DSM-5 Update: Transitioning to the Fifth Edition NASWIL October 28, 2013

1. DSM-5 Update:Transitioning to the Fifth EditionNASWILOctober 28, 2013 Susan McCracken, Ph.D. Private Practice & Adjunct Faculty susanm@uchicago.edu Stanley G. McCracken, Ph.D., LCSW, RDDP Senior Lecturer s-mccracken@uchicago.edu The University of Chicago School of Social Service Administration

2. Agenda • Introduction. Process of revision. General characteristics. • Structural, Conceptual, and Cross-cutting Changes • Dimensional approach • Severity Ratings and Assessment Tools • Spectra and clusters • Developmental Perspectives in DSM-5 • Changes to selected disorders and clusters • We will focus on DSM-5 changes to the DSM-IVTR. We will not cover all disorders. This workshop is not recommended for people preparing to take a licensing exam this year.

3. Process of Revision • DSM-5 represents the first major revision in 30 years. • Revisions of both DSM (5) and ICD (11 [2015]). Continuing effort to make DSM/ICD compatible • NIMH: Research Domain Criteria (RDoC). • Workgroups. Conferences. Field trials. APA website w/ updates & opportunity for feedback. • Both APA and WHO committed to making the DSM-5 and ICD-11 a “living document.” • Print and electronic versions plus a mobile app of diagnostic criteria for iOS and Android.

4. DSM-5 Structure • No more Axes I-V. Just list diagnostic codes. • There are still V codes ( Z codes in ICD-10CM). • 3 Sections and Appendix. • Section I, DSM-5 Basics: Introduction, Use of the Manual, Cautionary Statement for Forensic Use of DSM-5 • Section II, Diagnostic Criteria and Codes. • Section III, Emerging Measures and Models: Assessment Measures, Cultural Formulation, Alternative DSM-5 Model for Personality Disorders, Conditions for Further Study. • Appendix: Highlights of Changes from DSM-IV to DSM-5, Glossary of Technical Terms, Glossary of Cultural Concepts of Distress, etc.

5. Characteristics of DSM-5 • Final draft approved Dec. 1, 2012 and released May, 2013. • APA recommended implementation early 2014. Illinois DMH has not yet decided on a date. [Rumor: October, 2014 being considered???] • Coding: • Now: continue to use ICD-9CM (numbers only). • ICD-10CM scheduled for implementation in US in October, 2014. Use letter and number, e.g., F43.0. The specific code will depend on specifier. • ICD-11 due for release, 2015. Implementation???

6. Characteristics of DSM-5, cont. • DSM-5 website:http://www.psychiatry.org/dsm5 http://www.dsm5.org/Pages/Default.aspx • No more NOS. Instead: • Other specified _____ disorder • Other unspecified _____ disorder • Provisional diagnoses still allowed. • Many specifiers.

7. Diagnostic Groupings • Neurodevelopmental Disorders • Schizophrenia Spectrum and Other Psychotic Disorders • Bipolar and Related Disorders • Depressive Disorders • Anxiety Disorders • Obsessive-Compulsive and Related Disorders • Trauma- and Stressor-Related Disorders • Dissociative Disorders • Somatic Symptom and Related Disorders • Feeding and Eating Disorders • Elimination Disorders

8. Diagnostic Groupings, cont. • Sleep-Wake Disorders • Sexual Dysfunctions • Gender Dysphoria • Disruptive, Impulse-Control, and Conduct Disorders • Substance-Related and Addictive Disorders • Neurocognitive Disorders • Personality Disorders • Paraphilic Disorders • Other Mental Disorders • Medication-Induced Movement Disorders and Other Adverse Effects of Medication • Other Conditions that may be a Focus of Clinical Attention

9. Developmental Perspectives in DSM-5 • The full diagnostic manual provides many of the same informational features as did DSM IV but in expanded form – diagnostic criteria and recording codes with ICD 9 and 10, diagnostic features, description of symptoms, associated features supporting diagnosis, culture-related diagnostic issues, gender-related diagnostic issues, prevalence, and differential diagnoses. • New sections have been added (suicide risks, comorbidity) and applied to many different disorders. The addition of a developmental section, however, is a major thread throughout the DSM-5.

10. Developmental Perspective • DSM-5 diagnoses are anchored in the perspective that pathology in youth = deviation from developmental norms ( from delay in accomplishing developmental task to not accomplishing it at all). Diagnoses fall along a continuum or within a spectrum. • The “Development and Course” section for each disorder reflects a lifespan approach: • age at which typical symptoms present • detailed symptom presentation specific to each age group & descriptions of how presentations change over the lifespan • the trajectory over time of one disorder becoming another at a later point in time (fluidity of diagnoses)

11. Developmental Perspective (cont) • Risks and Prognostic Factors includes • Temperament, genetic or physiological factors • Descriptions of situations associated w/each age group in which the disorder would disrupt normal functioning • Expected long term outcome, points of increased risk, and course modifiers  improvement or stability • Recognition that changes in environment can moderate level of impairment in children (i.e. enabling parents as compared to non-enabling parents) • Associated Features section in DSM -5 • includes comprehensive information than DSM IV to support the diagnosis (medical, other behavioral or emotional signs, other common associations) as well as parent-child associations

12. Developmental Perspectives, cont. • Functional Consequences Section • Refers to consequences of having a disorder during different ages/stages of development • Comorbidity Section (greater number in DSM-5) • For some comorbidities, associations at different ages are highlighted • Some disorders in DSM-5 include: • Explicit descriptions of developmental manifestations as part of the diagnostic criteria for each disorder • Procedures for evaluating developmental subtypes of disorders

13. Dimensional Approach in DSM-5 • DSM-5 is shifting toward a more dimensional approach. • Disorders in several groups are structured or discussed as spectrum disorders or dimensions, e.g., Autism Spectrum, Mild and Major Neurocognitive Disorders.

