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What’s in DSM-5 DSM 5 diagnoses and numbers xiii-xl summary of changes from IV -preface How the DSM 5 was developed-Intro 5-19 Further description of.

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Presentation on theme: "What’s in DSM-5 DSM 5 diagnoses and numbers xiii-xl summary of changes from IV -preface How the DSM 5 was developed-Intro 5-19 Further description of."— Presentation transcript:

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2 What’s in DSM-5 DSM 5 diagnoses and numbers xiii-xl summary of changes from IV -preface How the DSM 5 was developed-Intro 5-19 Further description of major changes-intro 5-19 How to use the manual 19-24 Diagnostic codes and diagnostic criteria for every diagnosis pp31-715 Dimensional assessment measures 733-748 Dimensional assessment of personality disorders 761-783 Focus on cultural assessment 749-760 Cultural formulation interviews 749-760 Conditions for further study 783-808 Highlight of all changes from DSM-IV to DSM 5 PP 809 – 816 Glossary of mental terms 817-832 Glossary of cultural concepts of distress 833-838 DSM crosswalks for ICD-9 and ICD 10 863- 897

3 WHY CHANGE?

4 DSM-IV’s organizational structure failed to reflect shared features or symptoms of related disorders and diagnostic groups (like psychotic disorders with bipolar disorders, or internalizing (depressive, anxiety, somatic) and externalizing (impulse control, conduct, substance use) disorders.

5 DSM-IV Thin on Culture

6 Did not represent or integrate the latest findings from neuroscience, genetics and cognitive research

7 Multi axial structure was out of line with the rest of medicine

8 Global assessment of functioning was an unreliable measure Decision trees did not increase inter-rater reliability

9 Other problems Separates diagnoses from treatment Diagnosis has become an end in itself! (billability & pressure for scientific determinism) Minimizes TIME as a major factor in making diagnoses Minimizes emergent symptoms Minimizes lack of symptom clarity as an issue Ignores internal unobservables Funnels tx focus to symptom negation rather than well- being Forces clinician to make immediate diagnoses Forces clinician to more severe DX

10 There have been no no established "zones of rarity" between diagnosis (much symptom overlap) Law-like biological markers have not yet been found Categorical measurement (depressed vs NOT depressed) doesn’t capture clinical variance

11 DSM III & IV limits Focus on only what is observable; limits diagnostic possibilities Limited number of observable signs & symptoms (12 to 19 symptoms ) Because law-like biomarkers have not been found, Elements that cannot be seen directly are excluded. This is exactly the opposite of medicine which strives to see below the surface. Limited number of observable signs/symptoms But 400 diagnoses in DSM = diagnostic confusion Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK

12 DSM III & IV – problems with measuring Limited number of observable signs and Symptoms, Elements that cannot be seen directly are excluded. This is exactly the opposite of medicine which strives to see below the surface. Limited number of observable signs/symptoms But 400 diagnoses in DSM # 1 Problem = under- determination of diagnosis Consequences = - boundary problems (paris) - false positives - rise of comorbidity - problems of differential dx - one size fits all diagnoses - only agreement on most severe

13 The relationship between Categorical Dx, comorbidity and increased reliability 1. no major depression; 2. major depression 1. No generalized anxiety 2. generalized anxiety Depression 1 2 3 4 5 6 7 8 None minimal mild minor moderate major severe maximal 1 2 3 4 5 6 7 8 General anxiety Categorical measurement increases potential for inter-rater reliability. 50% chance of inter-rater reliability Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity Categorical measures = No clinical variance & no diagnostic threshold Decreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity Dimensional measure inter-rater reliability lower = 12% More choices = harder= more info Subtle distinctions ; less Potential for specious comorbidity

14 DSM III & IV turned assessment into yes/no decision trees Inflated comorbidity Inflated inter-rater reliability (but did not increase it) Never established true biological markers Reduced the rigorousness of good assessment in the name of clinical utility

15 DSM 5 1.Emphasizes dimensional measurement 2.Provides World Health Organization measure of overall well-being 3.Does away with Axes 4.Focuses more on culture 5.Attempts to “Re-organize” diagnostic categories according to what we now (think we)know 6.Attempts to “re-group” individual diagnoses according to what we now (think we) know 7.Includes crosswalks with ICD-9 and ICD 10 http://www.dsm5.org/Pages/Default.aspx

16 1. Dimensional measures http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1 Allows clinician opportunity to “fine tune” diagnosis Captures diagnostic complexity Should reduce inflated comorbidity. By allowing inclusion of crosscutting symptoms (such as anxiety) within other diagnoses Focuses assessment on crosscutting symptoms Creates "severity specifier" for many diagnoses Dimensions make diagnosis congruent with up- to-date neurocognitive research indicating symptoms are on a continuum

17 DSM 5 adds dimensional measures WITHOUT abandoning categorical measures Criteria are basically the same as they were in the DSM-IV

18 Crosscutting symptoms (symptoms that can occur across many DXs) Captures symptom comorbidity without diagnostic comorbidity Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses. They are intended to help identify additional areas of inquiry that may guide treatment and prognosis. The cross- cutting measures have two levels: Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients, and Level 2 questions provide a more in-depth assessment of certain domains. http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1

19 DomainDomain NameThreshold to guide further inquiry DSM-5 Level 2 Cross-Cutting Symptom Measure available online I.DepressionMild or greater LEVEL 2—Depression—Adult (PROMIS Emotional Distress—Depression—Short Form) 1 II.AngerMild or greaterLEVEL 2—Anger—Adult (PROMIS Emotional Distress—Anger—Short Form) 1 III.ManiaMild or greaterLEVEL 2—Mania—Adult (Altman Self-Rating Mania Scale) IV.AnxietyMild or greaterLEVEL 2—Anxiety—Adult (PROMIS Emotional Distress—Anxiety—Short Form) 1 V.Somatic SymptomsMild or greaterLEVEL 2—Somatic Symptom—Adult (Patient Health Questionnaire 15 Somatic Symptom Severity [PHQ-15]) VI.Suicidal IdeationSlight or greaterNone VII.PsychosisSlight or greaterNone VIII.Sleep ProblemsMild or greaterLEVEL 2—Sleep Disturbance - Adult (PROMIS—Sleep Disturbance—Short Form) 1 IX.MemoryMild or greaterNone X.Repetitive Thoughts and Behaviors Mild or greaterLEVEL 2—Repetitive Thoughts and Behaviors—Adult (adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B]) XI.DissociationMild or greaterNone XII.Personality Functioning Mild or greaterNone XIII.Substance UseSlight or greaterLEVEL 2—Substance Abuse—Adult (adapted from the NIDA-modified ASSIST) Table 1: Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure: domains, thresholds for further inquiry, and associated Level 2 measures for adults ages 18 and over

