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Forensic Behavioral Associates DSM 5 Changes: an overview

Forensic Behavioral Associates DSM 5 Changes: an overview. Presenter: James H. Andrews, LCSW, BCD. SW 2065: HBMH - DSM5 Material. Diagnostic Statistical Manual. 2. SW 2065: Human Behavior – Mental Health Use of the DSM5 in Practice. SW 2065: HBMH - DSM5 Material.

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Forensic Behavioral Associates DSM 5 Changes: an overview

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  1. Forensic Behavioral AssociatesDSM 5 Changes: an overview Presenter: James H. Andrews, LCSW, BCD

  2. SW 2065: HBMH - DSM5 Material Diagnostic Statistical Manual 2

  3. SW 2065: Human Behavior – Mental HealthUse of the DSM5 in Practice

  4. SW 2065: HBMH - DSM5 Material Diagnostic Statistical Manual DSM-I published in 1952. Subjective diagnosis. DSM-II published in 1968. Subjective diagnosis. 1974 homosexuality removed DSM-III published 1980. Objective diagnosis. DSM-III-R published in 1987. DSM-IV published in 1994. DSM-IV-TR published in 2000. DSM5 published July 2013 13 diagnostic workgroups. 6 issues study groups. Harmonization between the DSM and ICD (International Classification of Diseases) coding 4

  5. DSM5 Changes: an overview DSM5 Revision Process REVIEW AND UPDATE Work Groups (13) ADHD and Disruptive Behavior Disorders Anxiety, Obsessive-Compulsive Spectrum, Post-Traumatic and Dissociative Disorders Childhood and Adolescent Disorders Eating Disorders Mood Disorders Neurocognitive Disorders Neurodevelopmental Disorders Personality and Personality Disorders Psychotic Disorders Sexual and Gender Identity Disorders Sleep-Wake Disorders Somatic Symptom Disorders Substance-Related Disorders 5

  6. DSM5 Changes: an overview DSM5 Summary of Major Changes Number of Diagnoses DSM-IV-TR = 172 DSM5 = 157 Net diff = -15 New & eliminated disorders net difference = +13 Defense Mechanisms removed 27 defense mechanisms & coping styles removed Though ‘defense mechanism’ as a term is listed in the Technical Glossary Multi-Axial System removed Single or No-Axis system with subtypes/specifiers introduced ICD coding system transition 9  10  11 (2014  2015) Complete transition to ICD alpha-numeric system by ICD 11 in 2015 Criteria for change Higher standard was set then previous editions; predominantly a research focus. Issues of use Category changes, life span and developmental perspective , forensic settings, ethnic/cultural focus, shift from functioning (GAF) to disability rating and provision of assessment tools.. 6

  7. DSM5 Changes: an overview DSM5 Summary of Major Changes New disorders in DSM5 (n=15) 1. Social (Pragmatic) Communication Disorder 2. Disruptive Mood Dysregulation Disorder 3. Premenstrual Dysphoric Disorder (DSM-IV appendix) 4. Hoarding Disorder 5. Excoriation (Skin-Picking) Disorder 6. 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) 7

  8. DSM5 Changes: an overview DSM5 Summary of Major Changes New disorders in DSM5 (n=15) 11. Restless Legs Syndrome (Dysomnia NOS) 12. Caffeine Withdrawal (DSM-IV Appendix) 13. Cannabis Withdrawal 14. Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other Medical Conditions) 15. Mild Neurocognitive Disorder (DSM-IV Appendix) Eliminated disorders in DSM5 1. Sexual Aversion Disorder 2. Polysubstance-Related Disorder 8

  9. DSM5 Changes: an overview DSM5 Summary of Major Changes Combined/merged Disorders in DSM5 (n=15) 1. Language Disorder (Expressive Language Disorder & Mixed Receptive Expressive Language Disorder) 2. Autism Spectrum Disorder (Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder, & Rett’s disorder—PDD-NOS is in the NOS count) 3. Specific Learning Disorder (Reading Disorder, Math Disorder, & Disorder of Written Expression) 4. Delusional Disorder (Shared Psychotic Disorder & Delusional Disorder) 5. Panic Disorder (Panic Disorder Without Agoraphobia & Panic Disorder With Agoraphobia) 6. Dissociative Amnesia (Dissociative Fugue & Dissociative Amnesia) 7. Insomnia Disorder (Primary Insomnia & Insomnia Related to Another Mental Disorder) 8. Non-Rapid Eye Movement Sleep Arousal Disorders (Sleepwalking Disorder & Sleep Terror Disorder) 9

