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The DSM-5: New Directions for Mental Disorders Todd Finnerty, Psy.D. September, 2012 NADE.

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Presentation on theme: "The DSM-5: New Directions for Mental Disorders Todd Finnerty, Psy.D. September, 2012 NADE."— Presentation transcript:

1 The DSM-5: New Directions for Mental Disorders Todd Finnerty, Psy.D. September, 2012 NADE

2 Introductions… President of PsychContinuingEd.com, LLC APA Public Education Coordinator for the state of Ohio

3 ApA Permissions Policy The DSM-5, published by the American Psychiatric Association (APA), is in development and scheduled for publication in May It currently is undergoing review and revision and being prepared for eventual approval by the APA leadership. During the development process, the diagnostic criteria have been posted online at periodically opened for public comment, and updated in response to comments and reviews. DSM-5 is a registered trademark, and all content, whether in final or proposed form, is protected by copyright held by the APA. All rights are reserved, and written permission is required from the APA for use in any way, commercial or noncommercial. If permission is granted, it will be for one-time usage on the conditions that the content is not modified or adapted in any way and credit to the APA is indicated. During the development process, permission will not be granted for use of the diagnostic criteria. The criteria are subject to change, and it would be a disservice to the community to allow various preliminary versions to remain in circulation. For this reason, after the end of the current comment period, the content of DSM-5 will be under strict embargo until publication. This policy applies to all uses and parties, including for those who wish to produce DSM-5 educational materials, diagnostic instruments, or computer-assisted applications of these materials. The APA owns all products generated by the Work Groups developing DSM-5, but requests will be considered for permission to describe the criteria and development process in narrative form. However, APA will not grant permission to reproduce the diagnostic criteria while they are under development. Fair Use Resources:

4 Obligatory Opening Quote “Facts” in science do not speak for themselves but assume their meaning based on theoretical and ideological commitments. The practice and the beliefs of scientists are embedded in a greater social context. –Frank J. Sulloway

5 May 5-9, 2012

6 DSM5.org Important dates: ICD-10 codes- October, 2014 DSM-5 May, 2013 ICD ??? ?

7 DSM-V is now DSM-5 (DSM-5.0) Goodbye multiaxial system-  ICD Hello more decimal places in your diagnostic codes ?

8 We’re moving from 3-5 “digits” to 5-7 (4 potential decimal places instead of 2) “The Blue Book” : The ICD-10 Classification of Mental and Behavioural Disorders The ICD-11 Alpha draft’s “recurrent depressive disorder” doesn’t have specific codes listed yet F 33.1xx ? ?

9 What is a mental disorder? dsm5.org A Mental Disorder is a health condition characterized by significant dysfunction in an individual’s cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning. Some disorders may not be diagnosable until they have caused clinically significant distress or impairment of performance. A mental disorder is not merely an expectable or culturally sanctioned response to a specific event such as the death of a loved one. Neither culturally deviant behavior (e.g., political, religious, or sexual) nor a conflict that is primarily between the individual and society is a mental disorder unless the deviance or conflict results from a dysfunction in the individual, as described above.

10 WHODAS 2.0: disability assessment schedule Cognition – understanding & communicating Mobility– moving & getting around Self-care– hygiene, dressing, eating & staying alone Getting along– interacting with other people Life activities– domestic responsibilities, leisure, work & school Participation– joining in community activities Mild Moderate Severe Extreme Goodbye GAF?

11 Different Forms- ex: 12 and 36 items In the past 30 days how much difficulty have you had in… In the past 30 days, how many days were you totally unable to carry out your usual activities or work because of any health condition? …how many days did you cut-back or reduce your usual activities or work because of any health condition?

