1. LAURA HANKINS MISSISSIPPI STATE UNIVERSITY SEPTEMBER 17, 2013 DSM-5 Overview Understanding the Fifth Edition Changes

2. What is the DSM? Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition Produced by the American Psychiatric Association Used by clinicians, students, practitioners, and researchers from a wide range of professional fields associated with mental health. Created to serve a variety of functions:  A tool for clinicians.  Provides an organized way for professionals to gather and categorize information to accurately diagnose and treat mental disorders.  An essential educational resource for students and practitioners.  A reference for researchers in the field.

3. School Counselors need this book thing, too?? Diagnosing is not the first role of the majority of school counselors, but shouldn’t be overlooked.  Although diagnosis isn’t a daily part of all school counseling roles, being familiar with the language of the DSM and current trends in diagnosis can only provide benefits for both counselor and students. Often, school counselors do not like to diagnose, but it is important that they consider the reason diagnoses are given. The purpose of a diagnosis:  Provide a common language.  Prognosis and Course Information  Inform Treatment Planning

4. Definition of a Mental Disorder Inclusion Criteria:  A syndrome characterized by a disturbance in cognition, emotion regulation, or behavior.  Reflects dysfunction of psychological, biological, or developmental aspects of mental functioning.  Associated with clinically significant distress or disability. Exclusion Criteria:  Not simply an expected or culturally sanctioned behavior or response to a stressful event.  Not simply socially deviant behavior.

5. THESE FIVE MAJOR CHANGES PROVIDED THE BASIS FOR THE REVISED ORGANIZATIONAL STRUCTURE OF THE DSM-5 Major Innovations of DSM-5

6. Greater ICD/DSM Harmony It was the goal of both ICD and DSM revision groups to create as much harmony and overreach between the two classifications systems as possible because:  Two major classifications of mental disorders existing at the same time can cause problems for many aspects of research. Overall, there is just a clear need for a uniform classification system to reduce confusion and misinterpretation of mental disorders. ICD-11 codes will eventually be placed into the DSM following the current sequential format, but currently the ICD-9-CM and ICD-10-CM have been indicated for each disorder in the DSM-5.

7. Discontinuation of the Multiaxial System Previously, diagnosis was done using a five axis system, but now the DSM uses a more dimensional approach to diagnosis.  Basically, DSM-5 has employed a non-axial 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).  The revision is consistent with the text in the DSM-IV which states, “The multiaxial distinction among Axis I, Axis II, and Axis III disorders doesn’t imply that there are fundamental differences in thir conceptualization, that mental disorders are unrelated to physical or biological factors or processes, or hat general medical conditions are unreltated to behavioral or psychosocial factors or processes.” DSM-5 uses a single axis system that combines the former Axis I-III codes:  Mental Disorders  Medical Disorders  Reasons for Visit that are not mental disorders (V-codes)

8. Sample Diagnoses DSM-IV-TR Diagnosis: Axis I:296.22 Major Depressive Episode, Single Episode, Moderate Axis II: V71.09 No Diagnosis Axis III: None Axis IV: Recent Academic Problems, Few Peer Relationships Axis V: GAF=35 (Current) DSM-5 Diagnosis: 296.42Bipolar I Disorder, current episode manic, moderate severity, with anxious distress 301.83Borderline Personality Disorder

9. Spectrum Disorders and Dimensional Ratings Comorbidity and the need for NOS diagnoses being a substantial part of some disorders lead to the change in rating. Previous DSM viewed each diagnosis to be categorically different than any other health issue as well as any other diagnosis. Basically, the majority of disorders have been placed on a spectrum providing a wider range of possibility to fall within the diagnosis criteria.  This lowered diagnostic pathology has allowed the diagnosing of individuals to increase and as a result the validity is much greater.