  10. DSM5 Changes: an overview DSM5 Summary of Major Changes Combined/merged Disorders in DSM5 (n=15) 9. Alcohol Use Disorder (Alcohol Abuse and Alcohol Dependence) 10. Cannabis Use Disorder (Cannabis Abuse and Cannabis Dependence 11. Inhalant Use Disorder (Inhalant Abuse and Inhalant Dependence) 12. Opioid Use Disorder (Opioid Abuse and Opioid Dependence) 13. Stimulant Use Disorder (Amphetamine Abuse; Amphetamine Dependence; Cocaine Abuse; Cocaine Dependence) 14. Stimulant Intoxication (Amphetamine Intoxication and Cocaine Intoxication) 15. Stimulant Withdrawal (Amphetamine Withdrawal and Cocaine Withdrawal) 10

  11. DSM5 Changes: an overview DSM-IV-TR 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.1 Socially deviant behavior (e.g. political, religious, or sexual) and conflicts that are primarily between individual and society are not mental disorders unless the deviance or conflicts results from a dysfunction in the individual, as described above.” (DSM5, p 20) What stands out to you in the above definition?? 11

  12. DSM5 Changes: an overview DSM-IV-TR 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.1 Socially deviant behavior (e.g. political, religious, or sexual) and conflicts that are primarily between individual and society are not mental disorders unless the deviance or conflicts results from a dysfunction in the individual, as described above.” (DSM5, p 20) 12

  13. DSM5 Changes: an overview DSM-IV-TR Classification System (old) Axis I: Clinical disorders. Schizophrenia, Mood, Substance Abuse. Axis II: Personality/Developmental disorders The personality disorders & Developmental Axis III: Medical conditions relevant to case. Any medical condition that impacts or contributes to case Axis IV: Psychosocial/environmental stressors. Family, economic, occupational, legal etc. Axis V: GAF=Global Assessment of Function 100 point scale range 100 (superior) thru 1 Persistent danger harming self or 0 Inadequate info 13

  14. DSM5 Changes: an overview DSM-IV-TR Classification System (old) Axis I: Clinical disorders. Schizophrenia, Mood, Substance Abuse. Axis II: Personality/Developmental disorders The personality disorders & Developmental Axis III: Medical conditions relevant to case. Any medical condition that impacts or contributes to case Axis IV: Psychosocial/environmental stressors. Family, economic, occupational, legal etc. Axis V: GAF=Global Assessment of Function 100 point scale range 100 (superior) thru 1 Persistent danger harming self or 0 Inadequate info 14

  15. DSM5 Changes: an overview DSM5 Classification System (new) Clinical Formulation Involves a careful clinical history Concise summary of the social, psychological and biological factors contributing to the mental disorder(s) Not sufficient to check off the symptoms Relevant severity and valence of individual criteria contribution as important Current diagnostic categories do not fully capture the full range of psychopathology possible “other specified” and/or unspecified categories 15

  16. DSM5 Changes: an overview DSM5 diagnosis system (new) Five digit system 123.45 (until 2015) Coordinated with ICD codes 123: indicate type of disorder XXX.4X and XXX.X5 are subtype and severity specifiers to more accurately record the diagnostic category and condition. Not all dx uses 5 digits, 311.0 Depression NOS GAF: Replaced with WHODAS – World Health Organization Disability Assessment Scale 16

  17. DSM5 Changes: an overview DSM5 diagnosis system (new) What is ICD? International Classification of Disease (WHO) ICD uses an alpha-numerical system 3-7 characters; DSM will use 6 All letters except ‘U’ used. First position is letter. Not case-sensitive DSM will mostly utilize F (Mental and behavioural disorders) Decimal after third character Provides more accuracy than DSM coding ICD9 codes were limited in capturing clinical data ICD10 far more accurate and comprehensive Implementation date ICD10: 10.01.2014 2015 – ONLY ICD codes in DSM The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). 17

