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1 Utah Valley University
“The DSM-5 for Addiction Clinicians” © 2015, Shulman & Associates, Training & Consulting in Behavioral Health

2 The Basic Assessment System for Mental Health Disorders is the DSM-5
DSM-5 Conflicts NIMH stated that the manual is reliable but lacks validity and that "patients with mental disorders deserve better“ and "will be re-orienting its research away from DSM categories."

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 is a significantly sized group of psychiatrists who tried to block the release of the DSM-5 led by the psychiatrist who chaired the DSM-IV revision (Allen Frances, MD) Diagnoses of Bipolar Disorder in children have increased 40 times in the last 20 years, most of whom have never had a manic or hypomanic episode

4 Progress? DSM-I (1952) – 132 pages DSM-5 – (2013) pages

5 The DSM-5 Has 257 different diagnoses organized in 20 chapters restructured on the disorders’ apparent relatedness to one another Is 947 pages in length Has a helpful section comparing changes from the DSM-IV to the DSM-5 (p. 809)

6 U.R. Recommendation #1 U.R. Recommendation #2
When talking to insurance or managed care companies’ utilization reviewers, don’t talk about recovery (it doesn’t compute for them) Talk about “REMISSION” Before doing a precertification, ask the reviewer if they are using the DSM-IV or DSM-5 U.R. Recommendation #2 Our people with substance use or mental health problems are “PATIENTS” The people we treat are not “clients” Lawyers have “clients” Accountants have “clients” Prostitutes have “clients” We have patients!

7 General Changes Published 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

8 Cross Cutting Symptom Assessment*
Assessment across areas that are relevant (and “cut across”) regardless of specific diagnostic category depressed mood anxiety substance use sleep problems anger Usually single page 0-4 scale encouraged with 0 being absence of difficulty

9 A Description of A Mental Disorder (Allen Frances)
A Mental Disorder is a: Condition that clinicians treat Researchers research Educators teach and Insurers pay for! Allen Frances , MD

10 Five Axis Diagnostic Structure
Goes away for purposes of diagnosis Replaced with list of diagnoses Recommendation #1: Keep the 5 Axis system “in your head” as a way of organizing your assessment Recommendation #2: “Continue using Axes III, IV and V for purposes of informing the assessment”

11 Old Axis 3 General Medical Conditions
A common reason for relapse to opioid dependence is a chronic pain disorder Chronic pain disorders would have been coded on Axis III Don’t use the Axis III term – describe in a narrative form your findings

12 Old Axis IV Psychosocial and Environmental Problems
A review of these problems can help to develop a substance use or mental disorder relapse prevention plan Don’t use the Axis IV term – describe in a narrative form your findings

13 Axis V Global Assessment of Functioning


15 Old Axis 5 Global Assessment of Functioning
Assess for current level of functioning Assess for highest level of functioning in the past year Determines whether the patient’s functioning is deteriorating, improving or remain stable Questions about the GAF Scale number and admission to residential or inpatient treatment? Don’t use the Axis 5 term – describe in a narrative form your findings

16 Substance Use and Addictive Disorders

17 Why Start with Substance Use Disorders?
All of the other diagnoses in this training are presented in the order found in the DSM-5 manual with the exception of substance use disorders Substance use disorders co-occur with more diagnoses than any other diagnosis Many of the disorders have as a type: “substance use induced disorder” Example: Even though there are 257 different diagnoses in the DSM-5, 16% of diagnostic criteria are devoted to substance use disorders

18 Binge Drinking Most excessive drinkers (90%) did not meet the criteria for alcohol dependence (DSM-IV) Excessive alcohol consumption is responsible for an average of 88,000 deaths each year and cost the United States $223.5 billion in 2006 Half of these deaths and three-quarters of the economic costs are due to binge drinking (i.e., ≥4 drinks for women and ≥5 drinks for men in a single occasion Binge drinking is also associated with a myriad of health and social problems (e.g., violence, new HIV infections, unintended pregnancies, sexual assault, and alcohol dependence)

19 DSM-IV Diagnostic Assessment
Substance Dependence Substance Abuse Those individuals who do not meet the criteria for abuse, but whose drinking/drug use might still create problems (“sub-threshold” abuse)