12 “Cross-cutting” Assessments Symptoms experienced are not always communicated by a diagnosis (ex: suicidality) Many are still in development (ex: a possible new “PID-5” for personality disorders) The use of the PHQ-9 for depression and similar screeners will likely be endorsed Potential severity rankings which are qualitative/subjective Some may be used to track progress/outcomes

13 Organizational Structure Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Dissociative Disorders Somatic Symptom Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse Control, and Conduct Disorders Substance Use and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Disorders Developmental Lifespan/ related areas

14 Neurodevelopmental Disorders Goodbye “mental retardation” Hello “Intellectual Developmental Disorder” – Not Intellectual Disability? (see also Rosa’s Law) IQ scores may be removed from the criteria but kept in the text narrative. IQ-based severity cut- offs (ex: moderate, profound) will likely be eliminated in favor of severity being more associated with adaptive behaviors Adaptive behaviors may receive more emphasis

15 Will we use adaptive behavior measures more? “Adaptive functioning refers to how well a person meets the standards of personal independence and social responsibility in one or more aspects of daily life activities, such as communication, social participation, functioning at school or at work, or personal independence at home or in community settings. The limitations result in the need for ongoing support at school, work, or independent life.”

16 Neurodevelopmental Disorders Autism Spectrum Disorder – Fixated interests and repetitive behaviors – Social/communication deficits Aspergers and other Pervasive Developmental Disorders will be included together under one diagnosis that has multiple specifiers to communicate severity and associated features.

17 A more purely inattentive type of ADHD (ex: Sluggish Cognitive Tempo) compared to individuals with a mixture of hyperactive and inattentive symptoms? ADHD: Higher onset cut off than age 7 (ex: 12) ADHD: Fewer symptoms in an adult to make the diagnosis?

18 Specific Learning Disorder: History or current presentation of persistent difficulties in the acquisition of reading, writing, arithmetic, or mathematical reasoning skills during the formal years of schooling (i.e., during the developmental period). Reading, written expression, mathematics specifiers Proposal changed from: dyslexia, dyscalculia, etc.

19 Schizophrenia Spectrum and Other Psychotic Disorders the classic Schizophrenia subtypes will likely be deleted; “these subtypes provide a poor description of the enormous heterogeneity of this condition, have low diagnostic stability, and only the paranoid and undifferentiated subtypes are utilized with any frequency.” Attenuated Psychosis Syndrome (Proposed for Section III of the DSM-5)

20 Bipolar and Related Disorders A need to improve diagnostic precision – Many with bipolar disorder do not receive a “correct” diagnosis of bipolar until later increased energy/activity has been added as a core symptom of manic/hypomanic episodes “caution is indicated so that one or two symptoms (particularly increased irritability, edginess or agitation following antidepressant use) are not taken as sufficient for diagnosis of a Hypomanic Episode, nor necessarily indicative of a bipolar diathesis.”

21 Depressive Disorders Disruptive Mood Dysregulation Disorder????? (previously known as “Temper Dysregulation Disorder with Dysphoria) Ellen Leibenluft, MD: Severe Mood Dysregulation: – “severe, nonepisodic irritability and the hyperarousal symptoms characteristic of mania but who lack the well-demarcated periods of elevated or irritable mood characteristic of bipolar disorder. Levels of impairment are comparable between youths with bipolar disorder and those with severe mood dysregulation” – nonepisodic irritability in youths: associated with an elevated risk for anxiety and unipolar depression, but not bipolar disorder, in adulthood. – lower familial rates of bipolar disorder than those with bipolar disorder

22 Disruptive Mood Dysregulation Disorder Will it reduce pediatric bipolar diagnoses in children without an episodic presentation? Alternatives could also potentially be considered (ex: highlight the mood components of ODD & ADHD). In your practice you may treat irritability and anger like the non-specific symptoms that they are.

