1. New Diagnostic and Statistical Manual
2013 FAADA Conference
“Introduction to the
New Diagnostic and Statistical Manual
For Mental Disorders, 5th Edition,
DSM-5 and the New ASAM Criteria”
8/7/13
Orlando, FL
© 2013, Shulman & Associates,
Training & Consulting in Behavioral Health

3. CAUTIONS
The rates of psychiatric disorders have skyrocketed alongside the expanded DSM increasing the list of what constitutes a mental disorder
Most of the psychiatrist authors of the DSM-5 have ties to the pharmaceutical industry
There was a significantly sized group of psychiatrists who actually tried to block the release of the DSM-5

4. The DSM and Democracy
Winston Churchill said: No one pretends that democracy is perfect or all-wise. Indeed, it has been said that democracy is the worst form of government except all those other forms that have been tried from time to time.
Sounds like the DSM!

5. General Changes Publication 5/22/13 Two year phase-in
Movement from categories to continuums
Severity scales
Simplification (but not simple!)
Discontinuation of 5 Axis system for purposes of diagnosis
Replacement of NOS (Not Otherwise Specified) with NEC (Not Otherwise Categorized)
Coding will change to be consistent with the ICD-10

6. Dimensional Assessment
In DSM-IV, a categorical approach was used:
An individual either had a symptom of the disorder or they didn’t
They either met criteria (e.g., 4 of 7 symptoms) or they didn’t
An individual either had a disorder or they didn’t

7. Cross Cutting Symptom Assessment
Assessment across areas that are relevant (and “cut across”) but are not a specific diagnostic criterion
depressed mood
anxiety
substance use
sleep problems
anger
0-4 scale encouraged with 0 being absence of difficulty

8. Five Axis Diagnostic Structure
Goes away for purposes of diagnosis
Replaced with list of diagnoses
I strongly recommend, ”Continue using Axes 4, 5 and 6 for purposes of informing the assessment, even if not used for purposes of diagnosis”

9. Substance Use Disorders

10. DSM IV Criteria for Substance Dependence
A Maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12- month period:
(1) tolerance
(2) withdrawal
(3) the substance taken in larger amounts or over a longer period of time than was intended
(4) there is a persistent desire or unsuccessful attempts to cut down or control substance use
(5) a great deal of time spent is in activities necessary to obtain the substance, use the substance, or recover from its effects
(6) important social, occupational or recreational activities are given up or reduced because of substance use
(7) substance use is continued despite knowledge of having persistent or recurring physical or psychological problems that are likely to have been caused or exacerbated by the substance

11. DSM IV Criteria for Substance Abuse
A Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a 12-month period:
(1) Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home
(2) Recurrent substance use in situations in which it is physically hazardous
(3) Recurrent substance-related legal problems
(4) Continuing substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
B The symptoms have never met the criteria for Substance Dependence for this class of substance

12. The DSM-5 (May, 2013) Changes from DSM-IV Use of the term “addiction”
No longer diagnoses of “abuse” or “dependence”
“Substance Use Disorders” (DSM-IV) > “Substance Use and Addictive Disorders” (DSM-5)
The seven criteria from the DSM-IV for dependence and the four for abuse are collapsed into 11 criteria
Substance-related legal problems (from abuse criteria) has been removed???
A new criteria of craving, strong desire or urge to use a substance has been added

13. Removal of “Legal Problems”
Discrimination based on race and socioeconomic status
Misuse of a DUI as equivalent to old “abuse”
Geographic inequalities (crossing Colorado state line)
Con:
For some, serves an SBIRT function, as early intervention
May function as the impetus for treatment
54% of DUI offenders who received an abuse diagnosis under the DSM-IV will receive no diagnosis under the DSM-5 – what will this mean in terms of reoffending?