20 During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) I.1. Little interest or pleasure in doing things?01234 2. Feeling down, depressed, or hopeless?01234 II.3. Feeling more irritated, grouchy, or angry than usual?01234 III.4. Sleeping less than usual, but still have a lot of energy?01234 5. Starting lots more projects than usual or doing more risky things than usual? 01234 IV.6. Feeling nervous, anxious, frightened, worried, or on edge?01234 7. Feeling panic or being frightened?01234 8. Avoiding situations that make you anxious?01234 V.9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?01234 10. Feeling that your illnesses are not being taken seriously enough?01234 VI.11. Thoughts of actually hurting yourself?01234 VII. 12. Hearing things other people couldn’t hear, such as voices even when no one was around? 01234 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? 01234 VIII.14. Problems with sleep that affected your sleep quality over all?01234 IX. 15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)? 01234 X.16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?01234 17. Feeling driven to perform certain behaviors or mental acts over and over again?01234 XI. 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? 01234 XII.19. Not knowing who you really are or what you want out of life?01234 20. Not feeling close to other people or enjoying your relationships with them?01234 XIII.21. Drinking at least 4 drinks of any kind of alcohol in a single day?01234 22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?01234 23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]? 01234 DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult

21 THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS 1.POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I) 2.GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET 3.CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS DIAGNOSIS, BUT NOT NECESSARILY QUALIFY FOR ITS OWN DX DEPRESSION ANXIETY SOMATIC SYMPTOMS SLEEP ISSUES ETC.

22 level II measures(Dimensional) Level II crosscutting measures – Focus on one specific domain – Provides a more varied clinical profile within that domain – Allows for follow-up exploration with more than one domain in order to specify diagnostic boundaries. (For example, in my dealing with major depression with a co-occurring anxiety disorder or major depression, with anxious features – Provides clinical verification before diagnosis

23 Level 2 measures of symptoms Level 2 questions provide a more in-depth assessment of certain domains: http://www.psychiatry.org/practice/dsm/dsm 5/online-assessment-measures# Level2 http://www.psychiatry.org/practice/dsm/dsm 5/online-assessment-measures# Level 2 is given as a specific follow up, once the clinician is ‘oriented’ in a symptomatic direction they are focused WITHIN a specific symptom domain

24 Level 2 Cross-Cutting Symptom Measures For Adults LEVEL 2—Depression—Adult (PROMIS Emotional Distress—Depression—Short Form) LEVEL 2—Anger—Adult (PROMIS Emotional Distress—Anger—Short Form) LEVEL 2—Mania—Adult (Altman Self-Rating Mania Scale [ASRM]) LEVEL 2—Anxiety—Adult (PROMIS Emotional Distress—Anxiety—Short Form) LEVEL 2—Somatic Symptom—Adult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15]) LEVEL 2—Sleep Disturbance—Adult (PROMIS—Sleep Disturbance—Short Form) LEVEL 2—Repetitive Thoughts and Behaviors—Adult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B]) LEVEL 2—Substance Use—Adult (Adapted from the NIDA-Modified ASSIST) LEVEL 2—Depression—Adult LEVEL 2—Anger—Adult LEVEL 2—Mania—Adult LEVEL 2—Anxiety—Adult LEVEL 2—Somatic Symptom—Adult LEVEL 2—Sleep Disturbance—Adult LEVEL 2—Repetitive Thoughts and Behaviors—Adult LEVEL 2—Substance Use—Adult For Parents of Children Ages 6–17 LEVEL 2—Somatic Symptom—Parent/Guardian of Child Age 6–17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15]) LEVEL 2—Sleep Disturbance—Parent/Guardian of Child Age 6–17 (PROMIS—Sleep Disturbance—Short Form) LEVEL 2—Inattention—Parent/Guardian of Child Age 6–17 (Swanson, Nolan, and Pelham, version IV [SNAP-IV]) LEVEL 2—Depression—Parent/Guardian of Child Age 6–17 (PROMIS Emotional Distress—Depression—Parent Item Bank) LEVEL 2—Anger—Parent/Guardian of Child Age 6–17 (PROMIS Emotional Distress—Calibrated Anger Measure—Parent) LEVEL 2—Irritability—Parent/Guardian of Child Age 6–17 (Affective Reactivity Index [ARI]) LEVEL 2—Mania—Parent/Guardian of Child Age 6–17 (Adapted from the Altman Self-Rating Mania Scale [ASRM]) LEVEL 2—Anxiety—Parent/Guardian of Child Age 6–17 (Adapted from PROMIS Emotional Distress—Anxiety—Parent Item Bank) LEVEL 2—Substance Use—Parent/Guardian of Child Age 6–17 (Adapted from the NIDA-Modified ASSIST) LEVEL 2—Somatic Symptom—Parent/Guardian of Child Age 6–17 LEVEL 2—Sleep Disturbance—Parent/Guardian of Child Age 6–17 LEVEL 2—Inattention—Parent/Guardian of Child Age 6–17 LEVEL 2—Depression—Parent/Guardian of Child Age 6–17 LEVEL 2—Anger—Parent/Guardian of Child Age 6–17 LEVEL 2—Irritability—Parent/Guardian of Child Age 6–17 LEVEL 2—Mania—Parent/Guardian of Child Age 6–17 LEVEL 2—Anxiety—Parent/Guardian of Child Age 6–17 LEVEL 2—Substance Use—Parent/Guardian of Child Age 6–17 For Children Ages 11–17 LEVEL 2—Somatic Symptom—Child Age 11–17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15]) LEVEL 2—Sleep Disturbance—Child Age 11–17 (PROMIS—Sleep Disturbance—Short Form) LEVEL 2—Depression—Child Age 11–17 (PROMIS Emotional Distress—Depression—Pediatric Item Bank) LEVEL 2—Anger—Child Age 11–17 (PROMIS Emotional Distress—Calibrated Anger Measure—Pediatric) LEVEL 2—Irritability—Child Age 11–17 (Affective Reactivity Index [ARI]) LEVEL 2—Mania—Child Age 11–17 (Altman Self-Rating Mania Scale [ASRM]) LEVEL 2—Anxiety—Child Age 11–17 (PROMIS Emotional Distress—Anxiety—Pediatric Item Bank) LEVEL 2—Repetitive Thoughts and Behaviors—Child Age 11–17 (Adapted from the Children’s Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale) LEVEL 2—Substance Use—Child Age 11–17 (Adapted from the NIDA-Modified ASSIST) LEVEL 2—Somatic Symptom—Child Age 11–17 LEVEL 2—Sleep Disturbance—Child Age 11–17 LEVEL 2—Depression—Child Age 11–17 LEVEL 2—Anger—Child Age 11–17 LEVEL 2—Irritability—Child Age 11–17 LEVEL 2—Mania—Child Age 11–17 LEVEL 2—Anxiety—Child Age 11–17 LEVEL 2—Repetitive Thoughts and Behaviors—Child Age 11–17 LEVEL 2—Substance Use—Child Age 11–17 List of all the level 2 (disorder specific) cross-cutting symptom measures

