Presentation on theme: "DSM-5 Jim Messina, Ph.D., CCMHC, NCC Assistant Professor"— Presentation transcript:
1 DSM-5 Jim Messina, Ph.D., CCMHC, NCC Assistant Professor Troy University, Tampa Bay Site
2 Objectives DSM-5 Workshop Update status of new DSM-5Identify categories & changes in DSM-5Suggest impact of DSM-5 for Professional CounselorsUsing DSM-5 for Improved Clinical Assessment, Diagnosis and Treatment Planning
3 Websites on DSM-5 Official APA DSM-5 site: www.dsm5.org DSM-5 on:
4 Timeline of DSM-5 1999-2001 Development of Research Agenda APA/WHO/NIMH DSM-5/ICD-11 Research Planning conferencesAppointment of DSM-5 TaskforceAppointment of WorkgroupsLiterature Review and Data Re-analysisst phase Field Trials ended July 2011nd phase Field Trials began Fall 2011July Final Draft of DSM-5 for APA reviewMay Publication Date of DSM-5
5 Revision Guidelines for DSM-5 Recommendations to be grounded in empirical evidenceAny changes to the DSM-5 in the future must be made in light of maintaining continuity with previous editions for this reason the DSM-5 is not using Roman numeral V but rather 5 since later editions or revision would be DSM-5.1, DSM-5.2 etc.There are no preset limitations on the number of changes that may occur over time with the new DSM-5The DSM-5 will continue to exist as a living, evolving document that can be updated and reinterpreted over time
6 Focus of DSM-5 ChangesDSM-5 is striving to be more etiological-however disorders are caused by a complex interaction of multiple factors and various etiological factors can present with the same symptom patternThe diagnostic groups have been reshuffledThere is a dimensional component to the categories to be further researched and covered in Section III of the DSM-5Emphasis was on developmental adjustment criteriaNew disorders were considered and older disorders were to be deletedSpecial emphasis was made for Substance/Medication Induced Disorders and specific classifications for them are listed for Schizophrenia; Bipolar; Depressive, Anxiety, Obsessive Compulsive; Sleep-Wake; Sexual Dysfunctions; and Neurocognitive Disorders.
7 Definition of Mental Disorder A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition DSM-5. Arlington VA: Author, p. 20.)
8 Why identify a mental disorder diagnosis? The diagnosis of a mental disorder should have clinical utility:Helps to determine prognosisHelps in development of treatment plansHelps to give an indication of potential treatment outcomesA diagnosis of a mental disorder is not equivalent to a need for treatment. Need for treatment is a complex clinical decision that takes into consideration:Symptom severitySymptom salience (presence of relevant symptom e.g., presence of suicidal ideation)The client's distress (mental pain) associated with the symptom(s)Disability related to the client's symptoms, risks, and benefits of available treatmentOther factors such as mental symptoms complicating other illness
9 DSM-5 Diagnostic Categories Neurodevelopmental disordersSchizophrenia Spectrum and Other Psychotic DisordersBipolar and Related DisordersDepressive DisordersAnxiety DisordersObsessive Compulsive and Related DisordersTrauma- and Stressor-Related DisordersDissociative DisordersSomatic Symptom and Related DisordersFeeding and Eating DisorderElimination DisordersSleep-Wake DisordersSexual DysfunctionsGender DysphoriaDisruptive, Impulse-Control, and Conduct DisordersSubstance-Related and Addictive DisordersNeurocognitive DisordersPersonality DisordersParaphilic DisordersOther Mental Disorders
10 Obvious Changes in DSM-5 (1) The DSM-5 will discontinue the Multiaxial Diagnosis, No more Axis I,II, III, IV & V-which means that Personality Disorders will now appear as diagnostic categories and there will be no more GAF score or listing of psychosocial stressor or contributing medical conditionsThe Multi-axial model will be replaced by Dimensional component to diagnostic categories