20 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

21 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

22 The DSM-5 Diagnostic Criteria for Substance Use Disorders

23 The DSM-5 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

24 Removal of “Legal Problems”
Discrimination based on race and socioeconomic status Misuse of a DWI as equivalent to old “abuse” Geographic inequalities (crossing Colorado state line) A criterion that carried the least weight in making the diagnosis Con: For some, serves an SBIRT function, as early intervention May function as the impetus for treatment (drug courts) Potential insurance problems because of change in diagnosis

25 DSM-5 Criteria for Substance Use Disorders
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by two (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

26 DSM-5 Criteria for Substance Use Disorders (cont)
(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 (8) Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home (9) Recurrent substance use in situations in which it is physically hazardous (10) Craving (11) Continuing substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

27 Changes in the DSM–5 Diagnostic Criteria for Substance Use Disorders
Changes from DSM-IV 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”)

28 The Issue of Criteria “Weight”
All criteria are not equal in implications Some criteria are found almost exclusively among those in the severe alcohol use disorder designation Other criteria are more common among the mild to moderate alcohol use disorder group Tolerance and dangerous use are actually common among those with no diagnosis

29 The SUD Criteria Found Primarily in the Severe Designation
The “Big Five” Wanting to cut down/unable to do so Craving with compulsion to use Sacrifice activities to use Failure at role fulfillment due to use Withdrawal symptoms

Unplanned use Time spent using Medical/psych. consequences of use Use where impairment is dangerous Interpersonal conflicts Legal problems and use to relieve emotional distress similar in distribution to those above

31 SAMPLE HYPOTHESES Hypothesis #1: Clients positive on three or more of the “big five” (withdrawal, rule setting, sacrificing activities, role fulfillment failure, and craving/compulsion to use) will find recovery more difficult (e.g., higher relapse rates) Hypothesis #2: Clients in mild or moderate designations without any positive findings on the “big five” may be able to moderate use

Most of those in the “mild” designation can probably benefit from moderation and related harm reduction strategies (outpatient placement) Those in the “severe” designation will require more intensive and extended services where abstinence is essential to recovery (residential/inpatient or structured outpatient, IOP or PHP placement depending on the ASAM severity profile) The “moderate” group may contain cases that fit the mild or severe characteristics (placement dependent on the results of the ASAM severity profile)

33 Changes in Course Specifiers
Early remission From 1 month but less than 12 months in DSM-IV to 3 month in DSM-5, no criteria met except craving Early partial remission Sustained full remission No symptoms for 12 months except craving Sustained partial remission On agonist maintenance therapy In a controlled environment

34 Current Drug Use Status
Alcohol: Significant declines in use by adolescents and college students Palcohol: Powdered alcohol Cannabis: Significant increases in use by adolescents and college students Slight decrease in cannabis use last year Increase in pediatric overdoses Benzodiazepines: ER visits involving non- medical use of Xanax doubled from 2005 to and most common prescribed psychiatric medication in 2011

35 Opioids Sales of legal opioids have increased 400% in last 10 yrs
O.D. deaths among adolescents and 20 years olds O.D. deaths associated with Rx. Opioids increased 200% in last 15 years Evzio, a device for delivering naloxone (Narcan), an opioid antagonist to treat O.D.s, approved by the FDA, estimated to prevent 20,000 O.D. deaths/yr. in US Automatically injects correct dose in an easy to use device Easy for anyone to administer and when turned on it provides verbal instructions (like defibrillators) Size of a credit card FDA approved but not all states permit it Available by Rx to friends, families, other caregivers Now available as a nasal spray

36 The Great American Relapse: An Old Sickness has Returned to Haunt a New Generation
The face of heroin use in America has changed utterly. Forty or fifty years ago people addicted to heroin were overwhelmingly male, disproportionately black, and very young (the average age of first use was 16). Most came from poor inner-city neighborhoods These days, more than half are women, and 90% are white. The drug has crept into the suburbs and the middle classes. And although users are still mainly young, the age of initiation has risen: most first-timers are in their mid-20s Heroin overdoses increased 39% in 2013

Cannabis patterns empirically different from other substance groups Cannabis also most unique in terms of which receptor sites are involved Possible reasons for lack of severe cases Amotivational syndrome not part of DSM Cannabis users tend not to do wild things Cannabis consequences may not be associated with use

38 Cannabis Withdrawal (New)
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 (often viewed as “non-compliance) Anxiety Restlessness Sleep difficulties Dream rebound Physical symptoms (frequent but mild) Depressed mood Three (0r more) withi9n one week of cessation of use