25 DomainDomain NameThreshold to guide further inquiry DSM-5 Level 2 Cross-Cutting Symptom Measure available online I.DepressionMild or greater LEVEL 2—Depression—Adult (PROMIS Emotional Distress—Depression—Short Form) 1 II.AngerMild or greaterLEVEL 2—Anger—Adult (PROMIS Emotional Distress—Anger—Short Form) 1 III.ManiaMild or greaterLEVEL 2—Mania—Adult (Altman Self-Rating Mania Scale) IV.AnxietyMild or greaterLEVEL 2—Anxiety—Adult (PROMIS Emotional Distress—Anxiety—Short Form) 1 V.Somatic SymptomsMild or greaterLEVEL 2—Somatic Symptom—Adult (Patient Health Questionnaire 15 Somatic Symptom Severity [PHQ-15]) VI.Suicidal IdeationSlight or greaterNone VII.PsychosisSlight or greaterNone VIII.Sleep ProblemsMild or greaterLEVEL 2—Sleep Disturbance - Adult (PROMIS—Sleep Disturbance—Short Form) 1 IX.MemoryMild or greaterNone X.Repetitive Thoughts and Behaviors Mild or greaterLEVEL 2—Repetitive Thoughts and Behaviors—Adult (adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B]) XI.DissociationMild or greaterNone XII.Personality Functioning Mild or greaterNone XIII.Substance UseSlight or greaterLEVEL 2—Substance Abuse—Adult (adapted from the NIDA-modified ASSIST) Table 1: Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure: domains, thresholds for further inquiry, and associated Level 2 measures for adults ages 18 and over Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled b b b b b

26 Clinician Use In the past SEVEN (7) DAYS.... Item Score NeverRarelySometimesOftenOftenAlways 1.I felt worthless.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 2.I felt that I had nothing to look forward to.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 3.I felt helpless.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 4.I felt sad.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 5.I felt like a failure.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 6.I felt depressed.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 7.I felt unhappy.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 8.I felt hopeless.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 Total/Partial Raw Score: Prorated Total Raw Score: T-Score: LEVEL 2—Depression—Adult* *PROMIS Emotional Distress—Depression—Short Form Name: Age: Sex: Male Female Date:_ If the measure is being completed by an informant, what is your relationship with the individual receiving care? In a typical week, approximately how much time do you spend with the individual receiving care? hours/week Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by “no interest or pleasure in doing things” and/or “feeling down, depressed, or hopeless” at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking (P or x) one box per row.

27 During the past TWO (2) WEEKS, about how often did you use any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed? Clinician Use One ortwo daysOne ortwo days Several days More than half the days Nearly every day Item Score Not at all a.Painkillers (like Vicodin)q 0q 0q 1q 1q 2q 2q 3q 3q 4q 4 b.Stimulants (like Ritalin, Adderall)q 0q 0q 1q 1q 2q 2q 3q 3q 4q 4 c. Sedatives or tranquilizers (like sleeping pills or Valium) q 0q 0q 1q 1q 2q 2q 3q 3q 4q 4 Or drugs like: d.Marijuanaq 0q 0q 1q 1q 2q 2q 3q 3q 4q 4 e.Cocaine or crackq 0q 0q 1q 1q 2q 2q 3q 3q 4q 4 f.Club drugs (like ecstasy)q 0q 0q 1q 1q 2q 2q 3q 3q 4q 4 g.Hallucinogens (like LSD)q 0q 0q 1q 1q 2q 2q 3q 3q 4q 4 h.Heroinq 0q 0q 1q 1q 2q 2q 3q 3q 4q 4 i.Inhalants or solvents (like glue)q 0q 0q 1q 1q 2q 2q 3q 3q 4q 4 j.Methamphetamine (like speed)q 0q 0q 1q 1q 2q 2q 3q 3q 4q 4 Total Score: LEVEL 2—Substance Use—Adult* *Adapted from the NIDA-Modified ASSIST Name: Age: Sex: q Male q Female Date: If the measure is being completed by an informant, what is your relationship with the individual receiving care? In a typical week, approximately how much time do you spend with the individual receiving care? hours/week Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by “using medicines on your own without a doctor’s prescription, or in greater amounts or longer than prescribed, and/or using drugs like marijuana, cocaine or crack, and/or other drugs” at a slight or greater level of severity. The questions below ask how often you (the individual receiving care) have used these medicines and/or substances during the past 2 weeks. Please respond to each item by marking (P or x) one box per row. Useless for alcohol. Perhaps ADS