11 Obvious Changes in DSM-5 (2) Developmental adjustments will be added to criteriaThe goal has been to have the categories more sensitive to gender and cultural differencesDiagnostic codes will change from numeric to alphanumeric e.g., Obsessive Compulsive Disorder will change from to F42Diagnostic codes will change from numeric ICD-9-CM codes on September 30, 2014 to alphanumeric ICD-10-CM codes on October 1, 2014 e.g., Obsessive Compulsive Disorder will change from to F42They have done away with the NOS labeling and replaced it with Other Specified... or Unspecified
12 What Replaces NOS? NOS is replace by either: Other specified disorder or Unspecified disorder type are to be used if the diagnosis of a client is too uncertain because of:1. Behaviors which are associated with a classification are seen but there is uncertainty regarding the diagnostic category due to the fact thatThe client presents some symptoms of the category but a complete clinical impression is not clearThe client responds to external stimuli with symptoms of psychosis, schizophrenia etc. but does not present with a full range of the symptoms need for a complete diagnosis2. The client has been unwilling to provide information due to an unwillingness to be with the clinician or angry about being brought in to be seen or the there is too brief a period of time in which the client has been seen or the clinician is untrained in the classificationRules for use of Other Specific or UnspecifiedThis designation can last only six months and after that a specific diagnostic category has to be determined for the diagnosis of the client.
13 Principle DiagnosisPrinciple Diagnosis is to be used when more than one diagnosis for an individual is given in most cases as the main focus of attention or treatment:In an inpatient setting, the principle diagnosis is the condition established to be chiefly responsible for the admission of the individualIn an outpatient setting, the principle diagnosis is the condition established as reason for visit responsible for care to be received The principle diagnosis is often harder to identify when a substance/medication related disorder is accompanied by a non-substance-related diagnosis such as major depression since both may have contributed equally to the need for admission or treatment. Principle diagnosis is listed first and the term "principle diagnosis" follows the diagnosis nameRemaining disorders are listed in order of focus of attention and treatment
14 Provisional Diagnosis Specifier "provisional" can be used when there is strong presumption that the full criteria will be met for a disorder but not enough information is available for a firm diagnosis. It must be recorded "provisional" following the diagnosis given
15 Respect for Age, Gender & Culture in DSM-5 Each diagnostic definition, where appropriate will incorporate:1. Developmental symptom manifestation – regarding the age of client2. Gender specific disorders3. Cultural sensitivity in regards to certain behaviors
16 Specific Changes Per Diagnostic Category in DSM-5
17 Neurodevelopmental Disorders 1. Intellectual Disability (Intellectual Developmental Disorder) no longer relies on IQ used as specifier because it is the adaptive functioning that determines levels of support required.IQ measures are less valid in the lower end of the IQ rangeStill accepted that people with intellectual disability have scores two standard deviations or more below the population mean, including a margin for error which is generally +5 points. Thus on tests with standard deviations of 15 and mean of 100 the score for mild would involve (70+5).2. Asperger's Syndrome is lumped into Autism Spectrum since it is at the milder end of the Spectrum3. Childhood disintegrative disorder, Rett's disorder and Pervasive developmental disorder not otherwise specified are also now incorporated into the Autism Spectrum Disorder4. Autism Spectrum Disorder is now characterized by deficits in two domains:Deficits in social communication and social interactionRestricted repetitive patterns of verbal and nonverbal communication.