14. The DSM–5 (May, 2013)
Changes in the DSM-5 from Categories to Continuums
Meeting 0-1 of the 11 criteria results in No Diagnosis
Meeting 2-3 criteria qualifies as Mild (akin to old “abuse”)
Meeting 4-5 criteria qualifies as Moderate (akin to old “abuse” or “dependence”)
Meeting 6 or more qualifies as Severe (akin to old “dependence”)

15. Cannabis Withdrawal
Peak symptoms 1 – 21 days post cessation of heavy cannabis use, markedly reduced or absent by 4 weeks. Psychological symptoms may persist for up to a year
Anger
Decreased appetite
Irritability
Anxiety
Restlessness
Sleep difficulties
Dream rebound
Physical symptoms (frequent but mild)
Depressed mood

16. Other Changes in Substance Use and Addictive Disorders
Addition of:
“Alcohol-Related Disorders” changed to “Alcohol Use Disorders”
Gambling Disorder (from a type of OCD disorder to its own disorder)
Tobacco-Related Disorders
Caffeine withdrawal

17. Course Specifiers Early full remission
From 1 month but less than 12 months in DSM-IV to 3 month but less than 12 months in DSM-5, no criteria met
Early partial remission
Sustained full remission
Sustained partial remission
Sustained remission
No symptoms for 12 months except craving
On agonist maintenance therapy
In a controlled environment
With physiological dependence
Without physiological dependence

18. The Conundrum
Alcoholism/addiction is a chronic, relapsing brain disease
Alcoholism is an insidious, progressive, incurable and fatal disease and if the person doesn’t stop drinking/using, they will end up either dead or institutionalized
Yet some alcoholics are able to go back to “social” (non-problem) drinking???

19. Rethinking the Continuum of Substance Use
FOUR PHASE
RISK
MODEL
A New Way of
Conceptualizing Substance Use

20. Phases of Substance Use
Character-istics
Outcomes
Response
Phase 1
DSM-5 Severity Level 0-1
“Orphan”
(no dx.)
Low Risk Choices
No significant
increase in tolerance
Do not use illegal drugs
Use medications only as prescribed
Use results in no problems
Continue to make low risk choices

22. Phases of Substance Use
Character-istics
Outcomes
Response
Phase 2
DSM-5 Severity Level 2-3 – Mild –old “abuse”
Makes high risk choices
Drinks high risks amounts
May develop social dependence
State dependent learning begins
Abstract thinking skills may become impaired, e.g., illicit drug use
Return to Phase 1 to make low risk choices

23. Phases of Substance Use
Character-istics
Outcomes
Response
Phase 3
DSM-5 Severity Level 4-5 Moderate – old “abuse” or
“depend-ence”
Development of psychological dependence
Substance use more integrated into life
State dependent learning
High risk choices become more important than relationships
Defense of choices
Substance-related health or impairment problems
Blackouts
Drinking to cure hangovers
Continued use likely to lead to
Phase 4
Return to low-risk drinking choices may still be possible
May require outside help to change choices
50% are able to return to low-risk choices

24. Phases of Substance Use
Character-istics
Outcomes
Response
Phase 4
DSM-5 Severity Level 6+ Severe – old
“depend-ence”
Physical addiction
Withdrawal
Loss of control
Tolerance continues to increase
More negative, more severe outcomes than in Phase 3
Possible imprisonmentor death
Return to low-risk choices no longer possible
Requires abstinence
Usually requires outside help

25. Disorders Most Likely to Co-Occur with Substance Use Disorders

26. Eating Disorders Anorexia Nervosa Bulimia Nervosa
Binge Eating Disorder

27. Anorexia Nervosa

28. Anorexia Nervosa
Anorexia Nervosa is the most lethal of all psychiatric disorders with 5% dying per decade after diagnosis either from medical complications or suicide

29. Before 40 day fast
After 40 day fast

30. Bulimia Nervosa People with bulimia:
Binge on a regular basis. They eat large amounts of food in a short period of time, often over a couple of hours or less. During a binge they feel out of control and feel unable to stop eating
They purge to get rid of food and avoid weight gain. The may makes themselves vomit, exercise very hard or for a long time, or misuse laxatives, enemas, diuretics or other medications
All of this is based on how they feel about themselves, on how much they weigh and how they look
Prognosis more positive than with anorexia

31. Binge Eating Disorder
The difference from Bulimia in the course is that no compensatory behavior (e.g., purging) takes place
Binge will be differentiated from garden variety overeating in that the binger will have several of these features:
Eating more rapidly than normal
Feeling uncomfortably full
Feeling embarrassed or ashamed of eating behavior
Hiding eating
Eating when not hungry
Frequency will likely be the same as for Bulimia (averaging once/week for 3 months)
Prognosis more optimistic that Anorexia or Bulimia

32. Personality Disorders
The essential element of personality disorder is that it is not an episodic condition in an otherwise well-functioning individual
It is a chronic dysfunction that begins early in life and is slow to change
The DSM-IV system for categorizing personality disorders is unchanged in the DSM-5
Patients with these disorders are often not likeable, may be seen as difficult rather than sick and may be rejected by clinicians and payers (treatment refractory)
With Substance Use Disorders, Antisocial Personality Disorder is often associated with the use of illicit substances
Axis II has been eliminated

