3 CAUTIONSThe rates of psychiatric disorders have skyrocketed alongside the expanded DSM increasing the list of what constitutes a mental disorderMost of the psychiatrist authors of the DSM-5 have ties to the pharmaceutical industryThere was a significantly sized group of psychiatrists who actually tried to block the release of the DSM-5
4 The DSM and DemocracyWinston 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 continuumsSeverity scalesSimplification (but not simple!)Discontinuation of 5 Axis system for purposes of diagnosisReplacement 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’tThey either met criteria (e.g., 4 of 7 symptoms) or they didn’tAn 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 criteriondepressed moodanxietysubstance usesleep problemsanger0-4 scale encouraged with 0 being absence of difficulty
8 Five Axis Diagnostic Structure Goes away for purposes of diagnosisReplaced with list of diagnosesI strongly recommend, ”Continue using Axes 4, 5 and 6 for purposes of informing the assessment, even if not used for purposes of diagnosis”
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 substanceB 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 criteriaSubstance-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 statusMisuse of a DUI as equivalent to old “abuse”Geographic inequalities (crossing Colorado state line)Con:For some, serves an SBIRT function, as early interventionMay function as the impetus for treatment54% 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 ContinuumsMeeting 0-1 of the 11 criteria results in No DiagnosisMeeting 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 WithdrawalPeak 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 yearAngerDecreased appetiteIrritabilityAnxietyRestlessnessSleep difficultiesDream reboundPhysical 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 DisordersCaffeine 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 metEarly partial remissionSustained full remissionSustained partial remissionSustained remissionNo symptoms for 12 months except cravingOn agonist maintenance therapyIn a controlled environmentWith physiological dependenceWithout physiological dependence
18 The ConundrumAlcoholism/addiction is a chronic, relapsing brain diseaseAlcoholism is an insidious, progressive, incurable and fatal disease and if the person doesn’t stop drinking/using, they will end up either dead or institutionalizedYet some alcoholics are able to go back to “social” (non-problem) drinking???
19 Rethinking the Continuum of Substance Use FOUR PHASERISKMODELA New Way ofConceptualizing Substance Use
20 Phases of Substance Use Character-isticsOutcomesResponsePhase 1DSM-5 Severity Level 0-1“Orphan”(no dx.)Low Risk ChoicesNo significantincrease in toleranceDo not use illegal drugsUse medications only as prescribedUse results in no problemsContinue to make low risk choices
22 Phases of Substance Use Character-isticsOutcomesResponsePhase 2DSM-5 Severity Level 2-3 – Mild –old “abuse”Makes high risk choicesDrinks high risks amountsMay develop social dependenceState dependent learning beginsAbstract thinking skills may become impaired, e.g., illicit drug useReturn to Phase 1 to make low risk choices
23 Phases of Substance Use Character-isticsOutcomesResponsePhase 3DSM-5 Severity Level 4-5 Moderate – old “abuse” or“depend-ence”Development of psychological dependenceSubstance use more integrated into lifeState dependent learningHigh risk choices become more important than relationshipsDefense of choicesSubstance-related health or impairment problemsBlackoutsDrinking to cure hangoversContinued use likely to lead toPhase 4Return to low-risk drinking choices may still be possibleMay require outside help to change choices50% are able to return to low-risk choices
24 Phases of Substance Use Character-isticsOutcomesResponsePhase 4DSM-5 Severity Level 6+ Severe – old“depend-ence”Physical addictionWithdrawalLoss of controlTolerance continues to increaseMore negative, more severe outcomes than in Phase 3Possible imprisonmentor deathReturn to low-risk choices no longer possibleRequires abstinenceUsually requires outside help
25 Disorders Most Likely to Co-Occur with Substance Use Disorders
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 eatingThey 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 medicationsAll of this is based on how they feel about themselves, on how much they weigh and how they lookPrognosis more positive than with anorexia
31 Binge Eating DisorderThe difference from Bulimia in the course is that no compensatory behavior (e.g., purging) takes placeBinge will be differentiated from garden variety overeating in that the binger will have several of these features:Eating more rapidly than normalFeeling uncomfortably fullFeeling embarrassed or ashamed of eating behaviorHiding eatingEating when not hungryFrequency 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 individualIt is a chronic dysfunction that begins early in life and is slow to changeThe DSM-IV system for categorizing personality disorders is unchanged in the DSM-5Patients 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 substancesAxis 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 intentCutters are generally different and healthier than suicide attempters in significant ways; better self-esteem, better mood, better parental relationshipsCutting 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 oldHave 3 rather than 6 of the characteristic symptoms during childhoodFrom 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 populationis: %Up to 15% of adults with ADHD will still meet full criteria by age 25Up to 65% of adults with ADHD will still meet in “partial remission” criteria by age 30Rate of ADHD are higher among people with SUDs