18 Schizophrenia and Other Psychotic Disorders 1.Changes for Criteria A for Schizophrenia were made:1) elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (two or more voices conversing), leading to the requirement of at least two Criterion A symptoms for any diagnosis of schizophrenia2) the addition of the requirement that at least one of the Criterion A symptoms must be delusions, hallucinations, or disorganized speech.2. DSM-IV-TR subtypes of schizophrenia were eliminated3. Schizoaffective disorder is reconceptualized as a longitudinal rather than a cross sectional diagnosis and requires that a major mood episode be present for a majority of the total disorder's duration after Criterion A has been met4. Schizotypal Personality Disorder is now listed in this category
19 Bipolar and related disorders 1. Bipolar is now a free standing category2. Bipolar was taken out of the mood disorder category3. Diagnostic criteria now include both changes in mood and changes in activity or energy
20 Depressive Disorders1. Dysthymia is now called Persistent Depressive Disorder 2. Disruptive Mood Dysregulation Disorder has been added for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behaviors3. Premenstrual Dysphoric Disorder has been added
21 Anxiety Disorders 1. No longer has PTSD in this category 2. No longer has OCD in this category3. Social Phobia is now called Social Anxiety Disorder4. Panic Disorder and Agoraphobia are unlinked and each now have their own separate criteria5. Separation anxiety disorder and selective mutism are now classified as anxiety disorders
22 Obsessive-Compulsive and Related Disorders 1. OCD is now a stand alone category2. Body Dysmorphic Disorder is now listed under OCD3. Hoarding has been added under the category of OCD3. Trichotillomania (Hair-Pulling Disorder) is listed under OCD4. Excoriation (Skin Picking Disorder) is listed under OCD
23 Trauma and Stressor Related Disorders 1 Trauma related disorders are now a stand alone category 2. Reactive Attachment Disorder is now listed here 3. Disinhibited Social Engagement Disorder has been added 4. PTSD is listed here 5. PSTD in Preschool Children has been added 6. Acute Stress Disorder is listed here and requires qualifying traumatic events as explicit as to whether they were experienced directly, witnessed or experienced indirectly 7. Adjustment Disorders are now listed here and conceptualize as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event.
24 Dissociative Disorders 1. Dissociative Fugue has been removed from this category and is now a specifier of dissociative amnesia 2. Derealization is included in the name and symptom structure of the former depersonalization disorder to become: Depersonalization/Derealization disorder.
25 Somatic Symptom Disorder 1. Replaced Somatiform Disorders category with this category2. Somatization Disorder; Pain Disorder; Hypochondriasis and undifferentiated somatoform disorder were eliminated3. Complex Somatic Symptom Disorder was added4. Simple Somatic Symptom Disorder was added5. Illness Anxiety Disorder was added and replaces Hypochondriasis6. Conversion Disorders (Functional Neurological Disorder) have modified criteria to emphasize essential importance of neurological examination, in recognition that relevant psychological factors may not be demonstrable at time of diagnosis7. Psychological factors affecting other medical conditions has been added to this category and along with Factitious disorder both have been placed among the somatic symptom and related disorders because somatic symptoms are predominant in both disorders
26 Feeding and Eating Disorders 1. Pica was moved to this category2. Rumination Disorder was moved to this category3. The "feeding disorder of infancy or early childhood” has been renamed: Avoidant/Restrictive Food Intake Disorder 4. Binge Eating Disorder was added
27 Elimination Disorders 1. This category was created as freestanding category 2. Enuresis was moved to this category 3. Encopresis was move to this category
28 Sleep-Wake Disorders1. Primary Insomnia renamed Insomnia Disorder 2. Primary Hypersomnia joined with Narcolepsy without Cataplexy 3. Cheyne-Stokes Breathing added 4. Obstructive Sleep Apnea Hypopnea added 5. Idiopathic Central Sleep Apnea added 6. Congenital Central Alveolar Hypoventilation added 7. Rapid Eye Movement Behavior Disorder added 8. Restless Leg Syndrome added