10. Greater Recognition of the Influence of Age, Gender, and Culture Age is now considered as an important component of understanding and diagnosing mental disorders.  The entire DSM-5 is built from a developmental standpoint. Gender can influence illness in a variety of ways, such as:  determining if a person is at all at risk for a certain disease based on their gender,  susceptibility to certain disorders is higher for one gender than another,  and the symptoms of certain disorders being more readily endorsed by one gender, therefore increasing the extent to which the disorder appears. Culture provides the framework by which we interpret mental disorders because it shapes the expression and experience of that person affecting how the signs, symptoms, and behaviors appear to meet criteria for diagnosis.

11. New Organization of Chapters DSM-5 is organized on developmental and lifespan considerations.  It begins with diagnoses thought to reflect developmental processes that manifest early in life, followed by diagnoses more common to manifest in adolescence and young adulthood, and ends with diagnoses relevant to adulthood and later life. This approach has been taken on in a similar fashion when possible within each chapter.  The organizational structure facilitates the comprehensive use of lifespan information as a way to assist in diagnostic decision making.

12. THESE CHANGES INCLUDES THE CONSOLIDATION, ADDITION, EXTENSION, AND RELOCATION OF DISORDERS THROUGHOUT THE DSM-5 Additional Changes to DSM-5

13. Additional Changes Consolidation into Autism Spectrum Disorder  Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder were consolidated into one group known as Autism Spectrum Disorder.  Symptoms of these disorders represent a single continuum of mild to severe impairments in the two domains of social communication and restrictive repetitive behaviors/interests rather than being distinct disorders. Streamlined Classification of Bipolar and Depressive Disorders  These are the most commonly diagnosed conditions, so it was important to streamline the presentation of these disorders to enhance both clinical and educational use.  Now, they are separated into two different chapters but each have their own criteria definitions of manic, hypomanic, and major depressive episodes within these separate chapters.

14. Additional Changes Enhanced Specificity for Major and Mild Neurocognitive Disorders  Developments in neuroscience and neurology throughout the past decade have results in our recognition of specific brain disorders that were previously unable to be identified.  These disorders, such as Alzheimer’s disease and Huntington’s disease, have been separated into specific subtypes. Restructuring of Substance Use Disorders for Consistency and Clarity  The categories of substance abuse and substance dependence have been eliminated and replaced with an overarching new category of substance use disorders – with specific substance used defining the specific disorders.

15. Additional Changes Transition in Conceptualizing Personality Disorders  In DSM-5, the categorical personality disorders are virtually unchanged from the previous editions. However, an alternative model has been proposed in Section III to guide future research.  A more dimensional profile of personality trait expression is also proposed for a trait-specified approach. Section III: New Disorders & Features  This new section has been added to highlight disorder that require further study but are not sufficiently well established to be a part of the official classification of mental disorders for routine clinical use.

16. THIS SECTION PROVIDES AN OVERVIEW OF HOW THE DSM-5 IS COMPILED, BRIEFLY TOUCHING ON A FEW CHAPTERS RELEVANT TO OUR FIELD OF SCHOOL COUNSELING. A Brief Look into the DSM-5

17. Neurodevelopmental Disorders Highlights of this Chapter:  New Chapter in DSM.  Intellectual Disability replaces Mental Retardation.  Revised Communication Disorders  Introduction of Autism Spectrum Disorder  ADHD Criteria Changes Organization of Chapter:  Intellectual Disability (Intellectual Developmental Disorder)  Communication Disorders  Autism Spectrum Disorder  ADHD  Specific Learning Disorders  Motor Disorders  Other Neurodevelopmental Disorders

18. Bipolar and Related Disorders Highlights of this Chapter:  Bipolar Disorders and Depressive Disorders are separate chapters.  Mixed Episode removed.  Increased activity/energy added as core feature of mania.  New specifiers:  With mixed features  With anxious distress  With peripartum onset

19. Depressive Disorders Highlights of this Chapter:  Chronic depressive spectrum introduced.  Changes to Major Depression  Elimination of bereavement exclusion  New specifiers  New disorders added  Disruptive Mood Dysregulation Disorder is new within this category.  Dysthymia is know referred to as Persistent Depressive Disorder as part of this chapter.  Premenstrual Dysphoric Disorder was always added to this chapter. Grief can now be looked at as a mild form of depression instead of requiring the use of bereavement.

