment
21 Steps in Making a Diagnosis Administer cross-cutting assessmentsAdminister WHODAS 2.0Conduct clinical interviewDetermine whether a diagnostic threshold is metConsider subtypes and/or specifiersConsider contextual information, disorder text, distress, clinician judgmentApply codes and develop a treatment plan
22 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.
23 Section II: Diagnostic Criteria and Codes Highlights of Specific Disorder Revisions
24 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.
25 Intellectual Disability The term “Intellectual Disability” replaces “Mental Retardation.”DSM-5 places greater emphasis on adaptive functioning deficits rather than IQ scores alone.Begin the diagnostic process by looking at adaptive functioning. Then add in the information provided by IQ scores.
26 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 DisorderNow presented as a single disorder, with specifiers for deficits in reading, writing, and mathematics.
27 Schizophrenia Spectrum and Other Psychotic Disorders 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 DisorderNow based on the lifetime (rather than the episodic) duration of the illness.CatatoniaNow exists as a specifier for many mental disorders.There was poor reliability in distinguishing bizarre from non-bizarre delusions.DSM-IV said only one Criterion A symptom is required if delusions are bizarre or if hallucinations consist of a voice keeping a running commentary on the person’s behavior or two or more voices conversing with each other.Subtypes: Paranoid, Disorganized, Catatonic
28 Bipolar and Related Disorders Mania and HypomaniaCriterion 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.Increased energy is a major symptom of mania.This loosens the criteria some for clients with sub-threshold mixed states.
29 Depressive DisordersThe 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.This change allows such people to receive treatment for depression. In DSM-IV they could not be diagnosed.In DSM-IV bereavement is a V-code and required more than an two-month time frame before MDE could be diagnosed. This time period was arbitrary.
30 Anxiety DisordersDSM-5 has four chapters to cover the anxiety disorders covered by two chapters in DSM-IV.Anxiety DisordersObsessive-Compulsive & Related DisordersTrauma- & Stressor-Related DisordersDissociative DisordersPanic attacks was added as a specifier for any mental disorder.Panic attacks can occur in many mental disorders.It’s probably a good idea to separate PTSD, for example, from the other anxiety disorders.
31 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.
32 Trauma- & Stressor-Related Disorders Posttraumatic Stress DisorderThe 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.More children will meet the criteria for PTSD than before
33 Feeding and Eating Disorders Binge Eating Disorder (BED) is new.The diagnosis of Anorexia Nervosa no longer requires amenorrhea as a diagnostic criterion.There is now good evidence that BED is a valid and clinically useful diagnosis.
34 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.
35 Disruptive, Impulse-Control, and Conduct Disorders Added a specifier “with limited prosocial emotions.”Intermittent Explosive DisorderProvides 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.The conduct disorder specifier may help identify future psychopaths and provide them with treatment.
36 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.People think of dementia as occurring in older people, but neurocognitive problems can occur in young or older people, e.g., due to traumatic brain injury.
37 Adjustment DisordersThe 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.
38 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.
39 Alternate Model for PDs PDs are characterized by impairments in personality functioning and pathological personality traits.General Criteria for Personality DisorderSpecific Personality DisordersAntisocial, Avoidant, Borderline, Narcissistic, Obsessive- Compulsive, and Schizotypal.
40 Alternate Model for PDs Proposed Diagnostic CriteriaImpairment in personality functioning.IdentitySelf-directionEmpathyIntimacyPathological personality trait domains.Negative affectivity; detachment; antagonism; disinhibition; psychoticism.
41 Paraphilic DisordersEmphasizes 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.
42 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.The term dependence is often misunderstood and has negative connotations, but it is the normal pattern of withdrawal that can occur from the proper use of medications.
43 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.p. 481
44 Substance-Related & Addictive Disorders 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).
45 Substance-Related and Addictive Disorders Cannabis withdrawal is a new disorder.Caffeine withdrawal is a new disorder.
46 Substance-Related & Addictive Disorders Severity levels:Mild (2-3 symptoms)Moderate (4-5 symptoms)Severe (> 6 symptoms)Remission:Early vs Sustained;Maintenance therapyControlled environmentExample: Moderate Valium use disorder; Mild alcohol use disorder; Secobarbital withdrawal.