29 Sexual Dysfunctions1. Male orgasmic disorder renamed Delayed Ejaculation2. Premature (Early) Ejaculation renamed3. Dyspareunia and Vaginismus were combined into Genito-Pelvic Pain/Penetration Disorder4. Sexual Aversion Disorder combined in other categories5. For females-sexual desire and arousal disorders have been combined into one disorder: Female sexual interest/arousal disorder
30 Gender Dysphoria1 This is a new diagnostic class 2. It emphasizes the phenomenon of "gender incongruence" rather than cross-gender identification per se. 3. Posttransition specifier has been added to identify individuals who have undergone at least one medical procedure or treatment to support new gender assignment
31 Disruptive, Impulse Control, and Conduct Disorders 1. This is a new diagnostic class and combines "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" and the "Impulse-control Disorders Not Elsewhere Classified" 2. Oppositional Defiant Disorder was added here3. Trichotillomania removed from this category4. Conduct Disorder now in this freestanding category5. Antisocial Personality Disorder added to this category as well as in Personality Disorders Category
32 Substance Abuse and Addictive Disorders Only 3 qualifiers are used in the category: Use - replaces both abuse and dependenceIntoxication and Withdrawal remain the same2. Nicotine Related renamed Tobacco Use Disorder3. Caffeine Withdrawal added4. Cannabis Withdrawal added5. Polysubstance Abuse categories discontinued6. Gambling added to this category
33 Neurocognitive Disorders 1. Category replaces “Delirium, Dementia, and Amnestic and Other Cognitive Disorders” Category2. Now distinguishes between Minor and Major Disorders3. Replace wording of Dementia "due to" with Neurocognitive Disorder "Associated with" for all the conditions listed4. Added new Neurocognitive Disorders: Fronto-Temporal Lobar DegenerationTraumatic Brain InjuryLewy Body Disease5. Renamed Head Trauma to Traumatic Brain Injury6. Renamed Creutzfeldt-Jakob Disease to Prion Disease
34 Personality Disorders Cluster A Personality Disorders301.0 (F60.0) Paranoid Personality Disorder(F60.1) Schizoid Personality Disorder(F21) Schizotypal Personality DisorderCluster B Personality Disorders301.7 (F60.2) Antisocial Personality Disorder(F60.3) Borderline Personality Disorder(F60.4) Histrionic Personality Disorder(F60.81) Narcissistic Personality DisorderCluster C Personality Disorders(F60.6) Avoidant Personality Disorder301.6 (F60.7) Dependent Personality Disorder301.4 (F60.5) Obsessive-Compulsive Personality DisorderOther Personality Disorders310.1 (F07.0) Personality Change Due to Another Medical Condition Specify whether Labile type; Disinhibited Type; Aggressive Type; Apathetic Type; Paranoid Type; Other Type; Combined Type; Unspecified Type(F60.89) Other Specified Personality Disorder301.9 (F60.9) Unspecified Personality Disorder
35 Paraphilic Disorders 1. They all carried over to DSM-5 2. New names for them all but the category remains the same3. Overarching change is the addition of course specifiersin a controlled environmentin remission4. Distinction between paraphilias and paraphilic disorder was made:Paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. Paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not automatically justify or require clinical intervention
36 Conditions Designated for Further Study in DSM-5 in Section III Attenuated Psychosis SyndromeDepressive Episodes with Short-Duration HypomaniaPersistent Complex Bereavement DisorderCaffeine Use DisorderInternet Gaming DisorderNeurobehavioral Disorder Associated with Prenatal Alcohol ExposureSuicidal Behavior DisorderNonsuicidal Self-Injury
37 Possible Disorders Discussed But Not Included in Section III of DSM-5 Dissociative Trance DisorderAnxious DepressionFactitious disorder imposed on anotherHypersexual DisorderOlfactory Reference SyndromeParaphilic Coercive Disorder
38 Other Conditions That May Be a Focus of Clinical Attention (V Codes and TZ Codes) Relational ProblemsProblems Related to Family UpbringingOther Problems Related to Primary Support GroupAbuse and NeglectChild Maltreatment and Neglect ProblemsChild Physical Abuse; Child Sexual Abuse Child Neglect Child Psychological AbuseAdult Maltreatment and Neglect ProblemsSpouse or Partner Violence, Physical; Spouse or Partner Violence, Sexual; Spouse or Partner Neglect; Spouse or Partner Abuse, Psychological; Adult Abuse by Nonspouse or Nonpartner; Adult Sexual abuse by nonspouse or nonpartner; Adult Psychological abuse by nonspouse or nonpartner