28 Clinician Use During the past 7 days, how much have you been bothered by any of the following problems? Item Score Not bothered at all 0 Bothered a little 1 Bothered a lot 2 1.Stomach pain 2.Back pain 3.Pain in your arms, legs, or joints (knees, hips, etc.) 4. Menstrual cramps or other problems with your periods WOMEN ONLY 5.Headaches 6.Chest pain 7.Dizziness 8.Fainting spells 9.Feeling your heart pound or race 10.Shortness of breath 11.Pain or problems during sexual intercourse 12.Constipation, loose bowels, or diarrhea 13.Nausea, gas, or indigestion 14.Feeling tired or having low energy 15.Trouble sleeping Total/Partial Raw Score: Prorated Total Raw Score: (if 1-3 items left unanswered) LEVEL 2—Somatic Symptom—Adult Patient* *Adapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name: Age: Sex: q Male q Female Date: If the measure is being completed by an informant, what is your relationship with the individual receiving care? In a typical week, approximately how much time do you spend with the individual receiving care? hours/week Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by “unexplained aches and pains”, and/or “feeling that your illnesses are not being taken seriously enough” at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking (P or x) one box per row. Level 2 cross-cutting scale for Somatic symptoms - Adult

29 Clinician Use In the past SEVEN (7) DAYS.... Item Score NeverRarelySometimesOftenOftenAlways 1.I felt fearful.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 2.I felt anxious.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 3.I felt worried.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 4. I found it hard to focus on anything other than my anxiety. q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 5.I felt nervous.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 6.I felt uneasy.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 7.I felt tense.q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 Total/Partial Raw Score: Prorated Total Raw Score: T-Score: LEVEL 2—Anxiety—Adult* *PROMIS Emotional Distress—Anxiety—Short Form Name: Age: Sex: q Male q Female Date: If the measure is being completed by an informant, what is your relationship with the individual? In a typical week, approximately how much time do you spend with the individual? hours/week Instructions to patient: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (individual receiving care) have been bothered by “feeling nervous, anxious, frightened, worried, or on edge”, “feeling panic or being frightened”, and/or “avoiding situations that make you anxious” at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking (P or x) one box per row.

30 In the past SEVEN (7) DAYS, my child said that he/she … Clinician use Never 1 almost never 2 Sometimes 3 Often 4 Almost always 5 Item score 1. Felt like something awful might happen 2. Felt nervous 3. Felt scared 4. Felt worried 5. Worried about what could happen to him/her. 6. Worried when he/she went to bed at night 7. Got scared really easy. 8. Was afraid of going to school. 9 Worried when he/she was at home 10. Worried when he/she was away from home Total/partial raw score Prorated total raw score T-score Instructions to parent/guardian: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks your child receiving care has been bothered by “feeling nervous, anxious, or scared”, “not being able to stop worrying”, and/or “couldn’t do things he/she wanted to or should have done because they made him/her feel nervous” at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking ( or x) one box per row. Level 2 cross-cutting scale for anxiety in children – parent filled

31 Clinician Use In the past SEVEN (7) DAYS.... Not at allA little bitA little bitSomewhatQuite a bitVery much 1. My sleep was restless. q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 2. I was satisfied with my sleep. q 5q 5q 4q 4q 3q 3q 2q 2q 1q 1 3. My sleep was refreshing. q 5q 5q 4q 4q 3q 3q 2q 2q 1q 1 4. I had difficulty falling asleep. q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 In the past SEVEN (7) DAYS.... NeverRarelySometimesOftenOftenAlways 5. I had trouble staying asleep. q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 6. I had trouble sleeping. q 1q 1q 2q 2q 3q 3q 4q 4q 5q 5 7. I got enough sleep. q 5q 5q 4q 4q 3q 3q 2q 2q 1q 1 In the past SEVEN (7) DAYS.... Very PoorPoorFairGoodVery good 8. My sleep quality was... q 5q 5q 4q 4q 3q 3q 2q 2q 1q 1 Total/Partial Raw Score: Prorated Total Raw Score: T-Score: LEVEL 2—Sleep Disturbance—Adult* *PROMIS—Sleep Disturbance—Short Form Name: Age: Sex: q Male q Female Date: If the measure is being completed by an informant, what is your relationship with the individual receiving care? In a typical week, approximately how much time do you spend with the individual receiving care? hours/week Instructions to patient: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by “problems with sleep that affected your sleep quality over all” at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking (P or x) one box per row.

32 DIMENSIONAL SEVERITY MEASURES In addition to a diagnosis, DSM MEASURES SEVERITY OF MANY DIAGNOSIS SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOW – ONE EITHER WAS PSYCHOTIC OR ONE WAS NOT – THERE WERE NO GRADATIONS

33 Severity - The DSM uses 2 methods of assessing severity, depending on the diagnosis.. Method 1 involves using a specific dimensional measure or scale Called “disorder specific severity measures”. These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE ) Method 2 involves counting the number of symptoms and rating severity based on number of symptoms. For example, ‘mild alcohol use Disorder = 2 – 3 symptoms: moderate alcohol use disorder = 4 – 5 symptoms; severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)

