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DSM-5: Introduction to Classification, Criteria and, Use Qualis Behavioral Health Conference
April 23, 2014
Wandal W. Winn, M.D.Regional Medical DirectorQualis Health
4/21/2014, W. W. Winn, M.D.
IntroductionThis presentation is:
Introductory in nature;
Not a basic course on DSM-5;
Assumes some familiarity with psychiatric diagnostics;
For both clinical and administrative staff; and
For both mental health and non-mental health staff.
.
High rates of comorbidity
High use of NOS category
Treatment non-specificity
Inadequate laboratory markers / tests
Hindrance of research progress
Inconsistencies with ICD classification (ICD-9 -> ICD-10)
Desire for improved validity
Desire for etiology rather and descriptive drive schema
New data and new developments
Growing Problems with DSM-IV
.
New Data / Developments
.
Are there data in these areas that can be helpful in developing/changing/refining diagnoses?
Cognitive or behavioral science
Family studies and molecular genetics
Neuroscience—NIMH RDoC Program
Functional and structural imaging
International participation in criteria development
APA/WHO/NIH Diagnosis Research Planning Conferences: Participant Distribution
U.S.A., 194
Latin America, 16
Western Pacific, 32
Canada, 12
Africa, 9
South-East Asia, 10
Europe, 119
Eastern Mediterranean, 5
AfricaKenya, 2Nigeria, 3South Africa, 4
Latin AmericaArgentina, 2Brazil, 4Chile, 3Mexico, 5Puerto Rico, 2
Eastern MediterraneanBahrain, 1Israel, 3Lebanon, 1
EuropeBelarus, 1Belgium, 2Denmark, 4Estonia, 1France, 3Germany, 11
Europe (Cont)Greece, 1Hungary, 1Italy, 5Luxembourg, 1Netherlands, 12Norw ay, 2Russia, 4Spain, 5Sw eden, 4Sw itzerland, 21UK, 41
South-East AsiaIndia, 5Pakistan, 2Sri Lanka, 1Thailand, 2
Western PacificAustralia, 9China, 9Japan, 8Korea, 3New Zealand, 3
- 397 Participants- 39 Countries- 16 Developing Nations- 51% Non-US Participants- 10% Developing Nation Paticipants
.
The “Bible”
. . .
.
. . . and its children
Case formulation
Definition of a mental disorder
Clinical significance criteria
Structure of disorder chapters
ICD-9-CM and ICD-10-CM coding
Making a diagnosis
Uses of DSM-5
.
DSM-5 Structure
Section I: DSM-5 Basics
Section II: Essential Elements: Diagnostic Criteria and Codes
Section III: Emerging Measures and Models
Appendix
Index
.
Section I
Brief DSM-5 developmental history
Guidance on use of the manual
Definition of a mental disorder
Cautionary forensic statement
Brief DSM-5 classification summary
.
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 the 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.
Definition of a Mental Disorder
Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association.
Until incontrovertible etiological or pathophysiological mechanisms are identified to fully validate specific disorders or disorder spectra, the most important standard for the DSM-5 disorder criteria will be their clinical utility.
The diagnosis of a mental disorder should have clinical utility: it should help clinicians to determine prognosis, treatment plans, and potential treatment outcomes for their patients. However, the diagnosis of a mental disorder is not equivalent to a need for treatment.
Definition of a Mental Disorder
.Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association.
The validation of diagnostic criteria for discrete categorical mental disorders in DSM-5 included the following types of evidence:
Antecedent validators (similar genetic markers, family traits, temperament, and environmental exposure);
Concurrent validators (similar neural substrates, biomarkers, emotional and cognitive processing, and symptom similarity); and
Predictive validators (similar clinical course and treatment response).
Definition of a Mental Disorder
.Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association.
Sequence of Quality Care
Data
Dx
Rx
Response
Criteria
Subtypes and/or specifiers
Severity
Codes and recording procedures
Explanatory text: diagnostic and associated features; prevalence; development and course; risk and prognosis; culture- and gender-related factors; diagnostic markers; functional consequences; differential diagnosis; comorbidity
Structure of Section II
.
Administer cross-cutting assessments (suggested);
Administer WHODAS 2.0 (suggested) = Semi-replacement for Axis V;
Conduct clinical interview;
Determine whether or not diagnostic threshold is met;
Consider subtypes and/or specifiers.
Making a Diagnosis
.
Consider contextual information, disorder text (e.g., course, differential), distress, clinician judgment;
Diagnoses given as a list; no Axis I-V!
Administer severity assessments (suggested);
Apply codes and follow instructions as per coding and recording procedures;
Develop treatment plan and outcome monitoring approach.
Making a Diagnosis
.
Cautionary Note – Clinical Use
Diagnostic criteria are offered as guidelines for
making diagnoses, and their use should be
informed by clinical judgment. On the basis of
the clinical interview, text descriptions, criteria,
and clinician judgment, a final diagnosis is made.
