CMASA2016Stellenbosch

DrDavidSwingler

02June2016

Acknowledgements

Overview� DSM-5

� History&development� What’snew�  Concepts

� A‘speed-dating’surfthroughthedisordersWithparticularreferencetoconditionsofinteresttoCaseManagerssuchasADHD,Depression,BipolarDisorder,SubstanceUseandNeurocognitiveDisorders

DSM–abriefhistory� USA1840Census=idiocy&insanity� USA1880Census=7disorders� DSM-I(1952)AdolfMeyer/ICD-6=26� DSM-II(1968)‘reaction’withdrawn/ICD-8� DSM-III(1980)Newsystems/ICD-9� DSM-III-R(1987)� DSM-IV(1994)ApproximationwithICD-10� DSM-IV-TR(2000)� DSM-5(2013)ICD-11due2017/8

Organisa6onalStructure� HarmonizationwithICD-11

�  IncludesICD-9-CMandICD-10-CMcodes� Developmental/Lifespanapproach

�  SequentialOrderstartingwithNeurodevelopmentalDisorders,endingwithNeurocognitiveDisorders

� Dimensionalapproach�  Spectra�  Personality

TheMul6-AxialSystem–RIP�  Nonaxialdocumentationofdiagnosis(formerlyAxisI,IIandIII)

�  PrincipalDiagnosis:Theconditionchieflyresponsibleforcurrentpresentation.

�  Followedbyothersinorderoffocusofattentionandtreatment.�  Canuse“provisional”asaspecifierwherethereisastrong

presumptionthatfullcriteriawillbemet.�  Recordimportantpsychosocialandcontextualfactors(formerlyAxisIV)usingICD-9-CMVcodesorICD-10-CMZcodes

�  Disability(formerlyAxisV):GAFdropped.WHODAS2.0included‘forfurtherstudy’.�  36item,self-administeredscale.�  Ratesdifficultyinspecificareasoffunctioninginpast30days.�  Simpleorcomplexmethodsforcalculatingsummaryscore.

Chapters–1�  NeurodevelopmentalDisorders�  Schizophrenia-SpectrumandOtherPsychoticDisorders�  BipolarandRelatedDisorders�  DepressiveDisorders�  AnxietyDisorders�  Obsessive-CompulsiveandRelatedDisorders�  TraumaandStressor-RelatedDisorders�  DissociativeDisorders�  SomaticSymptomandRelatedDisorders�  FeedingandEatingDisorders�  EliminationDisorders�  Sleep-WakeDisorders�  SexualDysfunctions

Chapters–2�  GenderDysphoria�  Disruptive,Impulse-Control,andConductDisorders�  Substance-RelatedandAddictiveDisorders�  NeurocognitiveDisorders�  PersonalityDisorders�  ParaphilicDisorders�  OtherMentalDisorders� Medication-InducedMovementDisordersandOtherAdverseEffectsofMedication

�  OtherConditionsThatMayBeaFocusofClinicalAttention

EmergingMeasuresandModels�  AlternativeDSM-5ModelforPersonalityDisorders�  Conditionsforfurtherstudy

�  AttenuatedPsychosisSyndrome�  DepressiveEpisodeswithShort-DurationHypomania�  PersistentComplexBereavementDisorder�  CaffeineUseDisorder�  InternetGamingDisorder�  NeurobehaviouralDisorderAssociatedwithPrenatalAlcoholExposure

�  SuicidalBehaviorDisorder�  Non-suicidalSelf-Injury

NeurodevelopmentalDisorders� MentalRetardationbecomesIntellectualDisability

� AutismSpectrumDisorderencompasses(social/behaviour)�  Autism�  Asperger’s�  Rett’s�  PervasivedevelopmentaldisorderNOS

NeurodevelopmentalDisorders� ADHD

�  ‘Examplesaddedtofacilitateapplication’ofcriteria�  ‘Oftenhasdifficultywaitingturn(e.g.waitinginline)’

�  Ageofonsetrelaxedto<12(c.f.7years)�  Subtypesreplacedwithspecifiers�  ComorbiditywithAutismSpectrumnowallowed�  ‘Adult’variantformalisedandlessrestrictivelyat5/9(c.f.6)