34 Disorder-Specific Severity Measures For Adults Severity Measure for Depression—Adult (Patient Health Questionnaire [PHQ-9]) Severity Measure for Separation Anxiety Disorder—Adult Severity Measure for Specific Phobia—Adult Severity Measure for Social Anxiety Disorder (Social Phobia)—Adult Severity Measure for Panic Disorder—Adult Severity Measure for Agoraphobia—Adult Severity Measure for Generalized Anxiety Disorder—Adult Severity of Posttraumatic Stress Symptoms—Adult (National Stressful Events Survey PTSD Short Scale [NSESS]) Severity of Acute Stress Symptoms—Adult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS]) Severity of Dissociative Symptoms—Adult (Brief Dissociative Experiences Scale [DES-B]) Severity Measure for Depression—Adult Severity Measure for Separation Anxiety Disorder—Adult Severity Measure for Specific Phobia—Adult Severity Measure for Social Anxiety Disorder (Social Phobia)—Adult Severity Measure for Panic Disorder—Adult Severity Measure for Agoraphobia—Adult Severity Measure for Generalized Anxiety Disorder—Adult Severity of Posttraumatic Stress Symptoms—Adult Severity of Acute Stress Symptoms—Adult Severity of Dissociative Symptoms—Adult For Children Ages 11–17 Severity Measure for Depression—Child Age 11–17 (PHQ-9 modified for Adolescents [PHQ-A]—Adapted) Severity Measure for Separation Anxiety Disorder—Child Age 11–17 Severity Measure for Specific Phobia—Child Age 11–17 Severity Measure for Social Anxiety Disorder (Social Phobia)—Child Age 11–17 Severity Measure for Panic Disorder—Child Age 11–17 Severity Measure for Agoraphobia—Child Age 11–17 Severity Measure for Generalized Anxiety Disorder—Child Age 11–17 Severity of Posttraumatic Stress Symptoms—Child Age 11–17 (National Stressful Events Survey PTSD Short Scale [NSESS]) Severity of Acute Stress Symptoms—Child Age 11–17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS]) Severity of Dissociative Symptoms—Child Age 11–17 (Brief Dissociative Experiences Scale [DES-B]) Severity Measure for Depression—Child Age 11–17 Severity Measure for Separation Anxiety Disorder—Child Age 11–17 Severity Measure for Specific Phobia—Child Age 11–17 Severity Measure for Social Anxiety Disorder (Social Phobia)—Child Age 11–17 Severity Measure for Panic Disorder—Child Age 11–17 Severity Measure for Agoraphobia—Child Age 11–17 Severity Measure for Generalized Anxiety Disorder—Child Age 11–17 Severity of Posttraumatic Stress Symptoms—Child Age 11–17 Severity of Acute Stress Symptoms—Child Age 11–17 Severity of Dissociative Symptoms—Child Age 11–17 Clinician-Rated Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders Clinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book) Clinician-Rated Severity of Somatic Symptom Disorder Clinician-Rated Severity of Oppositional Defiant Disorder Clinician-Rated Severity of Conduct Disorder Clinician-Rated Severity of Nonsuicidal Self-Injury Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders Clinician-Rated Dimensions of Psychosis Symptom Severity Clinician-Rated Severity of Somatic Symptom Disorder Clinician-Rated Severity of Oppositional Defiant Disorder Clinician-Rated Severity of Conduct Disorder Clinician-Rated Severity of Nonsuicidal Self-Injury

35 This document is found on page 743 of the DSM. It allows the clinician to rate all of the salient dimensions that might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions

36 A. Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure 1. Depressed mood most of the day, nearly every day as indicated by subjective reporter observation. Yes or no 2. Marked diminished interest or pleasure in all our almost all activities. Most of the day, nearly every day. Yes or no 3. Significant weight loss when not dieting or weight gain or decrease in appetite, nearly every day. Yes or no 4. Insomnia or hypersomnia nearly every day. Yes or no 5. Psychomotor agitation or retardation nearly every day. Yes or no 6. Fatigue or loss of energy nearly every day. Yes or no 7. Feelings of worthlessness or excessive or inappropriate guilt. Yes or no 8. Diminished ability to think or concentrate or indecisiveness nearly every day. Yes or no 9. Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no B. The symptoms cause clinically significant distress or impairment Yes or no C. The episode is not attributable to the physiological effects of a substance or another medical condition Yes or no D. The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or no E. There has never been a manic episode or hypomanic episode Yes or no DSM 5 criteria for major depression Psycho-social HX MSE

37 Clinician Use Item score Not at all Several days More than half the days Nearly every day 1.Little interest or pleasure in doing things0123 2.Feeling down, depressed, or hopeless0123 3.Trouble falling or staying asleep, or sleeping too much0123 4.Feeling tired or having little energy0123 5.Poor appetite or overeating0123 6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 Total/Partial Raw Score: Prorated Total Raw Score: (if 1-2 items left unanswered) Adapted from the Patient Health Questionnaire–9 (PHQ-9) depression Name: Age: Sex: Male q Female q Date: Instructions: Over the last 7 days, how often have you been bothered by any of the following problems? Levels of depressive symptoms severityPHQ-9 Score None Mild depression Moderate depression Moderately severe depression Severe depression 0-4 5-9 10-14 15-19 20-27

38 Method #2 for severity

39 A.Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period 1.Alcohol taken in larger amount (need more for increased effect) 2.Persistent desire or efforts to quit Using alcohol 3.Time spent to obtain, use, recover from effects Of alcohol 4.Cravings Or urges to use Alcohol 5.Failure to fulfill significant roles 6.Continued use Alcohol despite persistent and recurrent problems 7.Important social/occupational activities are reduced 8.Recurrent use Of alcohol in physically hazardous situations 9.Use Of alcohol continues despite knowledge of impact of the problem 10.Tolerance, as defined by a. Increased amounts needed to achieve intoxication or b. Diminished effect Of alcohol 11.Withdrawal From alcohol Alcohol use disorder Severity Mild = presence of 2-3 symptoms moderate = presence of four – five symptoms severe = presence of six or more symptoms Course specifiers early remission = after full criteria were lpreviously met none of the criteria met for at least three months but less than 12 (with the exception of craving) In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more

40 2. NO MORE GAF WHODAS DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONING – THE ONLY DIMENSIONAL MEASURE IN THE DSM IV TR – USED BY CLINICIAN; COMPLETELY UNRELIABLE AND NOT VALID REPLACED WITH A SCALE THAT HAS RELIABILITY AND VALIDITY DATA – THE WORLD HEALTH ORGANIZATION DISABLITY ASSESSMENT SCALE (WHODAS PP 745-749)