47 Substance-Related & Addictive Disorders 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)
48 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)
49 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 hypersexualitySex Addiction is not in the DSM-5, even as a condition for further study.
50 Pathological Gambling: DSM-IV "chasing"lies to conceal the extent of involvement with gamblinghas committed illegal acts, to finance gamblinghas jeopardized or lost a significant relationship, job, or educational or career opportunity because of gamblingrelies on others to provide money to relieve a desperate financial situation caused by gamblingis preoccupied with gamblingneeds to gamble with increasing amounts of money for desired excitementrepeated unsuccessful efforts to control, cut back, or stoprestless or irritable when attempting to cut down or stop gamblinggambles as a way of escaping from problems or of relieving a dysphoric moodODADAS Advanced Training
51 Gambling Disorder: DSM-5 "chasing"lies to conceal the extent of involvement with gamblinghas committed illegal acts, to finance gamblinghas jeopardized or lost a significant relationship, job, or educational or career opportunity because of gamblingrelies on others to provide money to relieve a desperate financial situation caused by gamblingis preoccupied with gamblingneeds to gamble with increasing amounts of money for desired excitementrepeated unsuccessful efforts to control, cut back, or stoprestless or irritable when attempting to cut down or stop gamblinggambles as a way of escaping from problems or of relieving a dysphoric moodODADAS Advanced Training
52 DSM-5 Gambling Disorder SpecifiersSpecify ifEpisodic: meeting criteria at more than one point, symptoms subsiding between periods of gambling disorder for at least several monthsPersistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple yearsIn early remission: after full criteria met, none of the criteria have been met for at least 2 months but for less than 12 monthsIn sustained remission: after criteria met, none of the criteria have been met during a period of 12 or more monthsSpecify current severity levelMild: 4-5 criteriaModerate: 6-7 criteriaSevere: 8-9 criteriaODADAS Advanced Training
54 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
55 Windsor Items literature review and focus groups and testing 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? 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? 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. How often have you felt restless or irritable when you tried to cut down or stop gambling? 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? After you lost money gambling how often did you return another day to get even or try to win back your losses? How often have you lied to family members, therapists, or others to hide your gambling from them? 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? How often have you risked or lost a relationship with someone important to you, or a job, or career opportunity because of gambling?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 timesODADAS Advanced Training
56 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
57 Other Conditions That May Be A Focus of Clinical Attention The list of “V-Code” and other conditions was expanded to 134 separate conditions.ExamplesRelational ProblemsAbuse and NeglectEducational and Occupational ProblemsPhase of Life ProblemMalingering
58 V codesCode ConditionV Personal history (past history) of physical abuse in childhoodV Personal history (past history) of sexual abuse in childhoodV Personal history (past history) of spouse or partner violence, PhysicalV Personal history (past history) of spouse or partner violence, SexualV Personal history (past history) of neglect in childhoodV Personal history (past history) of psychological abuse in childhoodV Personal history (past history) of spouse or partner psychological abuseV Personal history (past history) of spouse or partner neglectV Other personal history of psychological traumaV Personal history of self-harm
59 V codes Code Condition V15.81 Nonadherence to medical treatment V Other personal risk factorsV Wandering associated with a mental disorderV60.0 HomelessnessV60.1 Inadequate housingV60.2 Extreme povertyV60.2 Insufficient social insurance or welfare supportV60.2 Lack of adequate food or safe drinking waterV60.2 Low incomeV60.3 Problem related to living alone
60 V codesCode ConditionV60.6 Problem related to living in a residential institutionV Discord with neighbor, lodger, or landlordV60.9 Unspecified housing or economic problemV Disruption of family by separation or divorceV Relationship distress with spouse or intimate partnerV Encounter for mental health services for victim of spouse or partner psychological abuseV Encounter for mental health services for victim of spouse or partner neglectV Encounter for mental health services for victim of spouse or partner violence, PhysicalV Encounter for mental health services for victim of spouse or partner violence, SexualV Encounter for mental health services for perpetrator of spouse or partner psychological abuseV Encounter for mental health services for perpetrator of spouse or partner neglect