Cautionary Note - Forensic Use“However, the use of DSM-5 should be informed by an awareness of
the risks and limitations of its use in forensic settings. In most
situations, the clinical diagnosis of a DSM-5 mental disorder . . . does
not imply that an individual with such a condition meets legal criteria
for the presence of a mental disorder or a specified legal standard
(e.g., for competence, criminal responsibility, or disability). For the
latter, additional information is usually required beyond that contained
in the DSM-5 diagnosis.”
Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association.
Section II: Disorder Chapters
A. Neurodevelopmental DisordersB. Schizophrenia Spectrum and Other Psychotic
DisordersC. Bipolar and Related DisordersD. Depressive DisordersE. Anxiety DisordersF. Obsessive-Compulsive and Related DisordersG. Trauma and Stressor Related Disorders
.
Section II: Disorder Chapters
H. Dissociative DisordersJ. Somatic Symptom and Related DisordersK. Feeding and Eating DisordersL. Elimination DisordersM. Sleep-Wake DisordersN. Sexual DysfunctionsP. Gender Dysphoria
.
Section II: Disorder Chapters
Q. Disruptive, Impulse-Control and Conduct Disorders
R. Substance-Related and Addictive DisordersS. Neurocognitive DisordersT. Personality DisordersU. Paraphilic DisordersV. Other Disorders:
Medication-Induced Movement Disorders and Other Adverse Effects of Medication
Other Conditions That May Be a Focus of Clinical Attention
.
Section III: Purpose
For items that appear to have initial support in terms of clinical use but require further research before being officially recommended as part of the main body of the manual
Separate from diagnostic criteria, text, and clinical codes
(This separation clearly conveys that the content may be clinically useful and warrants review, but is not a part of an official diagnosis of a mental disorder and cannot be used as such.)
.
Section III: Emerging Measures and Models
Assessment Measures
Cultural Formulation
Alternative DSM-5 Model for Personality Disorders
Conditions for Further Study
.
Section III: Conditions for Further Study
Attenuated Psychosis Syndrome
Depressive Episodes With Short Duration Hypomania
Persistent Complex Bereavement Disorder
Caffeine Use Disorder
Internet Gaming Disorder
Neurobehavioral Disorder Due to Prenatal Alcohol Exposure
Suicidal Behavior Disorder
Non-suicidal Self-Injury
.
New & Eliminated DisordersNew Disorders:1.
Social (Pragmatic) Communication Disorder2.
Disruptive Mood Dysregulation
Disorder3.
Premenstrual Dysphoric Disorder (DSM�IV appendix)4.
Hoarding Disorder5.
Excoriation (Skin�Picking) Disorder6.
Disinhibited Social Engagement Disorder (split from Reactive Attachment Disorder)7.
Binge Eating Disorder (DSM�IV appendix)8.
Central Sleep Apnea (split from Breathing�Related Sleep Disorder)9.
Sleep‐Related Hypoventilation (split from Breathing�Related Sleep Disorder)10.
Rapid Eye Movement Sleep Behavior Disorder (Parasomnia
NOS)11.
Restless Legs Syndrome (Dyssomnia
NOS)12.
Caffeine Withdrawal (DSM�IV Appendix)13.
Cannabis Withdrawal14.
Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other Medical
Conditions)
15.
Mild Neurocognitive Disorder (DSM�IV Appendix)
Eliminated Disorders:1.
Sexual Aversion Disorder2.
Polysubstance�Related Disorder
Net Difference = +13
.
Changes in Specific DSM Disorder Numbers; Combination of New, Eliminated, and Combined
Disorders
DSM-IV DSM-5
Specific Mental Disorders* 172 157
*NOS (DSM-IV) and Other Specified/Unspecified (DSM-5) conditions are counted separately.
(net difference = -15)
Examples of Specific Disorders
Revisions and Rationales
Specific subtypes have been eliminated;
Catatonia is now a specifier for multiple disorders; and
At least one of two required symptoms must be delusions, hallucinations, or disorganized speech
Schizophrenia
.
Largely unchanged
Same subtypes
Axis II is eliminated
“Alternative model" is presented in section III
Personality Disorders
.
Elimination of the "bereavement exclusion" for major depression;
Dysthymic Disorder subsumed under the diagnosis of "Persistent Depressive Disorder”;
PMDD has been added to the "Depressive Disorders" chapter; and
Disruptive Mood Dysregulation Disorder (DMDD) added.
Depressive Disorders
.
Consolidation of Autism, Asperger’s, and Pervasive Developmental Disorder into "Autism Spectrum Disorder”;
ADHD added to the chapter;
Age of onset raised from 7 to 12; and
Threshold for diagnosis in adults reduced from 6 to 5 symptoms.
Neurodevelopmental Disorders
.