41 DSM 5 recommends the following

42 WHODAS 2.0 Based on the International Classification of Functioning, Disability, and Health (ICF) Applicable to any health condition Reliability and clinical utility established in DSM 5 Field trials

43 see pages 745 to 748 in DSM 5 WHODAS Assesses the following six areas 1.Understanding and communicating 2.Getting around 3.Self-care 4.Getting along with people 5.Life activities 6.Participation in society

44 STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES DOES NOT TARGET SPECIFIC DISEASE, SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASE WHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM) In the past 30 days, how much difficulty did you have in: NoneMildModerateSevere Extreme or cannot do D1.1 Concentrating on doing something for ten minutes? 12345 D1.2Remembering to do important things?12345 D1.3 Analysing and finding solutions to problems in day-to-day life? 12345 D1.4 Learning a new task, for example, learning how to get to a new place? 12345 D1.5 Generally understanding what people say? 12345 D1.6Starting and maintaining a conversation? 12345 In the past 30 days, how much difficulty did you have in: NoneMildModerateSevere Extreme or cannot do D2.1 Standing for long periods such as 30 minutes? 12345 D2.2Standing up from sitting down?12345 D2.3Moving around inside your home?12345 D2.4Getting out of your home?12345 D2.5 Walking a long distance such as a kilometre [or equivalent]? 12345 Domain 1 Cognition Domain 2 Mobility

45 In the past 30 days, how much difficulty did you have in: NoneMildModerateSevere Extreme or cannot do D3.1Washing your whole body?12345 D3.2Getting dressed?12345 D3.3Eating?12345 D3.4Staying by yourself for a few days?12345 In the past 30 days, how much difficulty did you have in: NoneMildModerateSevere Extreme or cannot do D4.1Dealing with people you do not know?12345 D4.2Maintaining a friendship?12345 D4.3 Getting along with people who are close to you? 12345 D4.4Making new friends?12345 D4.5Sexual activities?12345 Domain 3 Self-care Domain 4 Getting along with people Because of your health condition, in the past 30 days, how much difficulty did you have in: NoneMildModerateSevere Extreme or cannot do D5.1 Taking care of your household responsibilities? 12345 D5.2 Doing your most important household tasks well? 12345 D5.3 Getting all the household work done that you needed to do? 12345 D5.4 Getting your household work done as quickly as needed? 12345 Because of your health condition, in the past 30 days how much difficulty did you have in: NoneMildModerateSevere Extreme or cannot do D5.5Your day-to-day work/school?12345 D5.6 Doing your most important work/school tasks well? 12345 D5.7 Getting all the work done that you need to do? 12345 D5.8 Getting your work done as quickly as needed? 12345 D5.9Have you had to work at a lower level because of a health condition?No1 Yes2 D5.10Did you earn less money as the result of a health condition?No1 Yes2 Domain 5 LIFE ACTIVITIES Domain 5 WORK OR SCHOOL ACTIVITIES

46 In the past 30 days:NoneMildModerateSevere Extreme or cannot do D6.1 How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can? 12345 D6.2 How much of a problem did you have because of barriers or hindrances in the world around you? 12345 D6.3 How much of a problem did you have living with dignity because of the attitudes and actions of others? 12345 D6.4 How much time did you spend on your health condition or its consequences? 12345 D6.5 How much have you been emotionally affected by your health condition? 12345 D6.6 How much has your health been a drain on the financial resources of you or your family? 12345 D6.7 How much of a problem did your family have because of your health problems? 12345 D6.8 How much of a problem did you have in doing things by yourself for relaxation or pleasure? 12345 Domain 6 Participation

47 If WHODAS is used, place results at the very end of assessment, after psychosocial stressors

48 3. How to chart without axes DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I, II, and III), with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V) Taken from Northstar behavioral health system http://www.northstarbehavioral.com/Overview%20of%20DSM%205%20changes%20HO%20Ver sion%20for%20Web%208-13-13.pdf

49 Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes. V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis, course, prognosis or treatment of a mental disorder Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders. Change to the World Health Organization Disability Assessment Schedule (WHO DAS 2.0) Taken from Northstar behavioral health system http://www.northstarbehavioral.com/Overview%20of%20DSM%205%20changes%20HO %20Version%20for%20Web%208-13-13.pdf

50 All diagnoses are considered primary diagnosis All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I, axis II or axis III) List diagnosis that is the reason for visit 1 st Primary-reason for visit, 296.33, major depressive disorder, recurrent, severe. Primary- Medical condition; Parkinson’s disease, moderate Primary-305.00 alcohol use disorder, mild. Primary -v15.81 non-adherence to medical treatment. (Patient continues to drink while on antidepressants and does not take antidepressants regularly.) If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition, the medical condition is listed 1 st Primary-Parkinson's disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr) Primary-Reason for visit, 296.22; major depressive disorder, single episode, moderate

51 Case example – for listing of DX John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years. He quit smoking 5 years ago after being diagnosed with Parkinson's disease. Over the last 5 years, John's ability to perform physical activity, has progressively deteriorated. Although John reports bouts of depression, beginning in adolescence and continuing throughout his adult life, he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinson’s). Since that time, he has been on several antidepressant medications, most recently Remeron. John reports that he has been a regular drinker since his days in college. Although he denies it, his alcohol use, according to his wife, has increased since his diagnosis of Parkinsons. However, upon evaluation both john and his wife agree that he drinks no more than 3 times per week – usually a six pack. Although John has been advised to discontinue drinking, he has not done so. According to both John and his wife. He misses his medication anywhere from 1 to 3 times per week. About 3 months ago john fell while at home. His wife at first thought it was a result of his drinking. According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinson’s Despite advice to the contrary, John has become progressively more sedentary and has discontinued all forms of exercise. About 1 month ago, John's employers required that John start working part-time and consider filing for early Social Security. According to them, John's ability to work has diminished. They too noted that he was having difficulty walking. For the last 3 weeks, John has met all of the criteria for a severe episode of major depression. Primary diagnosis Primary-reason for visit, 296.33, major depressive disorder, recurrent, severe. Primary- Medical condition; Parkinson’s disease-recently upgraded to moderate Primary-305.00 alcohol use disorder, mild. Primary -v15.81 non-adherence to medical treatment. Patient continues to drink while on antidepressants take antidepressants irregularly