39 New Findings re: Cannabis
Cannabis (particularly heavy use) is associated with short term memory deficits up to 2 years after stopping use Cannabis is associated with Social Anxiety Disorder Cause vs. effect Screen Cannabis user for Social Anxiety Disorder Synthetic Marijuana is NOT cannabis – bath salts, “K-2,” “Spice”

40 Caffeine Withdrawal (New)
Prolonged use of caffeine Abrupt cessation or reduction in caffeine use, followed within 24 hours by three (or more) of the following signs or symptoms Headache Marked fatigue of drowsiness Dysphoric mood, depressed mood or irritability Difficulty concentrating Flu-like symptoms (nausea, vomiting or muscle pain or stiffness

41 Tobacco Use Disorder Labeled “Nicotine Use Disorder” in the DSM-IV
Diagnoses for “Tobacco Use Disorder” and “Tobacco Withdrawal” More people die from the use of tobacco and second hand smoke than die from the use of alcohol and the other drugs combined Smoking serve as a trigger for relapse to other drugs When the route of administration of the drug of choice is smoking (e.g.,“crack”), the risk is increased Smoking interferes with neurocognitive recovery during abstinence from alcohol (first 8 months)

42 Implementing Tobacco Cessation Success vs. Failure
NOT tobacco cessation – don’t separate RECOVERY from substance use disorder Should be no different than cannabis use in the facility in someone with a severe alcohol use disorder The problem is not the drug of choice It is reliance on psychoactive substances to cope Tobacco use disorder treatment should be reflected in the: Assessment Treatment plan Progress notes

43 Recent Study Psychiatric patients who took part in a smoking- cessation program while they were in the hospital for treatment of mental illness were more likely to quit smoking and less likely to be hospitalized again for mental illness, a new study shows 224 patients at a smoke-free psychiatric hospital in California Eighteen months after leaving the hospital, 20 percent of those in the treatment group had quit smoking, compared with 7.7 percent of those in the control group Forty-four percent of patients in the treatment group and 56 percent of those in the control group had been readmitted to the hospital.

44 Schizophrenia & Tobacco Use Disorder
Addiction to nicotine is the most common form of substance abuse in people with schizophrenia They are addicted to nicotine at three times the rate of the general population

45 Three Types of Outcomes from Smoking
Addiction Toxicity Cancers (lung mouth, kidney) Death 480,000 people/year in the US Equals plane loads of people/day Vapor produced by e-cigarettes can contain formaldehyde at levels five to 15 times higher than regular cigarettes, a new study finds. Formaldehyde is a known carcinogen

46 Smoking causes 1/3 of all of the cancer deaths in the U.S.
This does not include the effects of secondhand smoke

47 The “E-Joint” A new device known as an “e-joint” brings together marijuana and an e-cigarette A brand of e-joint, JuJu Joint, holds 100 milligrams of THC, the psychoactive ingredient in marijuana—twice as much as a traditional joint It is disposable and comes filled with 150 hits. The device produces no smoke and has no smell.

48 Where Are You RE: Behavioral Health Patients Continuing Tobacco Use?

49 Gambling Disorder Persistent and recurring problematic gambling behavior leading to significant impairment and distress 4 or more of the following: Increased tolerance Restless or irritable when cutting down or stopping Loss of control Gambling when feeling distressed “Chasing” losses Lies to conceal extent of gambling Jeopardized or loss significant relationship, job or other opportunity Relies on other for money to relieve desperate financial situations Not better explained by a manic episode

50 Gambling Disorder One of most overlooked co-occurring disorders with substance use disorders Two item screen – “Lie-Bet” Screening Instrument 1) Have you ever felt the need to bet more and more money? 2) Have you ever had to lie to people important to you about how much you gambled?

51 Gambling Treatment Issues
Most addiction treatment programs do not routinely screen for gambling disorders A major concern is that substance use and gambling disorder treatment is almost totally separate with separate and distinct programs and certifications, a lack of screening of one disorder when assessing for the other and even separate conferences. All of this is reminiscent of the split between substance use and mental heath disorders of 20 years ago At very least, SUD treatment providers should at be screening for a co-occurring gambling disorder and if screened in, be prepared to refer to Gamblers Anonymous

52 Other Changes from DSM-IV to DSM-5 Mental Health Disorders

53 Neurodevelopmental Disorders

54 Neurodevelopmental Disorders
Intellectual Disability (formerly mental retardation) Assessment includes both IQ and adaptive functioning with severity determined by adaptive functioning rather than IQ Autism Spectrum Disorder (new and encompasses previous Autism and Asperger’s Disorder Assessment included deficits in (1) social communication and social interaction & (2) restricted repetitive patterns of behavior, interests and activities