SchizophreniaSpectrumtechnicalchanges

�  Schizophrenia*Spectrum&OtherPsychoticDisorders

� CriterionA�  SZsubtypeseliminated�  SchizoaffectiveDisorder� DelusionalDisorder� Catatonia�  Schizotypal(Personality)Disorder

DSM-5‘Mood’Disorders� DSM-IVMoodDisorderssplitinto

� BipolarandRelatedDisorders� DepressiveDisorders

� Twonewandcontentiousdisorders� DisruptiveMoodDysregulationDisorder� PremenstrualDysphoricDisorder

BipolarandRelatedDisorders�  BipolarIDisorder

�  Definedbymania�  Maniadefinedby

�  Elevated/expansiveORirritablemoodfor7days(orhospitalised)�  New:ANDincreasedgoaldirectedactivityORenergy�  PLUS3(4)of7symptoms

�  BipolarIIDisorder�  RootedinMajorDepressiveEpisode/s�  WithHypomanicEpisode/s,definedby

�  Elevated/expansiveORirritablemoodfor4days(orhospitalised)�  New:ANDincreasedgoaldirectedactivityORenergy�  PLUS3(4)of7symptoms

DepressiveDisorders� MDE

� CriterionAunchanged�  5/9ofwhichatleastoneofdepressedmoodorlossofinterestorpleasurex2weeks

� MixedEpisodeexclusiondropped–‘specifier’�  ‘Distress/Dysfunction’criterion‘elevated’CtoB� BereavementexclusionDROPPED

�  Was2/12�  Nowa‘Note’with‘clinicaljudgement’discretion

� Dysthymianow‘PersistentDepressiveDisorder’� Foldedinto‘chronicmajordepressivedisorder’

NewDepressiveDisorders!�  DisruptiveMoodDysregulationDisorder

�  ‘Toaddressover-diagnosisofBipolarDisorder<18years’�  Temperoutbursts

�  Severe,recurrent�  Verbal&/orbehavioural�  Outofproportioninintensity/durationtosituation/provocation�  Inconsistentwithdevelopmentallevel�  >3/week�  Withbackgroundirritable/angrymood�  Foratleastayear,withno3/12periodevent-free�  Onset<10years�  Firstdiagnosis6-18years

�  ExclusionsandNotes…

NewDepressiveDisorders!� PremenstrualDysphoricDisorder

� A:Majorityofmenstrualcycles� Atleast5Sx(of11)fromB+Cbelow� Inlastweekpriortomenses� Improvewithinafewdaysofonsetofmenses

� Minimal/absentintheweekpostmenses

NewDepressiveDisorders!�  5of11symptomsforB&Ccombined�  B:Atleast1of4

�  Markedaffectivelability�  Markedirritabilityorangerorinterpersonalconflicts�  Markeddepressivemood/hopelessness/self-deprecation�  Markedanxiety/tension/beingkeyedup/onedge

�  C:Atleast1of7�  Decreasedinterestinusualactivity�  Difficultyconcentrating�  Lethargy�  Appetite,overeating,foodcravings�  Sleepdisturbance:hyper-,insomnia�  Overwhelmed,outofcontrol�  Physicalsymptoms:breast,joint/muscle,‘bloating’,GOW

AnxietyDisorderstechnicalchanges

� SpecificPhobia&SocialPhobia� Panicattacks:nowaspecifiertoallDSM-5� PanicDisorderandAgoraphobiaun-linked� SeparationAnxietyDisorderandSelectiveMutismnowfindahomehere

ObsessiveCompulsive&RelatedDisorders

� Obsessive-CompulsiveDisordertheanchor� BodyDysmorphicDisordersmovein� New:

� HoardingDisorder�  Excoriation(Skin-Picking)Disorder�  Substance/Medicationinduced� DuetoAnotherMedicalCondition

� Trichotillomaniagets(Hair-PullingDisorder)clarifier

Trauma-&Stressor-RelatedDisorders

�  Acute/PosttraumaticStressDisorder�  Trauma‘moreexplicit’�  ‘Disempowerment’requirementremoved�  Threeclusters