  18. DSM5 Changes: an overview DSM5 Classification System (new) Diagnosis – formerly Axis I, II & III Stressors – formerly Axis IV now V & Z Codes DSM5 (pp. 715-727) Disability – formerly GAF now WHODAS score (pp. 745-748) Cross-Cutting Symptom Measures – various assessment tools in DSM5 (pp. 734-748) 18

  19. DSM5 Changes: an overview DSM5 Classification System (new) Diagnosis – formerly Axis I, II & III Multi-axial system removed DSM5 utilizes a non-axial documentation of diagnosis Separate notations for psychosocial and contextual factors (formerly Axis IV) and Disability (formerly Axis V = GAF) Axis III (related medical diagnosis) has been combined with former Axis I & II diagnosis in the listing of diagnoses Axis IV issues are addressed by ICD V-codes and ICD-10 Z codes. Axis V GAF scale is replaced by the WHODAS 2.0 score 19

  20. DSM5 Changes: an overview DSM5 Classification System (new) Elements of a diagnosis – formerly Axis I, II & III Diagnostic criteria are “guidelines” for making a diagnosis. Diagnostic criteria usage should be informed by clinical judgment. Severity & course specifiers are applied to denote the current presentation of the individual’s diagnosis. Only when full criteria are met, i.e. not in unspecified diagnoses Descriptors Severity: Mild, moderate, severe Descriptive features: With good insight, in controlled environment Course: In partial remission, in full remission, recurrent Final Diagnosis = clinical interview + text description + criteria met + clinician judgment 20

  21. DSM5 Changes: an overview DSM5 Classification System (new) Elements of a diagnosis – formerly Axis I, II & III Subtypes Mutually exclusive and jointly exhaustive phenomenological subgroupings in a diagnosis. Indicated by the instruction – “Specify whether. . . . “ in the criterion set. Specifiers Are not intended to be mutually exclusive nor jointly exhaustive so more than one may be given. Indicated by the instruction “Specify . . . .” or Specify if . . . “ in the criteria set. The fifth digit can sometimes serve this purpose. However the majority of subtypes and specifiers are codable in OCD 9 or 10 systems and must be indicated after the diagnostic label. 21

  22. DSM5 Changes: an overview DSM5 Classification System (new) Elements of a diagnosis – formerly Axis I, II & III Subtypes & Specifiers (cont’d) Diagnosis is applied to current presentation though past diagnoses in remission or recovered should be indicated. Specifiers indicating course should be listed after the diagnosis. Severity specifiers are often provided to guide clinicians in rating – intensity, frequency, duration, symptom count or other severity indicators. Descriptive features specifiers provided in the criteria set can provide additional information that can inform treatment planning. NOTE: Not all disorders include specifiers for course, severity, and/or descriptives. 22

  23. DSM5 Changes: an overview DSM5 Classification System (new) Elements of a diagnosis – formerly Axis I, II & III NOS replaced by “Other Specified” or “Unspecified” pp.15-16 Other Specified: Allows the clinician to present the reason the client presentation does not meet diagnostic class criteria. Format: record the diagnosis name followed by the specific reason, e.g. “Other specified depressive disorder, depressive episode with insufficient symptoms”. Unspecified: The clinician may choose not to indicate the reason the criteria are not met for a disorder. Format: record the diagnosis as for example :unspecified depressive disorder”. 23

  24. DSM5 Changes: an overview DSM5 Classification System (new) Elements of a diagnosis – formerly Axis I, II & III Principal diagnosis The principal diagnosis is the condition which is chiefly responsible for the client's presentation to treatment and will be the primary focus of treatment and intervention. The principal diagnosis is indicated by listing it first with the balance of disorders listed in order of focus of attention and treatment. If the principal diagnosis is a mental disorder “due to another medical condition”, then the medical condition must be listed first.1 Best practice: the principal diagnosis is followed by the notation “Principal Diagnosis) or “Reason for Visit”. NOTE: In dual-diagnosis or co-occurring treatment, under PA law, the principal diagnosis MUST be a substance use disorder. 24