33. Personality Disorders Most Likely to Co-occur with Substance Use Disorders
Antisocial Personality Disorder
&
Borderline Personality Disorder

34. Non-Suicidal Self Injury Disorder (Condition for Further Study)
At present, surface self-mutilation behavior is reflected only as a symptom of Borderline Personality Disorder (BPD). In reality the behavior occurs with a variety of psychiatric disorders and not all cutters have BPD.
The behavior is often labeled or interpreted as suicidal when there is no suicidal intent
Cutters are generally different and healthier than suicide attempters in significant ways; better self-esteem, better mood, better parental relationships
Cutting is a rare suicide method (.5%). However, many will make an actual suicide attempt. Risk increase with the number of incidents and number of modalities

35. Attention-Deficit/ Hyperactivity Disorder
Changes in DSM-5:
Onset prior to 12 years old rather than 7 years old
Have 3 rather than 6 of the characteristic symptoms during childhood
From 2 or more settings to “several”
Will make it easier to diagnose adults with ADHD

36. ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD)
Incidence in the General Population is: %
Incidence in a cocaine using population
is: %
Up to 15% of adults with ADHD will still meet full criteria by age 25
Up to 65% of adults with ADHD will still meet in “partial remission” criteria by age 30
Rate of ADHD are higher among people with SUDs

37. Note on Medications for ADHD
Medication works better for hyperactive than inattentive symptoms
Different disorders?

38. People DO NOT Outgrow ADHD!

39. Anxiety Disorders The DSM-IV described five forms of anxiety disorder
Panic Disorder
Generalized Anxiety Disorder (GAD)
Phobias
Post Traumatic Stress Disorder (PTSD)
Obsessive Compulsive Disorder (OCD)

40. Anxiety Disorders
There is symptomatic overlap between among the spectrum of anxiety disorders but they have different clinical presentations and are in different chapters of the DSM-5
Generalized Anxiety Disorder is kept in the DSM-5 but renamed Generalized Anxiety and Worry Disorder
Post Traumatic Stress Disorder (PTSD)
Obsessive Compulsive Disorder (OCD)
Phobias

41. Obsessive-Compulsive & Related Disorders
Obsessive-Compulsive disorder (OCD)
Body Dysmorphic Disorder
Hoarding Disorder*
Trichotillomania (hair pulling)
Excoriation Disorder (skin picking disorder)*
Substance-Induced Obsessive-Compulsive or Related Disorder (“coke bugs”)
Obsessive-Compulsive or Related Disorder Attributable to Another Medical Condition
*New

42. Symptoms of OCD Obsessions:
Unwanted thoughts, ides and urges that occur repeatedly and won’t go away
They get in the way of normal thoughts and cause anxiety and fear
The thoughts may be violent or sexual or worry about illness or infection
Example include:
Fear of harm to self or loved ones
A need to do things perfectly
Fear of getting dirty or infected

43. Symptoms of OCD Compulsions:
Repeated behaviors to try to control the obsessions
Some have behaviors that are rigid and structured while others have complex behaviors that change
Examples include:
Washing (e.g., hands)
Checking (e.g., doors & windows to see if locked)
Counting, often while doing another compulsive action
Repeating things or always moving items to keep them in perfect order
Hoarding
Praying incessantly

44. Substance-Induced Anxiety Disorder
Prominent anxiety symptoms that are due to the direct physiological effects of a substance
Symptoms may occur during intoxication or withdrawal
The disturbance may not be better accounted for by a mental disorder
The diagnosis is not made if the anxiety symptoms occur only during the course of delirium
The context may be specified as:
Onset during intoxication
Onset during withdrawal

45. Panic Attack – 4 or > Symptoms
Sudden high anxiety- with or without cause
Heart palpitations
Sweating
Shaking
A smothering sensation or shortness of breath
A feeling of choking
Chest pain or discomfort
Nausea
Dizziness or faintness
A sense of unreality
A fear of going crazy or losing control
A fear of dying
Numbness or tingling
Chills or hot flashes

46. Panic Disorder
Panic disorder describes the negative impact on an individual’s life from recurrent, unexpected Panic Attacks, taking the form of the restriction of daily or self-care activities to avoid further attacks or marked fear or distress while engaged in activities for fear of further Panic Attacks