61 V codesCode ConditionV Encounter for mental health services for perpetrator of spouse or partner violence, PhysicalV Encounter for mental health services for perpetrator of spouse or partner violence, SexualV Parent-child relational problemV Encounter for mental health services for victim of child neglect by parentV Encounter for mental health services for victim of nonparental child neglectV Encounter for mental health services for victim of child abuse by parentV Encounter for mental health services for victim of nonparental child abuseV Encounter for mental health services for victim of child psychological abuse by parentV Encounter for mental health services for victim of nonparental child psychological abuseV Encounter for mental health services for victim of child sexual abuse by parentV Encounter for mental health services for victim of nonparental child sexual abuse
62 V codesCode ConditionV Encounter for mental health services for perpetrator of parental child neglectV Encounter for mental health services for perpetrator of parental child abuseV Encounter for mental health services for perpetrator of parental child psychological abuseV Encounter for mental health services for perpetrator of parental child sexual abuseV Child affected by parental relationship distressV61.5 Problems related to multiparityV61.7 Problems related to unwanted pregnancyV61.8 High expressed emotion level within familyV61.8 Sibling relational problemV61.8 Upbringing away from parentsV Problem related to current military deployment status
63 V codesCode ConditionV Exposure to disaster, war, or other hostilitiesV Personal history of military deploymentV Other problem related to employmentV62.3 Academic or educational problemV62.4 Acculturation difficultyV62.4 Social exclusion or rejectionV62.4 Target of (perceived) adverse discrimination or persecutionV62.5 Conviction in civil or criminal proceedings without imprisonmentV62.5 Imprisonment or other incarcerationV62.5 Problems related to other legal circumstancesV62.5 Problems related to release from prisonV Uncomplicated bereavement
64 V codesCode ConditionV Encounter for mental health services for perpetrator of nonspousal adult abuseV Encounter for mental health services for perpetrator of nonparental child neglectV Encounter for mental health services for perpetrator of nonparental child abuseV Encounter for mental health services for perpetrator of nonparental child psychological abuseV Encounter for mental health services for perpetrator of nonparental child sexual abuseV Borderline intellectual functioningV Discord with social service provider, including probation officer, case manager, or social services workerV Other problem related to psychosocial circumstancesV Phase of life problemV Religious or spiritual problemV Victim of crime
65 V codes Code Condition V62.89 Victim of terrorism or torture V62.9 Unspecified problem related to social environmentV62.9 Unspecified problem related to unspecified psychosocial circumstancesV63.8 Unavailability or inaccessibility of other helping agenciesV63.9 Unavailability or inaccessibility of health care facilitiesV65.2 MalingeringV Other counseling or consultationV Encounter for mental health services for victim of nonspousal adult abuseV Sex counselingV69.9 Problem related to lifestyleV Adult antisocial behaviorV Child or adolescent antisocial behavior
66 Section III: Emerging Measures and Models Optional Assessment MeasuresLevel 1 Cross-Cutting Symptom MeasureTo 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 MeasureTo be done when a Level 1 item is endorsed at the level of “mild” or greater.
67 Emerging Measures, cont. Diagnosis-Specific Severity MeasuresTo document the severity of a specific disorder.Some are clinician-rated, some are patient-rated.
68 Emerging Measures, cont. WHO Disability Assessment Schedule 2.0Replaces the GAF Scale in DSM-IVIs recommended but not required.Has 36 self-administered questions.Cultural FormulationOutline for Cultural FormulationCultural Formulation InterviewThe GAF (Globa Assessment of Functioning) was fairly useless and had poor reliability and validity.
69 Conditions for Further Study Attenuated Psychosis SyndromePersistent Complex Bereavement DisorderCaffeine Use DisorderInternet Gaming DisorderSuicidal Behavior DisorderNon-suicidal Self-Injury
70 Suicidal Behavior Disorder A suicide attempt within the past 24 months.The act is not non-suicidal self-injury.Suicidal ideation does not qualify.
71 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.
73 ReferencesAmerican 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.