37 Note on Medications for ADHD Medication works better for hyperactive than inattentive symptomsDifferent disorders?
39 Anxiety Disorders The DSM-IV described five forms of anxiety disorder Panic DisorderGeneralized Anxiety Disorder (GAD)PhobiasPost Traumatic Stress Disorder (PTSD)Obsessive Compulsive Disorder (OCD)
40 Anxiety DisordersThere is symptomatic overlap between among the spectrum of anxiety disorders but they have different clinical presentations and are in different chapters of the DSM-5Generalized Anxiety Disorder is kept in the DSM-5 but renamed Generalized Anxiety and Worry DisorderPost Traumatic Stress Disorder (PTSD)Obsessive Compulsive Disorder (OCD)Phobias
41 Obsessive-Compulsive & Related Disorders Obsessive-Compulsive disorder (OCD)Body Dysmorphic DisorderHoarding 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 awayThey get in the way of normal thoughts and cause anxiety and fearThe thoughts may be violent or sexual or worry about illness or infectionExample include:Fear of harm to self or loved onesA need to do things perfectlyFear of getting dirty or infected
43 Symptoms of OCD Compulsions: Repeated behaviors to try to control the obsessionsSome have behaviors that are rigid and structured while others have complex behaviors that changeExamples include:Washing (e.g., hands)Checking (e.g., doors & windows to see if locked)Counting, often while doing another compulsive actionRepeating things or always moving items to keep them in perfect orderHoardingPraying incessantly
44 Substance-Induced Anxiety Disorder Prominent anxiety symptoms that are due to the direct physiological effects of a substanceSymptoms may occur during intoxication or withdrawalThe disturbance may not be better accounted for by a mental disorderThe diagnosis is not made if the anxiety symptoms occur only during the course of deliriumThe context may be specified as:Onset during intoxicationOnset during withdrawal
45 Panic Attack – 4 or > Symptoms Sudden high anxiety- with or without causeHeart palpitationsSweatingShakingA smothering sensation or shortness of breathA feeling of chokingChest pain or discomfortNauseaDizziness or faintnessA sense of unrealityA fear of going crazy or losing controlA fear of dyingNumbness or tinglingChills or hot flashes
46 Panic DisorderPanic 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 PhobiasThe 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 irrationalSocial 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 PhobiaSocial phobia renamed Social Anxiety Disorder has significant implications for treatment for when it co-occurs with substance use disorders:For treatmentFor self-help recovery groups
49 Generalized Anxiety and Worry Disorder Characterized by excessive, exaggerated anxiety and worry about everyday life for no obvious reasonsPatients tend to expect disaster and can’t stop worrying about health, money, family, work or schoolThe worry is often unrealistic or out of proportion for the situation
50 Post Traumatic Stress Disorder Such disorders reflect a biological predisposition or vulnerabilityMost people who are exposed to trauma do not develop PTSDThe DSM-5 combines a recognized cause (a traumatic event) with a set of characteristic symptomsThe 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 traumaSpecifically, the DSM-5 :Allows being a witness to a disasterReactions to learning about disasters
52 Depressive DisordersDisruptive Mood Dysregulation Disorder (previously combined with Attention Deficit, now a Depressive Disorder)Major Depressive Disorder, Single EpisodeMajor Depressive Disorder, RecurrentDysthymic Disorder (renamed “Persistent Depressive Disorder” but criteria the same)Substance-Induced Depressive DisorderDepressive Disorder Associated with Another Medical ConditionPremenstrual Dysphoric Disorder