47. Phobias
The classic picture of a specific phobia need not lead to serious dysfunction and clinicians rarely see these cases (arachnophobia)
One change in the DSM-5 is removal of the requirement that phobias be recognized by patients who suffer from them as irrational
Social Anxiety Disorder (previously social phobia) , because of the high prevalence of social anxiety and shyness in community populations may be too broadly defined (e.g., anxiety about speaking in public)

48. Social Phobia
Social phobia renamed Social Anxiety Disorder has significant implications for treatment for when it co-occurs with substance use disorders:
For treatment
For self-help recovery groups

49. Generalized Anxiety and Worry Disorder
Characterized by excessive, exaggerated anxiety and worry about everyday life for no obvious reasons
Patients tend to expect disaster and can’t stop worrying about health, money, family, work or school
The worry is often unrealistic or out of proportion for the situation

50. Post Traumatic Stress Disorder
Such disorders reflect a biological predisposition or vulnerability
Most people who are exposed to trauma do not develop PTSD
The DSM-5 combines a recognized cause (a traumatic event) with a set of characteristic symptoms
The traumatic event is either life threatening, could lead to serious injury or rape

51. Broadening the Diagnosis of PTSD
The DSM-5 diagnosis has been broadened to incidents that consist only of hearing about the trauma
Specifically, the DSM-5 :
Allows being a witness to a disaster
Reactions to learning about disasters

52. Depressive Disorders
Disruptive Mood Dysregulation Disorder (previously combined with Attention Deficit, now a Depressive Disorder)
Major Depressive Disorder, Single Episode
Major Depressive Disorder, Recurrent
Dysthymic Disorder (renamed “Persistent Depressive Disorder” but criteria the same)
Substance-Induced Depressive Disorder
Depressive Disorder Associated with Another Medical Condition
Premenstrual Dysphoric Disorder

53. Major Depressive Disorder (MDD)
As many as 40% of those diagnosed with MDD actually have Bipolar Disorders
If misdiagnosed as MDD and prescribed anti- depressive drugs instead of a mood stabilizer, the anti-depressive medication may precipitate mania or hypomania
When do you medicate for an anxiety, depressive or bipolar disorder?
When the risk of not medicating exceeds the risk of medicating!

54. Time for Medications to Work
6 to 8 weeks minimum
To find the correct drug in the correct dose may take up to 6 months
Complicated by who prescribes (PCPs)
Antidepresssant drugs now the most commonly prescribed class of drug in the U.S. (1 in 10 people)
Work best for very severe cases of depression and have little or no benefit over placebo (inactive pills) in less serious cases.

55. Depression - Bereavement
Many symptoms are characteristic of a major depressive episode
Feelings of sadness
Insomnia
Loss of appetite
Weight loss
In the DSM-IV a diagnosis of MDD was made for a death unless symptoms persist for over 2 months but not other losses
In the DSM-5, don’t diagnose MDD if bereavement symptoms best account for the depressive symptoms
“Persistent Complex Bereavement Disorder”*
*Proposed for further study

56. Bipolar Disorder Unipolar disorders present with only depression
Bipolar Disorder presents with both depression and mania and is divided into two types:
Bipolar I: with full mania (not changed in the DSM-5)
Bipolar II: with hypomania
Bipolar Disorder is one of the most misdiagnosed, over-diagnosed psychiatric disorder

57. Bipolar Disorder Misdiagnosis*
Total misdiagnosis %
Times individual misdiagnosed
Physicians consulted before correct diagnosis
Misdiagnosed as:
Unipolar Depression %
Anxiety Disorder (especially PTSD) %
Schizophrenia %
Borderline or Antisocial Personality Disorder 17%
* Hirschfield, RM et al. J Clin Psychiatry. 2003, 64(2):

58. Autism Spectrum Disorder
Now encompasses range from Asperger’s to Autism
Concern: Many higher functioning Asperger’s or those with Pervasive Developmental Disorder may not be diagnosed with ASD
If so, may lose services available through Medicaid waivers available in a number of states through the Social Security Act. Under a waiver program, states can choose to waive income when determining Medicaid eligibility.