"Neurocognitive Disorders" replaces delirium, dementia, amnestic, and geriatric cognitive disorders;
Elevation of 10 etiological subtypes (e.g., fronto- temporal dementia, dementia with Lewy Bodies, etc.) to separate, independent disorders;
Addition of "Mild Neurocognitive Disorder” to this chapter and differentiated from Major by:
1) Single cognitive domain impairment and
2) Preservation of independence.
Neurocognitive Disorders
.
Separation of Anxiety Disorders into four distinct chapters:1) fear-based anxiety disorders (e.g., phobias);
2) disorders of obsessions or compulsions (e.g., OCD);
3) trauma-related anxiety disorders (e.g., PTSD);
4) dissociative disorders (e.g., Fugue, DID, etc.)
Panic now a specifier for any mental disorder
Panic and Agoraphobia now separate disorders
Social Phobia is now Social Anxiety Disorder
Anxiety Disorders
.
Mental Retardation renamed Intellectual Disability (Intellectual Developmental Disorder)
Greater emphasis on adaptive functioning deficits rather than IQ scores alone
Intellectual Disability
.
New Chapter
PTSD moved from Anxiety Disorders chapter to Trauma and Stressor Related Disorders
Adjustment Disorders now included in Trauma and Stressor Related Disorders
Trauma & Stressor Related Disorders
.
Moved to new TSRD chapter;
Stressor criteria (Criterion A) are more explicit (e.g., elimination of “non-violent death of a loved one” as a trigger) and subjective reaction (Criterion A2) is eliminated;
Expansion to four symptom clusters (intrusion symptoms; avoidance symptoms; negative alterations in mood and cognition; alterations in arousal and reactivity), with the avoidance/numbing cluster divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood;
Separate criteria are now available for PTSD occurring in preschool-age children (i.e., 6 years and younger).
Posttraumatic Stress Disorder
.
Consolidation of Substance Abuse with Substance Dependence into a single disorder called Substance Use Disorder;
Removal of one DSM-IV abuse criterion (legal consequences) and addition of a new criterion for SUD diagnosis (craving or strong desire or urge to use the substance).
Substance Use Disorder
.
Section III: Optional Measures Recommended for Further Study and Evaluation
Level 1 Cross-Cutting Symptom Measures
Referred to as “cross-cutting” because it calls attention to symptoms relevant to most, if not all, psychiatric disorders (e.g., mood, anxiety, sleep disturbance, substance use, suicide)
Self-administered by patient
13 symptom domains for adults
12 symptoms domains for children 11+, parents of children 6+
Brief—1-3 questions per symptom domain
Screen for important symptoms, not for specific diagnoses (i.e., “cross-cutting”)
.
.
.
Level 2 Cross-Cutting Measure
Completed when the corresponding Level 1 item is endorsed at the level of “mild” or greater (for most but not all items, i.e., psychosis and inattention)
Gives a more detailed assessment of the symptom domain
Largely based on pre-existing, well-validated measures, including the SNAP-IV (inattention); NIDA-modified ASSIST (substance use); and PROMIS ® forms (anger, sleep disturbance, emotional distress)
.
Example of a Level 2 Cross-cutting Assessment: SleepPlease respond to each item by choosing one option per question.
In the past SEVEN (7) DAYS....Not at all A little
bitSomewhat Quite a
bitVery much
My sleep was restless.
1
2
3
4
5
I was satisfied with my sleep.
5
4
3
2
1
My sleep was refreshing.
5
4
3
2
1
I had difficulty falling asleep.
1
2
3
4
5
In the past SEVEN (7) DAYS.... Never Rarely Sometime s
Often Always
I had trouble staying asleep.
1
2
3
4
5
I had trouble sleeping.
1
2
3
4
5
I got enough sleep.
5
4
3
2
1
In the past SEVEN (7) DAYS… Very Poor Poor Fair Good Very goodMy sleep quality was...
5
4
3
2
1
World Health Organization Disability Assessment Schedule (WHODAS 2.0)
Recommended (but not required) assessment for disability
Corresponds to disability domains of ICF;
For use in all clinical and general population groups;
Tested world-wide and in DSM-5 Field Trials;
36 questions, self-administered with clinician review;
For Adult Patients (child version developed by DSM-5, not yet approved by WHO).
.
WHODAS Domains
Understanding and communicating;
Getting around;
Self Care;
Getting along with people;
Life activities (household, work, & school);
Participation in society.
.
Coding Aspects of DSM-5
For more information about CMS acceptance of DSM-5 and ICD-9-CM and ICD-10-CM codes, visit their online FAQ at: https://questions.cms.gov/faq.php?id=5005&faqId=1817
For more information about DSM-5 implementation, a detailed Frequently Asked Questions document can be found at www.DSM-5.org
Questions not addressed by the online FAQs can be submitted to the APA through the Website.
Coding Questions?
.
DSM-5Questions
&Answers
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