55 Other Neurodevelopmental Disorders
Communication Disorders (includes stuttering) Attention-Deficit/Hyperactivity Disorder (ADHD) Specific Learning Disorder Motor Disorders (included Tourette’s Disorder) Other Neurodevelopmental Disorders

56 DSM-5 Criteria for ADHD Inattention
Six or more (of 9) symptoms persisting at least 6 months to a degree that is inconsistent with the developmental level and negatively impacts directly on social and academic/occupational activities For adolescents (17 and older) and adults at least five symptoms are required

57 DSM-5 Criteria for ADHD Hyperactivity and Impulsivity
Six or more (of 9) symptoms persisting at least 6 months to a degree that is inconsistent with the developmental level and negatively impacts directly on social and academic/occupational activities Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 Symptoms present in two or more settings For adolescents (17 and older) and adults at least five symptoms are required

58 DSM-5 Criteria for ADHD Specifications (subtypes):
Combined presentation Predominantly inattentive presentation Predominantly hyperactive-impulsive presentation Changes DSM-IV to DSM-5 Some symptoms to several symptoms Onset changed from 7 to 12 years New language for subtypes but same as in DSM-IV Cut-off from 6 to five symptoms Will make it easier to diagnose adults with 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


61 Consideration of the Use of ADHD Medications in SUD
Early in addiction recovery it is not prudent to begin ADHD treatment with stimulants, and the use of non-stimulants, like Stattera may be warranted For patients who have been abstinent for some period of time, the risk of using stimulants to effectively treat ADHD symptoms is generally believed to be lower. In these cases, the use of extended-release formulations of stimulants including transdermal formulations is preferred Consider non-drug therapies such as cognitive therapy, behavior modification, anger management, social training & family therapy Combination of drug & non-drug tx. may be best

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

63 Schizophrenia Spectrum & 0ther Psychotic Disorders

64 Schizophrenia Spectrum & Psychotic Disorders
No bulleted type listing of disorders in section as with DSM-IV-TR; also difference in ordering Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizophrenia Schizoaffective Disorder DSM-5 differences in organization and emphasis (e.g., no subtypes of schizophrenia in DSM-5) – only catatonia as a specifier Follows concept of dimensions vs. categories

65 Schizophrenia Conditions defined by one or more of :
Delusions Hallucinations Disorganized thinking Disorganized/abnormal motor behavior Negative symptoms: anhedonia, diminished emotional expression, avolition, etc. Impairments in functioning; duration of 6 month minimum Rule out schizoaffective or substance related Dx

66 Schizophreniform Disorder
Same symptoms as Schizophrenia Differs from Schizophrenia in terms of duration of illness (at least one month but less then 6 months) Course: About 1/3 of initial cases recover within 6 mo. About 2/3 go on to be diagnosed as Schizophrenia or Schizoaffective Disorder DSM-5 provides no guidance as to clinical services or case management issues

67 Brief Psychotic Disorder
A. One or more of the following, with one of (1), (2) or (3) required: Delusions Hallucinations Disorganized speech (frequent derailment or incoherence) Grossly disorganized or catatonic behavior B . Duration at least one day but less than one month C. Not better explained by major depressive or bipolar disorder with psychotic features or other psychotic disorder such as schizophrenia or the physiological effects of a substance

68 Schizoaffective Disorder
Diagnostic criteria Uninterrupted period of illness with major mood episode concurrent with Criterion A of schizophrenia Delusions or hallucinations for 2+ weeks in absence of a major mood episode during some period Major mood episode criteria met for majority of illness duration Diagnosis can change to schizophrenia if psychotic systems persist without recurrent mood episode

69 Substance/Medication-Induced Psychotic Disorder
Between 7% and 25% presenting with a first episode of psychosis in different setting are reported to have Substance/Medication- Induced Psychotic Disorder

70 Schizophrenia & Substance Use
Some people who abuse drugs show symptoms similar to those of schizophrenia. Therefore, people with schizophrenia may be mistaken for people who are affected by drugs. Most researchers do not believe that substance abuse, particularly cannabis, causes schizophrenia However, people who have schizophrenia are much more likely to have a substance or alcohol abuse problem than the general population

71 Schizophrenic Disorder
RATE OF LIFETIME SUBSTANCE USE DISORDER In the General Population: % For Persons With Schizophrenia: 48%