�  Re-experience�  Avoidance/Numbing�  Arousal

�  Becomesfour,as#2split�  Avoidance�  Persistentnegativealterationincognition&mood

�  Thresholdforchildren&adolescentslowered,now<6years

Soma6cSymptom&RelatedDisorders

DSM-5

AnorexiaNervosaDSMIV-TR:Refusaltomaintainbodyweightatoraboveaminimallynormalweightforageandheight(e.g.,weightlossleadingtomaintenanceofbodyweightlessthan85%ofthatexpected;orfailuretomakeexpectedweightgainduringperiodofgrowth)leadingtobodyweightlessthan85%ofthatexpected

DSM-5Restrictionofenergyintakerelativetorequirements,leadingtoasignificantlylowbodyweightinthecontextofage,sex,developmentaltrajectory,andphysicalhealth.Significantlylowweightisdefinedasaweightthatislessthanminimallynormalor,forchildrenandadolescents,lessthanthatminimallyexpected.

BulimiaNervosaDSM-5

A.  Recurrentepisodesofbingeeating…B.  Recurrentinappropriatecompensatory

behaviour…C.  Thebingeeatingandinappropriate

compensatorybehaviorsbothoccur,onaverage,atleastonceaweekfor3months.

D.  Self-evaluation…E.  Thedisturbancedoesnotoccurexclusively

duringepisodesofAnorexiaNervosa.

BingeEa6ngDisorderA.  Recurrentepisodesofbingeeating.Anepisodeofbingeeatingis

characterisedbybothofthefollowing:1.eatinglargeamounts…2.Asenseoflackofcontrolovereating…

A.  Thebingeeatingepisodesareassociatedwith3ormoreofthefollowing:

1.eatingmuchmorerapidlythannormal2.eatinguntiluncomfortablyfull3.eatinglargeamountsoffoodwhennotfeelingphysicallyhungry4.eatingalone/feelingembarrassedbyhowmuchoneiseating5.feelingdisgustedwithoneself,depressed,orveryguiltyafterward

B.  Markeddistressregardingbingeeatingispresent.C.  Thebingeeatingoccurs,onaverage,atleastonceaweekfor3months.D.  Thebingeeatingisnotassociatedwithrepeateduseofinappropriate

compensatorybehaviourasinbulimianervosaanddoesnotoccurexclusivelyduringthecourseofbulimianervosaoranorexianervosa

SLEEP-WAKE DISORDERS

DSM-5

Sleep-Wake Disorders (Previously Sleep Disorders)

DSM-IV-TR •  Primary Insomnia (name changed) •  Primary Hypersomnia (name changed) •  Narcolepsy (same name) •  Breathing-Related Sleep Disorder (divided into 3 disorders) •  Circadian Rhythm Sleep Disorder (name

changed) •  Nightmare Disorder (same name) •  Sleep Terror Disorder (combined into Non

REM Sleep Arousal Disorder) •  Sleepwalking Disorder (combined into Non

REM Sleep Arousal Disorder) •  Sleep Disorders Related to Another Mental

Disorder (removed) •  Sleep Disorders Due to a General Medical

Condition (removed) •  Substance-Induced Sleep Disorder (name

change)

DSM-5 •  Insomnia Disorder •  Hypersomnolence Disorder •  Narcolepsy •  Breathing-Related Sleep Disorder -  Obstructive Sleep Apnea Hypopnea -  Central Sleep Apnea -  Sleep-Related Hypoventilation •  Circadian Rhythm Sleep-Wake Disorder •  Non-Rapid Eye Movement Sleep Arousal

Disorder •  Nightmare Disorder •  Rapid Eye Movement Sleep Behaviour

Disorder •  Restless Legs Syndrome •  Substance/Medication-Induced Sleep

Disorder

Previously Substance-Related Disorders in DSM-IV

Substance Related and Addictive Disorders in DSM-5

Summary of Changes �  Removal of the distinction between substance “abuse” and “dependence”

in DSM-IV �  DSM-5: Criteria are provided for “substance use disorder” (SUD) – they

are a combination of “abuse” and “dependence” criteria from DSM-IV (that required a threshold of 1-2 for abuse, and 3 or more for dependence)

