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

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

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

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

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

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

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

Substance Use Disorders

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Disorders Most Likely to Co-Occur with Substance Use Disorders

Eating Disorders Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder

Anorexia Nervosa

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

Before 40 day fast After 40 day fast

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

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

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

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

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

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

ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD) Incidence in the General Population is: 2.3% Incidence in a cocaine using population is: 32-34% 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

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

People DO NOT Outgrow ADHD!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bipolar Disorder Misdiagnosis* Total misdiagnosis 69% Times individual misdiagnosed 3.5 Physicians consulted before correct diagnosis 4 Misdiagnosed as: Unipolar Depression 60% Anxiety Disorder (especially PTSD) 26% Schizophrenia 18% Borderline or Antisocial Personality Disorder 17% * Hirschfield, RM et al. J Clin Psychiatry. 2003, 64(2):161-174

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

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

What’s New in the ASAM Criteria?

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

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

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

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

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

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

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

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

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

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

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