53 Major Depressive Disorder (MDD) As many as 40% of those diagnosed with MDD actually have Bipolar DisordersIf misdiagnosed as MDD and prescribed anti- depressive drugs instead of a mood stabilizer, the anti-depressive medication may precipitate mania or hypomaniaWhen 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 minimumTo find the correct drug in the correct dose may take up to 6 monthsComplicated 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 episodeFeelings of sadnessInsomniaLoss of appetiteWeight lossIn the DSM-IV a diagnosis of MDD was made for a death unless symptoms persist for over 2 months but not other lossesIn 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 hypomaniaBipolar Disorder is one of the most misdiagnosed, over-diagnosed psychiatric disorder
57 Bipolar Disorder Misdiagnosis* Total misdiagnosis %Times individual misdiagnosedPhysicians consulted before correct diagnosisMisdiagnosed 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 AutismConcern: Many higher functioning Asperger’s or those with Pervasive Developmental Disorder may not be diagnosed with ASDIf 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 treatmentAs complex as the DSM-5 is, it will get easier over time
61 ASAM CRITERIA BACKGROUND Previous EditionsPPC ( 1991)PPC-2 (1996)PPC-2R (2001)Upcoming Edition:“The ASAM Criteria”Release October, 2013What is the ASAM Critera: Most widely used and comprehensive set of guidelinesUsed across all settings and by different levels of professionals (clinicians and non-clinicians)Criteria Development: 1980s ASAM entrusted to unifying addiction field around national criteriaCriteria address board continuum of addiction servicesRequired in over 30 statesSince Frist Edition 1991, Criteria considered Board approved and endorsedRevised 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 2001Addresses application to special patient populationsApplies to a wide variety of clinical settingsImproved user-friendly designLead into next slide:How has the text been vetted?
62 Assessment of Biopsychosocial Severity and Level of FunctionDimensions are not changed in the new ASAM CriteriaAcute Intoxication and/or Withdrawal PotentialBiomedical conditions and complicationsEmotional/Behavioral/Cognitive conditions and complicationsReadiness to ChangeRelapse/Continued Use/Continued Problem potentialRecovery Environment
63 Broad Treatment Levels of Service Description of the Continuum of Care 1. Outpatient Treatment2. Intensive Outpatient and Partial Hospitalization3. Residential/Inpatient Treatment4. Medically-Managed Intensive Inpatient TreatmentNo changes except:New edition changes to Arabic numerals from Roman numerals e.g., Level II.1 becomes Level II.1The 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 ConditionsShift away from “placement” criteria to “treatment” criteria: it’s more than just “placement”Diagnostic Admission Criteria terminology changed to be compatible with DSM-5Section on working with managed careSection 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 decisionsADOLESCENT CRITERIA NO LONGER SEPARATE/STAND-ALONE: consolidated Adult and Adolescent content to minimize redundancy while preserving adolescent-specific contentAppendices 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 ManagementThe overall section that used to be called “detoxification” is now called “Withdrawal Management” and the Levels are now called1-D is now 1-WM; 2-D is now 2-WM; 3-D is now 3- WM and 4-D is now 4-WMNew 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 AdultsPersons in Safety Sensitive OccupationsParents with Children and Pregnant WomenPerson 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 DisorderGambling 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 careThe role of physicians in the care team, addiction specialist physicians in particular (addiction medicine physicians, addiction psychiatrists)