�  The threshold for SUD in DSM-5 is two or more (of 11) �  Severity of DSM-5 SUD is based on the number of criteria

Ø 2-3 criteria indicate a mild disorder Ø 4-5 criteria, a moderate disorder and Ø 6 or more a severe disorder

�  “Cannabis- & caffeine-withdrawal” are new for DSM-5

Summary continued �  Criteria groupings for Criterion A:

�  Impaired control 1-4 �  Social impairment 5-7 �  Risky use 8-9 �  Physiological i.e. tolerance and withdrawal 10-11

�  Lastly… �  Gambling Disorder included & Internet gaming is described �  Behavioural addictions: “sex addiction”, “exercise addiction”

and “shopping addiction” are not included due to insufficient peer-reviewed evidence on diagnostic criteria

Substance-Induced Disorders �  Remain the same for DSM-IV and DSM-5

SUBSTANCE INDUCED DISORDERS

Substance Intoxication and Withdrawal

Substance/Medication-Induced Mental Disorders

Neurocognitive Disorders of DSM-5

Major changes in DSM-5 DSM-IV-TR: Delirium, Dementia and Amnestic

disorders DSM-5: � Delirium retained � Dementia and Amnestic Disorders subsumed under

the newly named entity Major Neurocognitive Disorder – the term ‘dementia’ is not disallowed ‘where the term is standard’

� Addition of a new diagnostic category: “Minor Neurocognitive Disorder”

Delirium: main change DSM-IV

A.  Disturbance of consciousness (i.e.. reduced clarity of awareness of

the environment) with reduced ability to focus, sustain or shift attention

DSM-5

A.  Disturbance in attention (reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment).

Neurocognitive Disorders Major vs Mild

�  1. Severity �  Major and Mild NCDs exist on a spectrum of cognitive and functional

impairment

�  2. Independence �  Relates to the individual's level of independence in everyday functioning �  Mild NCD will have preserved independence �  Major NCD will have impairment of sufficient severity so as to interfere

with independence �  .

�  3. Usually a continuum with evolution �  The distinction between Major and Mild NCD is inherently arbitrary, and

the disorders exist along a continuum.

Major Neurocognitive Disorder Diagnostic Criteria

�  A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on: 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and 2. A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.

�  B. The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum,

requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications).

�  C. The cognitive deficits do not occur exclusively in the context of a delirium

�  D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

Mild Neurocognitive Disorder Diagnostic Criteria

•  A. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual motor, or social cognition) based on: 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function; and

2. A modest impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.

•  B. The cognitive deficits do not interfere with capacity for independence in everyday activities

(i.e., complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater effort, compensatory strategies, or accommodation may be required).

•  C. The cognitive deficits do not occur exclusively in the context of a delirium.

•  D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

Neurocognitive Disorders Domains Domain Tasks �  Complex attention Major: diminished, multiple stimuli

Mild: takes longer -------------------------------------------------------------------------------------------------------- �  Executive function Major: abandon complex activities

Mild: effort, multi-tasking -------------------------------------------------------------------------------------------------------- �  Learning/memory Major: repeat self in conversation

Mild: recent events, occasionally repeats -------------------------------------------------------------------------------------------------------- �  Language Major: anomia, paraphasias

Mild: naming, word finding -------------------------------------------------------------------------------------------------------- �  Perceptual-Motor Major: can’t drive, navigation, confused at dusk

Mild: notes, maps, follows, effort -------------------------------------------------------------------------------------------------------- �  Social cognition Major: insensitivity social contexts

Mild: subtle personality change, empathy

Major or Mild NCD: Specify… �  Alzheimer’s disease �  Frontotemporal lobar degeneration �  Lewy body disease �  Vascular disease �  Traumatic brain injury �  Substance/medication-induced �  HIV infection �  Prion disease �  Parkinson’s disease �  Huntington’s disease �  Another medical condition / Multiple aetiologies

Notdealtwith�  SexualDysfunctions� GenderDysphorias� ParaphilicDisorders� Disruptive,Impulse-Control,andConductDisorders� PersonalityDisorders� Medication-inducedMovementDisorders� V-codes� Conditionsforfurtherstudy

Q&A