52 V codes -psychosocial stressors Greatly expanded in the DSM 5 V codes (codes V01–V91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury. V codes are taken from the ICD. Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis, course, prognosis or treatment of the mental disorder. First Incorporated in the DSM-III Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)

53 1.Focus or need for clinical attention (along with the billable diagnosis). Can be a primary diagnosis. 2.Psychosocial stressors - Conditions that affect the mental health diagnosis and/or contribute to the development or exacerbation of the DX 3.Other issues, circumstances, conditions that need attention or affect the diagnosis, course and outcome of treatment) Use V codes To indicate V codes (codes V01–V91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury V codes are taken from the ICD. Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis, course, prognosis or treatment of the mental disorder. First Incorporated in the DSM-III Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)

54 Code in the following ways 1.As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis 2.As a Psychosocial/ Environmental stressor = Place code as A stressor at the end of all of the diagnoses

55 John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years. He quit 5 years ago after being diagnosed with Parkinson's disease. Over the last 5 years, John's ability to perform physical activity, has progressively deteriorated. Although John reports bouts of depression, beginning in adolescence and continuing throughout his adult life, he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinson’s). Since that time, he is been on several antidepressant medications, most recently Remeron. John reports that he has been a regular drinker since his days in college. Although he denies it, his alcohol use, according to his wife, has increased since his diagnosis of Parkinsons. However, upon evaluation both john and his wife agree that he drinks no more than 3 times per week – usually a six pack. Although John has been advised to discontinue drinking, he has not done so. And according to both John and his wife. He misses his medication anywhere from 1 to 3 times per week. About 3 months ago john fell while at home. His wife at first thought it was a result of his drinking. According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinson’s Despite advice to the contrary, John has become progressively more sedentary and has discontinued all forms of exercise. About 1 month ago, John's employers required that John start working part-time and consider filing for early Social Security. According to them, John's ability to work has diminished. They too noted that he was having difficulty walking. For the last 3 weeks, John has met all of the criteria for a severe episode of major depression. Primary diagnosis Primary-reason for visit, 296.33, major depressive disorder, recurrent, severe. Primary- Medical condition; Chronic Obstructive Pulmonary Disease, moderate Primary-305.00 alcohol use disorder, mild. Primary -v15.81 non-adherence to medical treatment. Patient continues to drink while on antidepressants take antidepressants irregularly Psychosocial stressors and factors that might affect treatment v278.00 – Obesity v69.9 - Problems related to lifestyle. John's diet and his progressive sedentary behavior, along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses v62.29 - Other problems related to employment. John has recently had his work hours cut in half WHODAS raw score = 98: domain averages: Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 2.5 mild- moderate work activities = 3, moderate participation = 3.5moderate- severe

56 4. A cultural framework: The DSM and cultural formulation DSM calls for systematic cultural assessment in these areas 1.Cultural identity of the individual-describe reference group that might influence his or her relationships resources, developmental, and current challenges 2.Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others 3.Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment, role of religion, family and other social. 4.Cultural features or influencing factors of the relationship between the individual and clinician.-Identify differences that may cause difficulties in communication and may influence diagnosis 5.Overall cultural assessment-summarize the implications of the components of the cultural formulation, identified earlier. (DSM 5, pp749-750)

57 DSM and the cultural formulation interview 16 questions used to obtain information about the impact of culture on key aspects of a person's clinical presentation Assesses 4 areas 1.Cultural definition of the problem (Q1 – 3) 2.Cultural perceptions of cause, context and support (Q4 – 10) 3.Culture of factors affecting self coping and past help seeking (Q 11 – 13 4.Cultural factors affecting current help seeking (Q 14 – 16)

58 This page and the 3 following are reprinted from the DSM 5 website at psychiatry.org. Please see provisions for copying at the bottom of the slides

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62 5. Overall organization of disorders

63 Neuro develop mental Bipolar SchizophreniaDepressive Anxiety Obsessive- compulsive and related Trauma related Dissociative Somatic symptom related Feeding and eating disorders Sexual dysfunctions Sleep wake disorders Elimination disorders Substance related and addictive disorders Disruptive, impulse control disorders Neurocognitive disorders Personality disorder Gender dysphoria Paraphilia disorders Others Younger Older The progression from younger to older in the DSM is general and there are specific disorders such as some early childhood feeding disorders that clearly occur later Initial occurrence DSM categories organized over developmental lifespan

64 Neuro develop mental Bipolar SchizophreniaDepressive Anxiety Obsessive- compulsive and related Trauma related Dissociative Somatic symptom related Feeding and eating disorders Sexual dysfunctions Sleep wake disorders Elimination disorders Substance related and addictive disorders Disruptive, impulse control disorders Neurocognitive disorders Personality disorder Gender dysphoria Paraphilia disorders Others These distinctions have some strong validation from recent neuro-scientific and genetic research DSM categories organized using empirically validated common factors Neural commonalities Externalizing Symptom factors Physiological Symptom factors Internalizing Symptom factors Bio-genetic similar factors

65 6. Highlight of specific changes in diagnosis

66 Gone Disorders usually evident in infancy, childhood and adolescence. Factitious disorders and malingering adjustment disorders (now included in trauma and stress-related disorders) NOS Diagnosis for all categories Added neurodevelopmental disorders obsessive-compulsive and related disorders (moved out of anxiety) trauma and stress-related disorders (moved out of anxiety) Disruptive, impulse control, and conduct related disorders "Specified" and “Unspecified" disorder for all diagnoses "Suicide risk" is now specified for 25 diagnosis Changed Delirium, dementia and cognitive disorders = neurocognitive disorders psychotic disorders = schizophrenia spectrum and other psychotic disorders mood disorders = bipolar and related disorders & depressive disorders somatoform disorders = somatic symptom and related disorders