72 Schizophrenia & Substance Abuse
Substance abuse can make treatment for schizophrenia less effective. Some drugs, like marijuana and stimulants such as amphetamines or cocaine, may make symptoms worse Research has found increasing evidence of a link between marijuana and schizophrenia symptoms People who abuse drugs are less likely to follow their treatment plan

73 Schizophrenia & Tobacco Use Disorder
Addiction to nicotine is the most common form of substance abuse in people with schizophrenia They are addicted to nicotine at three times the rate of the general population

74 Bipolar & Related Disorders

75 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 One of the most common features of the mania or hypomania is the decreased need for sleep (feels rested after only 3 hours of sleep) as contrasted with insomnia in which the individual wants to sleep or feels the need to sleep but is unable Bipolar Disorder is one of the most misdiagnosed, over-diagnosed psychiatric disorder

76 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):

77 Connection Between Bipolar Disorder and Alcohol Problems
Women with bipolar disorder are SEVEN times more likely to have alcohol problems than women without Men with bipolar disorder are FOUR times more likely to have alcohol problems than men without

78 Substance Use & Bipolar Disorders
Substance abuse is very common among people with bipolar disorder, but the reasons for this link are unclear Some people with bipolar disorder may try to treat their symptoms with alcohol or drugs However, substance abuse may trigger or prolong bipolar symptoms, and the behavioral control problems associated with mania can result in a person drinking too much.

79 Cyclothymic Disorder A chronic fluctuating mood disturbance involving a number of periods of hypomanic symptoms and depressive symptoms that are distinct from one another Both the hypomanic and depressive symptoms are of insufficient number, severity pervasiveness or duration to meet full criteria for a hypomanic or major depressive episode

80 Rapid Cycling Bipolar Disorder
This is when a person has four or more episodes of major depression, mania, hypomania, or mixed symptoms within a year Some people experience more than one episode in a week, or even within one day. Rapid cycling seems to be more common in people who have severe bipolar disorder and may be more common in people who have their first episode at a younger age

81 Recent Research Premature mortality in Bipolar Disorder
Die an average of 9 years earlier than rest of the population (study of 6.6 million adults, 6600 with BPD) Death associated with: Ischemic heart disease COPD, flu or pneumonia Unintentional injuries Suicide Colon cancer (women only) Possible solution – better provision of primary medical care

82 Depressive Disorders

83 Depressive Disorders Disruptive Mood Dysregulation Disorder*
Major Depressive Disorder, Single Episode Major Depressive Disorder, Recurrent Dysthymia (Persistent Depressive Disorder, also include chronic major depression)* Substance-Induced Depressive Disorder Depressive Disorder Associated with Another Medical Condition Premenstrual Dysphoric Disorder (no longer “for further study”)* * New

84 Changes from the DSM-IV
Depressive disorders now its own chapter, separated from Bipolar & Related Disorders Premenstrual Dysphoric Disorder* (no longer in Appendix B, “for further study”) Disruptive Mood Dysregulation Disorder is new

85 Major Depressive Disorder (MDD)
MDD is the product of a complex interaction between multiple “vulnerability” genes and environmental factors (and early trauma?) MDD is not only chronic and recurrent, it may be progressive Sustained functional changes in the brain may precipitate a change in structure Mood disorders are associated with changes in endocrine, immune, autonomic function and earlier mortality (cardiac problems)

86 Major Depressive Disorder (MDD)
Requires meeting 5 of 9 criteria (unchanged) Depressed mood most of day, nearly every day Loss of interest or pleasure Significant weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy nearly every day Feelings of worthlessness Reduced ability to concentrate or think or indecisiveness Recurrent thoughts of death or suicidal ideation Accompanied by clinically significant distress

87 Dysthymia Clinically depressed mood that occurs for most of the day more days than not, for at least 2 years (one years in children & adolescents) No symptom free interval for longer than 2 months in the 2 years Free of manic or hypomanic episodes Can be diagnosed with MDD after 2 years if meets the MDD criteria Meet 2 of criteria (subclinical) Renamed “Chronic Depressive Disorder”

88 Time for Anti-Depressant 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) Antidepressant 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.