59. So What Now?
Even if you are not permitted under your scope of practice to do a formal diagnosis, you can always do a “diagnostic impression”
Become familiar enough with the DSM-5 diagnoses to assure that your patients/clients with co-occurring disorders are getting what they need in treatment
As complex as the DSM-5 is, it will get easier over time

60. What’s New in the ASAM Criteria?

61. ASAM CRITERIA BACKGROUND
Previous Editions
PPC ( 1991)
PPC-2 (1996)
PPC-2R (2001)
Upcoming Edition:
“The ASAM Criteria”
Release October, 2013
What is the ASAM Critera: Most widely used and comprehensive set of guidelines
Used across all settings and by different levels of professionals (clinicians and non-clinicians)
Criteria Development: 1980s ASAM entrusted to unifying addiction field around national criteria
Criteria address board continuum of addiction services
Required in over 30 states
Since Frist Edition 1991, Criteria considered Board approved and endorsed
Revised Edition: Major changes—(David Mee-Lee can chime in as needed)
Updated to reflect changes in the addiction field since the last edition published in 2001
Addresses application to special patient populations
Applies to a wide variety of clinical settings
Improved user-friendly design
Lead into next slide:
How has the text been vetted?

62. Assessment of Biopsychosocial Severity
and Level of Function
Dimensions are not changed in the new ASAM Criteria
Acute Intoxication and/or Withdrawal Potential
Biomedical conditions and complications
Emotional/Behavioral/Cognitive conditions and complications
Readiness to Change
Relapse/Continued Use/Continued Problem potential
Recovery Environment

63. Broad Treatment Levels of Service Description of the Continuum of Care
1. Outpatient Treatment
2. Intensive Outpatient and Partial Hospitalization
3. Residential/Inpatient Treatment
4. Medically-Managed Intensive Inpatient Treatment
No changes except:
New edition changes to Arabic numerals from Roman numerals e.g., Level II.1 becomes Level II.1
The old Level III.3, Clinically Managed Moderate Intensity Residential Treatment becomes Level 3.3, High-Intensity, Population-Focused Residential Treatment

64. What’s new in The ASAM Criteria? The Title!
The Title: “The ASAM Criteria” - Treatment Criteria for Substance, Addictive and Co-Occurring Conditions
Shift away from “placement” criteria to “treatment” criteria: it’s more than just “placement”
Diagnostic Admission Criteria terminology changed to be compatible with DSM-5
Section on working with managed care
Section on the Affordable Care Act

65. What’s new in The ASAM Criteria? The Table of Contents!
Re-ordered to be more user-friendly and follow the flow from Historical Foundations to Guiding Principles to Assessment, Service Planning and Placement decisions
ADOLESCENT CRITERIA NO LONGER SEPARATE/STAND-ALONE: consolidated Adult and Adolescent content to minimize redundancy while preserving adolescent-specific content
Appendices include Withdrawal Management instruments, Dimension 5 constructs, and a Glossary

66. What’s new in The ASAM Criteria?
The wording in the Levels of Care for Withdrawal Management
The overall section that used to be called “detoxification” is now called “Withdrawal Management” and the Levels are now called
1-D is now 1-WM; 2-D is now 2-WM; 3-D is now 3- WM and 4-D is now 4-WM
New approaches described to support increased use of lower levels of care for safe/effective management of withdrawal

67. What’s new in The ASAM Criteria?
Updated/revised terminology, to be contemporary and strength-based, recovery-oriented:
“dual diagnosis” becomes “co-occurring disorders”
“inappropriate use of substances” becomes “high risk use of substances”
“admitted” becomes “stated”
“compliance” becomes “adherence”

68. What’s new in The ASAM Criteria?
Specialized services for opioid use disorder re-named:
“Opioid Maintenance Therapy”(OMT) becomes “Opioid Treatment Services”(OTS)
Within OTS, mention is made of the use of opioid antagonist medications as well as opioid agonist medications that can be used in OTPs (regulated “Opioid Treatment Programs”) or in office-based opioid treatment (OBOT)

70. New Content and Sections
Additional text to improve application to address addiction treatment for Special Populations:
Older Adults
Persons in Safety Sensitive Occupations
Parents with Children and Pregnant Women
Person in the Criminal Justice System (CJS)

71. New Content and Sections
Additional text to address treatment of conditions not traditionally included in specialty addiction treatment services:
Tobacco Use Disorder
Gambling Disorder

72. New Content and Sections
Revision of the text to address emerging issues:
Health Reform and the integration of addiction treatment into general medical care
The role of physicians in the care team, addiction specialist physicians in particular (addiction medicine physicians, addiction psychiatrists)