  25. DSM5 Changes: an overview DSM5 Classification System (new) Elements of a diagnosis – formerly Axis I, II & III Provisional diagnosis – two uses FIRST: When there a strong presumption that full criteria will be met but sufficient information currently lacking for a firm diagnosis. Format: The term “Provisional” follows the diagnostic label, e.g. Post-Traumatic Stress Disorder (Provisional) SECOND When the differential diagnosis of a disorder depends exclusively on the duration of the illness. Format: The term “Provisional” follows the diagnostic label, e.g. Schizophrenia (Provisional) 25

  26. DSM5 Changes: an overview DSM5 Classification System (new) Elements of a diagnosis – formerly Axis I, II & III Coding & Reporting procedures Each disorder is delineated by both a Diagnostic or nominal label, and a Statistical or numerical code; often used for data collection and billing purposes (i.e. ICD 9 & 10 coding). The diagnostic designation is incomplete unless BOTH designations are used. ICD-10: Adoption in US will occur 10/01/2014 Parenthetical codes inDSM5 should not be utilized until that time. For 2015 and thereafter, only the current ICD codes will be listed in the DSM. 26

  27. DSM5 Changes: an overview DSM5 Classification System (new) Stressors – formerly Axis IV; now V & Z Codes DSM5 DSM5 pp 715-727 for detail. Broad categories include: Problems related to family upbringing Other problems related to primary support group Child maltreatment and neglect problems Adult maltreatment and neglect problems Educational problems Occupational problems Housing problems Economic problems Other problems related to social environment Problems related to crime or interaction with legal system Other health service encounters for counseling and advice Problems related to other psychosocial, personal and environmental circumstance Problems related to access to medical and other health care Non-adherence to medical treatment 27

  28. DSM5 Changes: an overview DSM5 Classification System (new) Assessment of Disability: formerly GAF now WHODAS World Health Organization Disability Assessment Schedule 2.0 Recommended (but not required) assessment for disability. . . yet it’s the one included in the DSM5. . . Corresponds to International Classification of Functioning (ICF).1 For use in all clinical and general population groups Tested world-wide through DSM5 field trials 28

  29. DSM5 Changes: an overview DSM5 Classification System (new) WHODAS 2.0 36 questions self administered with clinical social work interview For adult patients Child version developed by DSM5 Taskforce is pending WHO approval Domains: 6 Understanding and communicating Getting around Self care Getting along with other people Life activities Household Work or school Participation in society 29

  30. DSM5 Changes: an overview DSM5 Classification System (new) Assessment – Cross-Cutting Symptom Measures Level 1: Calls attention to symptoms relevant to most psychiatric disorders. 13 Symptom domains for adults 12 symptoms domains for children aged 11+ and for parents of children 6-11. Brief as there are 1-3 questions per symptom domain Screens for important symptoms, not specific diagnoses Self administered by patient 30

  31. DSM5 Changes: an overview DSM5 Classification System (new) Assessment – Cross-Cutting Level 1: 31

  32. DSM5 Changes: an overview DSM5 Classification System (new) Assessment – Cross-Cutting Level 2: Used when the corresponding level 1 assessment ranks as mild or greater. Used to give a more detailed assessment of the given symptom domain. 32

  33. DSM5 Changes: an overview DSM5 Classification System (new) Assessment – Cross-Cutting Level 2: 33

  34. DSM5 Changes: an overview DSM5 Classification System (new) Critical Caveats for diagnosing: There must be “clinically significant disturbance”, “significant distress or disability” or “dysfunction in the individual”. The disturbance, distress, disability or dysfunction is not attributable to physiological effects of a substance (used as prescribed, abused or used illicitly). The disturbance, distress, disability or dysfunction is not attributable to some other medical condition. 34

  35. DSM5 Changes: an overview DSM5 Classification System (new) Developmental & Lifespan organization Diagnoses that reflect developmental processes early in life Diagnoses that typically manifest in adolescence young adulthood Diagnoses that usually manifest in adulthood and later life 35