89 When Do You Medicate for Psychiatric Disorders?
When the risk of not medicating exceeds the risk of medicating!

90 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 if symptoms persisted for over 2 months but not other losses Was a V code (V62.82) In the DSM-5, don’t diagnose MDD if bereavement symptoms best account for the depressive symptoms “Persistent Complex Bereavement Disorder” (for further study) Don’t diagnose unless symptoms last more than 12 month, 6 months for children

91 Bereavement To distinguish grief from a major depressive episode (MDE): Grief Predominant affect is feelings of loss or emptiness Dysphoria associated with grief is likely to decrease in intensity in days and weeks and occurs in waves and associated with thoughts and reminders of the deceased Self-esteem is generally preserved MDE: Predominant affect is persistent depressed mood and the inability to anticipate please or happiness Depressed mood of MDE are persistent and not tied to thoughts and reminders of the deceased Feelings of worthlessness and self-loathing are common

92 Anxiety Disorders

93 Anxiety Disorder The DSM-IV described five forms of anxiety disorder
Panic Disorder Generalized Anxiety Disorder (GAD) Phobias Change: For social anxiety disorder, if over 18, no longer have to recognize their anxiety is excessive or unreasonable Post Traumatic Stress Disorder (PTSD) Obsessive Compulsive Disorder (OCD)

94 Specific Anxiety Disorder Diagnoses in the DSM-5
Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder (Social Phobia in DSM-IV) Panic Attack (not a diagnosis) Panic Disorder Agoraphobia Generalized Anxiety and Worry Disorder

95 Panic attacks can now be a specifier for all DSM-5 diagnoses
Panic Attack 4 or > Symptoms Panic Attack is a Specifier and not a Mental Disorder DO NOT CODE Panic attacks can now be a specifier for all DSM-5 diagnoses

96 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 Change in the delinking of Panic Disorder and Agoraphobia

97 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 but rather out of proportion to the threat Social Anxiety Disorder (previously social phobia), may be too broadly defined because of the high prevalence of social anxiety and shyness in community populations (e.g., anxiety about speaking in public)

98 Specific Phobia Having a phobia includes feeling stressed about being near the object, being in the situation or doing the activity It also includes being afraid of the object, situation or activity itself Patient is aware that the fear is unreasonable or excessive Persistent for more than 6 months

99 Agoraphobia A mental disorder characterized by an irrational fear of leaving the familiar setting of home, or venturing into the open, so pervasive that a large number of external life situations are entered into reluctantly or avoided; often associated with Panic Attacks Now a stand alone diagnosis, not part of Panic Attacks Sufferers less likely to show up for treatment

100 Social Phobia (renamed “Social Anxiety Disorder”)
Social Anxiety Disorder is a psychological condition that causes overwhelming fear of situations that require social interaction or performance in front of others, such as public speaking The fear often triggers physical symptoms such as blushing, rapid heartbeat and trouble concentrating and it may interfere with activities of daily living

101 Social Anxiety Disorder
Social Anxiety Disorder has significant implications for treatment for when it co-occurs with substance use and mental health disorders : For treatment For self-help recovery groups

102 Symptoms of GAD Excessive, ongoing worry and tension
An unrealistic view of problems * Muscle tension * Restlessness or a feeling of being “on edge” * Irritability Headaches Sweating * Difficulty concentrating or mind going blank Nausea The need to go to the bathroom frequently * Easily fatigued * Trouble falling or staying asleep Trembling Being easily startled

103 Diagnosis of GAD Three of more of 6 specific symptoms (asterisked) with at least some symptoms for more days than not in the past 6 months Only one symptom required for children

104 Renamed “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

105 Substance-Induced Anxiety Disorder
Substance-Induced Anxiety Disorder may include prominent anxiety, Panic Attacks, phobias or obsessions or compulsions Substance-Induced Anxiety Disorder may resemble Panic Disorder, Generalized Anxiety and Worry Disorder, Social Anxiety Disorder but will not meet full criteria for these disorders

106 Substance/Medication-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

107 Obsessive-Compulsive and Related Disorders

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

109 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

110 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

111 Body Dysmorphic Disorder
Preoccupation with defects in physical appearance not observable or slight to others Performs repetitive behaviors (e.g., excessive grooming) in response to appearance concerns Clinically significant distress or impairment Appearance preoccupation not better explained by concerns with body fat or diagnosis of eating disorder Specify if: With muscle dysmorphia Preoccupation that body build is too small or insufficiently muscular