20. Anxiety Disorders Highlights of this Chapter:  New organization of former Anxiety Disorder Chapter  Panic and Agoraphobia become separate disorders.  Panic attacks can be applied to any disorder.  Generalized Anxiety Disorder is unchanged.  Separation Anxiety Disorder is now for adults instead of only children.  Selective Mutism is now apart of this chapter.  What was previously Social Phobia is now referred to as Social Anxiety Disorder.

21. Obsessive-Compulsive and Related Disorders OCD is no longer under the category of anxiety, but instead has a separate individual chapter, including:  OCD  Body Dysmorphic Disorder  Hoarding Disorder (new disorder)  Trichotillomania (hair-pulling)  Excoriation (skin-picking) disorder  Substance/Medication induced OCD  OCD due to a medical condition  Other specified OCD

22. Trauma- and Stressor-Related Disorders Highlights:  New chapter for disorders related to exposure to stress  PTSD has modified criteria and new subtypes  Now is a PTSD for Children 6 years and younger category  Acute Stress Disorder criteria was modified

23. Feeding and Eating Disorders Highlights:  New title and organization  Avoidant/Restrictive Food Intake Disorder Added  Modifications to Anorexia and Bulimia  Binge-Eating Disorder added as new disorder. Organization of Chapter:  Pica  Rumination Disorder  Avoidant/Restrictive Food Intake Disorder  Anorexia Nervosa  Bulimia Nervosa  Binge Eating Disorder (new)  Other Specified Feeding or Eating Disorder  (added so we no longer have to use NOS)

24. Substance-Related and Addictive Disorders Highlights:  New chapter title.  Two types of disorders:  Substance USE  Substance INDUCED  Dependence and abuse combined into spectrum  Changing face of “dependence” Substance Categories in DSM-5:  Alcohol, Caffeine, Cannabis, Hallucinogen, Inhalants, Opioids, Sedative/Hypnotics/Anxiolytics, Stimulants, Tobacco-Related, Other (or unknown) Substance, and Non-Substance-Related Disorders (Gambling)

25. THIS SECTION PROVIDES INFORMATION TO HELP YOU IN YOUR USE OF THE DSM-5. ADDITIONALLY, THIS SECTION OUTLINES THE STEPS IN WRITING A DIAGNOSIS ALONG WITH CASE STUDIES TO DIAGNOSE USING THE DSM-5. Using the DSM-5

26. Tips in Using DSM-5 The DSM-5 is a GUIDE that requires clinical judgment. Use the whole manual. Take it one step at a time. Exercise diagnostic hygiene.  Diagnosis is drawn from your case formulation.  Use diagnostic hierarchies for differential diagnosis.  Watch and wait if you are unsure.  Check how your diagnosis stands the test of time.

27. Steps in Writing a Diagnosis 1. Locate the disorder that meets criteria. 2. Write out he name of the disorder:  Ex: Posttraumatic Stress Disorder 3. Now add any subtype or specifiers that fit presentation:  Ex: Posttraumatic stress disorder, with dissociative symptoms, with delayed expression 4. Add the code number (located either at the top of the criteria set or among the subtypes or specifiers):  All codes are ICD codes. Two code numbers are listed, one in bold (ICD-9) and one in parentheses (ICD-10), for example, 309.81 (F43.10). Use the ICD-10 codes starting October 1, 2014. 5. Order of multiple diagnoses: The focus of treatment or reason for visit is listed first, followed by the other diagnoses in descending order of clinical focus.

28. Now it’s your turn … You have two case studies. Starting with the first case, Mikayla, take the time to read through and determine the issues faced by Mikayla.  Using the DSM handouts, give Mikayla the diagnosis you think is appropriate. Once Mikayla’s diagnosis is complete, move on to the next case, Tracey, and provide a diagnosis for her as well.

29. Just a little funny …

30. References American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorder-IV Text Revision. Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Hawkins, J. (2013, September 11). Personal interview.