67 Neuro developmental disorders 1.The term "mental retardation" has been changed to intellectual disability 2.The term "phonological disorders" has been changed to "communication disorders". 1.A new diagnosis of social/pragmatic communication disorder has been added here 2.childhood onset fluency disorder new name for stuttering 3.Speech sound disorder is new name for phonological disorder 3.Autism spectrum disorder is the new term and DSM 5 which consolidates Aspergers disorder, autism, and pervasive developmental disorder. Severity measures are included 4.Several changes have been made to the diagnostic criteria for attention deficit hyperactive disorder 5.Specific learning disorder combines DSM-IV diagnosis of reading disorder mathematics disorder disorder of written expression and learning disorder NOS 6.Language disorder combines expressive and mixed receptive expressive into one 7.Symptom onset for ADHD was extended to before age 12; Subtypes eliminated and replaced by specifiers; now allowed to make a comorbid diagnosis with ASD; Symptom criteria for adults reduced to 5 instead of 6

68 Schizophrenia spectrum and other psychotic disorders 1.The spectrum seems to emphasize degrees of psychosis 2.Change in criteria for schizophrenia now requires at least one criteria to be either a. Delusions, b. Hallucinations or c. Disorganized speech 3.Subtypes of schizophrenia were eliminated 4.Dimensional measures of symptom severity are now included 5.Schizoaffective disorder has been reconceptualized 6.Delusional disorder no longer requires the presence of “non- bizarre" in delusions. There is now specifier for bizarre delusions. 7.Schizotypal personality disorder is now considered part of the spectrum

69 Bipolar and related disorders Diagnosis must now include both changes in mood and changes in activity/energy level Some particular conditions can now be diagnosed under "other specified bipolar and related disorders“ An "anxiety" specifier has now been included Attempts made to clarify definition of 'hypomania". However it was not successful

70 Depressive disorders New diagnosis included = "disruptive mood dysregulation disorder”-use for children up to age 18 New diagnosis included = "premenstrual dysphoric disorder“ What used to be called dysthymic disorder is now "persistent depressive disorder“ Bereavement is no longer excluded – used to be an exclusion for 2 months New specifiers such as mixed features. And anxious distress

71 Obsessive-compulsive and related disorders A completely new diagnostic grouping category Hoarding disorder-new diagnosis Excoriation (skin picking) disorder-new diagnosis Substance induced obsessive-compulsive disorder-new diagnosis Trichotillomania now called hair pulling disorder Tic specifier has been added Muscle dysphoria is now a specifier within body dysmorphic disorder

72 Trauma and stress related disorders For diagnosis of acute stress disorder, it must be specified whether the traumatic events were experienced directly or indirectly Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress Major changes in the criteria for the diagnosis of PTSD

73 Anxiety disorders Obsessive-compulsive disorder has been moved out of this category PTSD has been moved out of this category Acute stress disorder has been moved out of this category Changes in criteria for specific phobia and social anxiety have been made Panic attacks can now be used as a specifier within any other disorder in the DSM Separation anxiety disorder has been moved to this group Selective mutism has been moved to this group

74 Dissociative disorders Depersonalization disorder has been relabeled “Depersonalization/Derealization disorder“ Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of "dissociative amnesia“ Changes in criteria for the diagnosis of "dissociative identity disorder"

75 Somatic symptom and related disorders This is a new name for what was previously called "somatoform disorders“ The number of diagnoses in this category has been reduced. The diagnoses of somatization disorder, hypochondriasis, pain disorder and undifferentiated somatoform disorder have all been removed "Illness anxiety disorder" has been an added diagnosis and replaces hypochondriasis Factitious disorder is now included in this group

76 Feeding and eating disorders "Binge eating disorder' is now included as a separate diagnosis also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter "disorders usually 1st diagnosed during infancy childhood and adolescence“. – Pica and rumination disorder are 2 examples

77 Elimination disorders Originally classified in chapters on childhood and infancy. Now have separate classification Primary insomnia renamed "insomnia disorder« Narcolepsy now distinguished from other forms of hypersomnia Breathing related sleep disorders have been broken into 3 separate diagnoses Rapid eye movement disorder and restless leg syndrome are now independent diagnoses within this category Sleep wake disorders

78 Sexual dysfunctions Some gender related sexual dysfunctions have been outed Now only 2 subtypes-acquired versus lifelong and generalized versus situational New diagnostic class and the DSM 5 Include separate classifications for children adolescents and adults The construct of gender has replaced the construct of sex Gender dysphoria

79 Disruptive, impulse control and conduct disorders New diagnostic grouping and DSM 5 Combines a group of disorders previously included in disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified Oppositional defiant disorder now has 3 subtypes Intermittent explosive disorder no longer requires physical violence but can include verbal aggression

80 Substance related and addictive disorders The distinctions between substance abuse and substance dependence are no longer made – Now includes criteria for intoxication, withdrawal and substance induced disorders Now includes gambling disorder Cannabis and caffeine withdrawal are now new disorders

81 Neuro-cognitive disorders New diagnostic group Dementia and amnestic disorder are included in this new group Mild NCD is a new diagnosis

82 Personality disorders Nothing changes

83 DSM 5 promised major changes in criteria Promised dimensional focus Promised reduction in number of personaliity disorders to five Changes did not occur Dimensional focus for personality disorders was moved to section 3

84 Primary Criteria in DSM 5 (Unchanged from DSM-IV TR) A.Enduring pattern of inner experience & behavior that deviates markedly from expectations of the culture. This pattern is manifested in 2 or more of the following areas A.Cognition; B.Affect; C.Interpersonal; D.Impulse control B.Inflexible & pervasive across situation C.Distress or impairment in social, occupational interpersonal..… D.Long-standing (back to adolescence or early adulthood)

85 Dimensional classification of personality disorders Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders They plan to reduce personality disorders from 10 to 5 This changed in a closed-door meeting Dimensional measures are now in section 3

86 Proposed changes in assessment of PDs Two broad dimensions Overall personality functioning 5 Broad Pathological Trait Domains self Interpersonal Identity Self direction Empathy Intimacy Negative affectivity Detachment Antagonism Disinhibition Psychoticism


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