112 Hoarding Disorder General Criteria (New)
The individual has great difficulty disposing of possessions or assessing relative importance The individual feels compared to keep these possessions and is pained by the idea of disposing of them These possessions impair the use or safety of the individual’s home, or utility of the home is only maintained by the intervention of others Clinically significant distress of impairment Some individuals will be aquisitive, others simply let things pile up without excessive shopping Some individuals will have insight into the hoarding related problems, others will have insight impaired to varying degrees Some medical conditions can produce this problem (e.g., brain injury, cerebrovascular disease) – rule out

113 Trauma- and Stressor-Related Disorders

114 Trauma- and Stressor-Related Disorders
Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Adjustment Disorders Acute Stress Disorder

115 Post Traumatic Stress Disorder
Such disorders reflect a biological predisposition or vulnerability (and early trauma?) 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

116 New Findings PTSD & Alcohol Use in College Students
Heavy drinking is common on college campuses and related to risk for sexual assault, interpersonal violence and serious injury, any of which may trigger PTSD Alcohol use and associated problems are linked over time to an exacerbation in PTSD symptoms, and that PTSD symptoms show a similar effect on alcohol consumption

117 Childhood Psychological Abuse as Harmful Sexual or Physical Abuse
5,616 youths with lifetime histories of one or more of the three types of abuse Psychological maltreatment include caregiver bullying, terrorizing, coercive control, severe insults, debasement, threats, overwhelming demands, shunning and/or isolation Psychologically abused children suffered anxiety, depression, low self-esteem, symptoms of PTSD and suicidality at same rate or greater than children who had been sexually or physically abused To be published in the APA Journal, Trauma: Theory, Research, Practice & Theory

118 Dissociative Disorders

119 Dissociative Disorders
Dissociative Identity Disorder (commonly called “Multiple Personality Disorder”) Dissociative Amnesia (dissociative fugue now a specifier for Dissociative Amnesia) Depersonalization/Derealization Disorder

120 Dissociative Identity Disorder
Disruption of identity characterized by two or more distinct personality states Recurrent gaps in recall of everyday events, personal information and/or traumatic events inconsistent with ordinary forgetting (DSM- IV only included traumatic events) Clinically significant distress or impairment

121 Somatic Symptom and Related Disorders (in DSM-IV – “Somatoform Disorders”)

122 Somatic Symptom and Related Disorders
Somatic Symptom Disorder (replaces Somatization Disorder and Hypochondiasis) Illness Anxiety Disorder Conversion Dis0rder (Functional Neurological Symptom Disorder) Factitious Disorder Imposed on self - commonly Munchausen’s Syndrome Imposed on others - commonly Munchausen’s Syndrome by Proxy

123 Somatization Disorder
Somatization disorder is a long-term (chronic) condition in which a person has vague physical symptoms in at least four different functions or parts of the, but no physical cause can be found. The pain and other symptoms people with this disorder feel are real, and are not created or faked on purpose (malingering).

124 Hypochondriasis People with hypochondriasis are very worried about getting a disease or are certain they have a disease, even after medical tests show they do not. Further, these people often misinterpret minor health problems or normal body functions as symptoms of a serious disease. An example is a person who is sure that her headaches are caused by a brain tumor. The symptoms associated with hypochondriasis are not under the person's voluntary control, and can cause great distress and/or can interfere with a person's normal functioning.

125 Conversion Disorder Conversion disorder is a condition in which people show psychological stress in physical ways. The condition was so named to describe a health problem that starts as a mental or emotional crisis — a scary or stressful incident of some kind — and converts to a physical problem. Conversion disorder signs and symptoms appear with no underlying physical cause, and you can't control them. Signs and symptoms of conversion disorder typically affect your movement or your senses, such as the ability to walk, swallow, see or hear. Conversion disorder symptoms can be severe, but for most people, they get better within a couple of weeks.

126 Symptoms Include the loss of one or more bodily functions, such as:
Blindness Inability to speak Numbness Paralysis Common signs of conversion disorder include: A debilitating symptom that begins suddenly History of a psychological problem that gets better after the symptom appears Lack of concern that usually occurs with a severe symptom

127 Feeding and Eating Disorders

128 Eating Disorders Pica (in children or adults) Rumination Disorder
Avoidant/Restrictive Food Intake Disorder Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder

129 Anorexia Nervosa

130 Anorexia Nervosa Their lives become focused on controlling their weight. They may: Obsess about food, weight and dieting Strictly limit how much they eat Exercise a lot, even when they are sick Vomit or use diuretics to avoid weight gain but no binging Anorexia Nervosa is the most lethal of all psychiatric disorders with 5% dying per decade after diagnosis either from medical complications or suicide