39 Other Conditions That May Be a Focus of Clinical Attention Continued: Educational and Occupational ProblemsHousing and Economic ProblemsOther Problems Related to Social EnvironmentProblems Related to Crime or Interaction with Legal SystemOther Health Services Encounters for Counseling and Medical AdviceProblems Related to Other Psychosocial, Persons and Environmental CircumstancesOther Circumstance of Personal HistoryProblems Related to Access to Medical and Other Health CareNonadherence to Medical Treatment
40 Steps to formulate an initial tentative diagnosis Do a thorough Psychosocial HistoryDo a Mental Status ExaminationDevelop a Diagnosis using DSM-5
42 First: Establish - WHY NOW? You must be able to describe the presenting problemListing specific symptoms and complaints which would justify diagnosisYou must be able to list the duration of the symptoms or at least estimate the duration
43 Second: Review client’s mental health history Previous treatment for mental health problems?Hospitalization for psychiatric conditions?As child involved in family therapy?Treatment for substance abuse problems-outpatient or inpatient?
44 Third: Determine if client is on any psychotropic medications What medications?Level of prescription?Who prescribed medications?For what are the medications prescribed?
45 Fourth: Review client’s relevant medical history What is current overall physical health of client?When was last physical?Is there anything currently or in the past medically accounting for this current mental health complaint?
46 Fifth: Review client’s family history Do a genogram of the familyIdentify psychosocial stressors within the family structureMental health and/or substance abuse history with in the family and if successfully treated
47 Sixth: Review client’s social history School history: Failed grades? Academic success? Social interaction with peers? Highest academic level attained?Community history: Peer group? Current network of social support? Activities and interests: sports, hobbies, social functioning?
48 Seventh: Review client’s vocational history Level of current employment and commitment to current job?Relevant past employment history: length of tenure on past jobs, job hopping, relationships with work peers?Level of satisfaction with current employment?
49 Eighth: List client’s strengths Identify those strengths which make the client a good candidate for successful therapy to address the “here and now” mental health problemHow motivated for therapy is client?How insightful to symptoms?How psychologically minded is client?How verbal and intelligent?
50 Ninth: List liabilities client brings to therapy Level of present social support system?Mandated for freely coming to therapy?Perceptual problems which could interfere e.g. hearing, vision, etc.Risk of decompensating (relapsing) if not treated
51 Tenth: Rate Client on ACE Scale Identify Relevant ACE (Adverse Childhood Experiences)Abuse1. Emotional Abuse2. Physical Abuse3. Sexual AbuseNeglect4. Emotional Neglect5. Physical NeglectHousehold Dysfunction6. Mother was treated violently7. Household substance abuse8. Household mental illness9. Parental separation or divorce10. Incarcerated household member
55 Formulate Tentative Diagnosis You are ready to make a tentative Diagnosis using DSM-5 Including:Principle DiagnosesAny Provisional DiagnosisAny relevant Other Conditions That May Be a Focus of Clinical Attention
56 DSM-5 Single Diagnosis Use DSM-5 Most Appropriate Classification Include relevant rule-out diagnosesCompare client’s symptoms lists with those contained in DSM-5 to get to most appropriate tentative Principle diagnosisThen list any and all secondary diagnosis if the client’s symptoms match up for such classificationsAlso list Provisional diagnoses if the client’s presentation allows for these additional diagnosesList all relevant V (T,Z) Code ConditionsEach must be listed with number & description just like the principal diagnosis
57 It is important to remember The Diagnosis given a client is tentative dependent on gathering more data in future anticipated treatmentDiagnoses can ALWAYS be changed to address changes with the individual’s presentation & functioning