23 Premenstrual Dysphoric Disorder: In the majority of menstrual cycles, symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post- menses – Likely brought in from the appendix Depressive Disorders

24 Anxiety Disorders Panic Disorder and Agoraphobia will likely be split in to two separate diagnoses Hoarding disorder and Skin-picking disorder may be added (separately from OCD) Obsessive- Compulsive a Related Disorders Trauma and Stressor Related Disorders

25 Some Additional Changes: Somatic Symptom Disorders may include “Illness Anxiety Disorder” (as opposed to hypochondriasis) Binge Eating Disorder will likely be brought in from the DSM-IV appendix Substance Use and Addictive Disorders: “Internet Use Disorder” for further research (heavily focused on “internet gaming”) The term “Dementia” is likely out; and the term “Neurocognitive Disorder” is likely in

26 “Guide to Implementation” from DSM5.org A standard approach to the assessment of personality pathology using the DSM-5 model could be the following: 1. Is impairment in personality functioning (self and interpersonal) present or not? – We evaluate the presence of impairment first and then “severity” of impairment second 2. If so, rate the level of impairment in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning on the Levels of Personality Functioning Scale. – Ranges from Healthy Functioning to Extreme Impairment 3. Is one of the 6 defined types present? 4. If so, record the type and the severity of impairment. 5. If not, is PD-Trait Specified present? 6. If so, record PDTS, identify and list the trait domain(s) that are applicable, and record the severity of impairment. 7. If a PD is present and a detailed personality profile is desired and would be helpful in the case conceptualization, evaluate the trait facets. 8. If neither a specific PD type nor PDTS is present, evaluate the trait domains and/or the trait facets, if these are relevant and helpful in the case conceptualization.

27 The 6 Types (at first 5) DSM-IV has 10 Personality Disorders not counting PD NOS and the ones in the appendix. The DSM-5 proposal deletes the names of all but 6 of them and re-conceptualizes them as personality “types.”

28 Disorders we “lost” Goodbye Paranoid (they were out to get you) Goodbye Schizoid (though you don’t seem to care) Goodbye Histrionic (yes, I’m sorry that no one is paying attention to you) Goodbye Dependent (at this point I’m not sure if we can help you any more) Hey, close call Narcissistic-- it was all about you for a while wasn’t it? – These “disorders” can still theoretically be addressed to some extent as personality traits & facets

29 The DSM-5 Personality “Types” (the names are what have remained the same– not the “criteria”) Borderline Personality Disorder Obsessive-Compulsive Personality Disorder Avoidant Personality Disorder Schizotypal Personality Disorder Antisocial (Dyssocial) Personality Disorder Narcissistic Personality Disorder

30 Personality Disorder Trait Specified Originally some proposed to have only one personality disorder at all that included a description of traits and their facets (and possibly type specifiers as well). This proposal did not survive. PDTS replaces Personality Disorder NOS and is a “make-your-own-ice-cream-sundae” personality disorder with the trait and facet options provided on the “sundae bar.”

31 Personality Disorder Trait Specified (cont.) A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning. B. One or more pathological personality trait domains OR specific trait facets within domains, considering ALL of the following domains: 1. Negative Affectivity 2. Detachment 3. Antagonism 4. Disinhibition (vs. Compulsivity) 5. Psychoticism (see DSM5.org)

32 DSM-5 CLINICIANS’ PERSONALITY TRAIT RATING FORM  Very little or not at all descriptive  Mildly descriptive  Moderately descriptive  Extremely descriptive Negative Affectivity Detachment Antagonism Disinhibition Psychoticism Currently available at

33 The FFM (“the big five”) Neuroticism Extraversion Openness to Experience* Agreeableness Conscientiousness Negative Emotionality Psychoticism* Introversion Disconstraint Aggressiveness “higher order” traits with each having a number of facets/sub- traits PSY-5

34 Personality Assessment Options Under DSM-5 include… Five-Factor Model NEO inventories (ex: NEO- PI-3, NEO-FFI-3) MMPI-2 PSY-5 Scale: (Negative Emotionality, Psychoticism, Introversion, Disconstraint and Aggressiveness) SNAP-2; DAPP-BQ (these and the PAI were authored by PD Work Group Members) New Scales involved in research? ex: The Personality Inventory for DSM-5 (PID-5)

35 Thank you! Questions? Contact: Todd Finnerty, Psy.D. twitter.com/DrFinnerty (330)


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