131 Bulimia Nervosa Change: reduction in binge eating & compensatory behavior from twice to once weekly
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. 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 Difference on how much they weigh and how they look (their perception) Prognosis more positive than with anorexia

132 Binge Eating Disorder Change: reduction in binge eating from twice to once weekly
Criterion A will likely be the same as DSM-IV Bulimia Nervosa Recurrent episodes of binge eating characterized by both of the following: Eating within a discrete period of time (e.g., usually less than any 2 hour period of time), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances A sense of lack of control over eating during that period

133 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) Causes marked distress Prognosis more optimistic that Anorexia or Bulimia

134 Sleep-Wake Disorders

135 Insomnia Disorder Difficulty initiating Sleep
Difficulty maintaining Sleep Early morning awakening with inability to return to sleep At least 3 nights/week for at least 3 months Occurs despite adequate opportunity for sleep Not better explained by another sleep disorder (e.g., narcolepsy), the physiological effects of a substance or a co-occurring mental health disorder

136 Sexual Dysfunctions

137 Sexual Dysfunctions Erectile Disorder – persistence of the problems for 6 months, 75% of the time Female Orgasmic Disorder – same persistence; removal of “normal excitement phase;” recognition that orgasm is “not all or nothing;” allows for comorbid diagnosis of Arousal Disorder and Orgasmic Disorder Delayed Ejaculation Premature Ejaculation Female Sexual Interest/Arousal Disorder – only change is persistence Male Hypoactive Sexual Desire Disorder Genito-Pelvic Pain/Penetration Disorder- this diagnosis will likely be made for those previously diagnosed with either Vaginismus or Dyspareunia Substance/Medication Induced Sexual Dysfunction

138 Neurocognitive Disorders

139 Neurocognitive Disorders (NCD)
Delirium Major or Mild NCD due to Alzheimer’s Disease Major or Mild Frontotemporal NCD Major or Mild NCD with Lewy Bodies Major or Mild Vascular NCD Major or Mild NCD Due to Traumatic Brain Injury Major or Mild NCD Due to HIV Infection Major or Mild NCD Due to Prion Disease Major or Mild NCD Due to Parkinson’s Disease Major or Mild NCD Due to Huntington’s Disease

140 Delirium An alteration of mental status characterized by an inability to appreciate and respond normally to the environment, often with altered awareness, disorientation, inability to process visual and auditory stimuli, and other signs of cognitive dysfunction. Causes include fever, infection, toxicity (including to alcohol), dehydration, over- hydration, certain drugs and extreme sleep deprivation. Generally has acute onset. Delirium can often be reversed with proper medical treatment.

141 Kinds of Dementia Alzheimer disease (affects 66 per cent of people with dementia) Vascular dementia caused by stroke (the second most common form) Lewy body dementia (affects 15 to 20 per cent of people with dementia) frontal lobe dementia (affects two to five per cent of people with dementia) alcohol-related dementia and Korsakoff’s Psychosis Dementia secondary to AIDS or Prion disease (e.g., mad cow disease)

142 *SIGNIFICANT LOSS OF COGNITIVE FUNCTIONING (enough to interfere with activities of daily living) IS NOT A NORMAL PART OF AGING!

143 Personality Disorders

144 Personality Disorders
Cluster A Personality Disorders Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Cluster B Personality Disorders Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Cluster C Personality Disorders Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder

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

146 Borderline Personality Disorder

147 Non-Suicidal Self Injury Disorder (Condition for Further Study)
The disorder entails repeated and intentional self- inflicted damage to the body May include burning or bruising as well as cutting Is associated with the build up of negative feelings and preoccupation with the behavior The act is stated to be, and appears to be, non- suicidal in nature and intent The behavior is not associated with a primary medical or substance related cause, nor a quasi sanctioned cultural activity such as piercing or tattoos The behavior is done to provide relief, distraction or release from the negative affective state

148 Paraphilic Disorders

149 Paraphilic Disorders Voyeuristic Disorder Exhibitionistic Disorder
Frotteuristic Disorder Sexual Masochism Disorder Sexual Sadism Disorder Pedophilic Disorder Fetishistic Disorder Transvestic Disorder Specifier for all “In a controlled environment” or “In remission”

150 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 with disorders are getting what they need in treatment As complex as the DSM-5 is, it will get easier over time

151 If patients can’t get better the way we provide treatment, maybe we should provide treatment the way they can


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