  36. DSM5 Changes: an overview DSM5 Classification System (new) Cultural issues Disorders are defined in relation to cultural social and familial norms. Experience and expression of symptoms, signs and behaviors are viewed through the interpretative framework of culture. The decision that a given behavior is abnormal requires intervention and/or treatment is dependent upon cultural norms. DSM5 Cultural Concepts Cultural syndrome: a cluster of group of symptoms not viewed by the native culture as an illness but recognized by external observers. Cultural idiom of distress: a linguistic term, phrase or way of talking about distress in a culture independent of an illness or disorder. Cultural explanation of perceived cause: a label, attribution of feature that provides a culturally conceived cause for an illness. 36

  37. DSM5 Changes: an overview DSM5 Classification System (new) Gender differences Sex and gender differences are applicable to several disorders in the DSM5 Sex differences: variations of individual’s reproductive organs and XX/XY chromosomal distribution Gender differences: variations resulting from both an individual's biological sex and self-representation of one’s perceived gender Gender influences illness determines risk, moderates risk of development and likelihood of particular symptoms being experienced. 37

  38. DSM5 Changes: an overview DSM5 Classification System (new) Online enhancements http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures Tablet app available iTunes - $69.99 (regular updates included) Regular online updates will be maintained. DSM5 online subscription from psychiatryonline.org APA Member: $291 APA Nonmember: $420 annually 38

  39. DSM5 Changes: an overview DSM5 Classification System (new) Cautionary Statement for Forensic Use of DSM5 DSM5 is a reference tool for courts in determining forensic consequences of mental disorders. There is an imperfect fit between the questions of concern for the law and clinical diagnosis. Diagnosis does not imply a specific level of impairment or disability. Diagnosis does not carry any implication regarding culpability, causes of behavior, behavioral control (or lack of) or aspects of control at a particular time (e.g. at commission of an alleged crime). 39

  40. DSM5 Changes: an overview DSM5 Section Organization (new) 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 40

  41. DSM5 Changes: an overview DSM5 Section Organization (new) Section II: Chapter Structure – 20 Disorders Neurodevelopmental Disorders (31) Schizophrenia Spectrum and Other Psychotic Disorders (87) Bipolar and Related Disorders (123) Depressive Disorders (155) Anxiety Disorders (189) Obsessive-Compulsive and Related Disorders (235) Trauma- and Stressor-Related Disorders (265) Dissociative Disorders (291) 41

  42. DSM5 Changes: an overview DSM5 Section Organization (new) Section II: Chapter Structure – continued Somatic Symptom and Related Disorders (309) Feeding and Eating Disorders (329) Elimination Disorders (355) Sleep-Wake Disorders (361) Sexual Dysfunctions (423) Gender Dysphoria (451) Disruptive, Impulse-Control, and Conduct Disorders (461) 42

  43. DSM5 Changes: an overview DSM5 Section Organization (new) Section II: Chapter Structure – continued Substance-Related and Addictive Disorders (481) Neurocognitive Disorders (591) Personality Disorders (645) Paraphilic Disorders (685) Other Disorders (707) Medication-Induced Movement Disorders and Other Adverse Effects of Medication (709) Other Conditions that may be a Focus of Clinical Attention (715) 43

  44. DSM5 Changes: an overview DSM5 Chapter Organization (new) Section III: Purpose Section III serves as a designated location 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. This separation 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. 44

  45. DSM5 Changes: an overview DSM5 Chapter Organization (new) Section III: Emerging Measures and Models Assessment Measures Cultural Formulation Alternative DSM-5 Model for Personality Disorders 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 45

  46. DSM5 Changes: an overview DSM5 Chapter Organization (new) Appendix: Content Separate from Section III is an Appendix, which includes Highlights of Changes From DSM-IV to DSM-5 Glossary of Technical Terms Glossary of Cultural Concepts of Distress A list of DSM-5 Diagnoses and Codes A list of ICD-9-CM codes A list of ICD-10-CM codes A crosswalk of the ICD-9-CM to the ICD-10-CM DSM-5 Advisors and Other Contributors 46

  47. DSM5 Changes: an overview QUESTIONS 47

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