14. Dimensional Assessment • Assessment measures placed in Section III. Available: http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures • Cross-cutting symptom measures. • Level 1 (Screening) brief survey of 13 (adults) or 12 (child and adolescent) symptom domains. • Adults: Depression, Anger, Mania, Anxiety, Somatic symptoms, Suicidal ideation, Psychosis, Sleep problems, Memory, Repetitive thoughts & behaviors, Dissociation, Personality functioning, Substance use. • Child/adolescent (6-17): Somatic symptoms, Sleep problem, Inattention, Depression, Anger, Irritability, Mania, Anxiety, Psychosis, Repetitive thoughts & behaviors, Substance use, Suicidal ideation/suicide attempt.

15. Dimensional Assessment, cont • Cross-cutting symptom measures, cont • Level 1 • Items rated on 5-point scale: 0=none/not at all; 1=slight or rare; <a day or two; 2=mild or several days; 3=moderate or >half the days; 4=severe or nearly every day. • Items rated >mild or >slight (Suicidal, Psychosis, Substance use; Inattention) or Yes/Don’t Know (Substance use and Suicidal ideation/suicide attempts-child/adol)  further assessment with relevant Level 2 measure. http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1

16. Dimensional Assessment, cont • Cross-cutting symptom measures. • Level 2. Detailed clinical inquiry. Currently available: • Adult: Depression, Anger, Mania, Anxiety, Somatic Symptom, Sleep Disturbance, Repetitive Thoughts and Behaviors, Substance Use. None currently available for: Dissociation or Psychosis (see Clinician-Rated Dimensions of Psychosis Symptom Severity). • Child (6-17) (Child Self-Report ages 11-17; Parent/Guardian-rated ages 6-17): Somatic Symptoms, Sleep Disturbance, Inattention, Depression, Anger, Irritability, Mania, Anxiety, Substance Use. None currently available for: Psychosis, Repetitive thoughts and behaviors, Suicidal ideation/suicide attempts. http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level2

17. Assessment, cont • Other Measures of Symptoms and Functioning • Disorder-specific Severity Measures • Adult: Depression, Separation Anxiety, Specific Phobia, Social Anxiety Disorder, Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, Post-traumatic Stress Symptoms, Acute Stress Symptoms, Dissociative Symptoms • Children S-R (11-17): Depression, Separation Anxiety, Specific Phobia, Social Anxiety Disorder, Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, Post-traumatic Stress Symptoms, Acute Stress Symptoms, Dissociative Symptoms • Clinician-rated: Severity of Autism Spectrum and Social Communication Disorders, Dimensions of Psychosis Symptom Severity, Severity of Somatic Symptom Disorder, Severity of Conduct Disorder, Severity of Oppositional Defiant Disorder, Severity of Nonsuicidal Self-Injury

18. Assessment, cont • Other Measures of Symptoms and Functioning • Disability Measures • World Health Organization Disability Schedule (WHODAS 2.0) 36 item self-administered. • World Health Organization Disability Schedule (WHODAS 2.0) 36 item proxy-administered. • Personality Inventories • Adult: Personality Inventory for DSM-5—Brief form (PID-5-BF)—Adult; Personality Inventory for DSM-5 (PID-5)—Adult; Personality Inventory for DSM-5-Informant form (PID-5-IRF)—Adult. • Child S-R (11-17): Personality Inventory for DSM-5—Brief form (PID-5-BF)—Child 11-17; Personality Inventory for DSM-5 (PID-5)—Child 11-17.

19. Assessment, cont • Other Measures of Symptoms and Functioning • Early Development and Home Background • For Parents of Children Ages 6–17: Early Development and Home Background (EDHB) Form—Parent/Guardian. • Clinician Rated: Early Development and Home Background (EDHB) Form—Clinician. • Cultural Formulation Interviews • Cultural Formulation Interview. • Cultural Formulation Interview—Informant version. • Supplementary Modules to the Core Cultural Formulation Interview (CFI). • The question is whether, how, and when will any of these be used, and who will require.(Too early to tell.)

20. Disorders Usually First Diagnosed in Childhood Disorders: Where are they ? What Changed? DSM IV DSM-5 “Disorders Usually First” has been eliminated and several disorders moved to new a group category - Neurodevelopmental Disorders which includes: MR -Renamed Intellectual Disability, changes in criteria One LD Renamed “Specific Learning Disorder” (specifiers w/ impairment in reading, in written expression, in math) Developmental Coordination Disorder ADHD • Disorders Usually First Diagnosed in Childhood and Early Adolescence…. • Mental Retardation • 3 Learning Disorders • Developmental Coordination Disorder • ADHD

21. Other Disorders Moved from “First Diagnosed.. in….” to “Neurodevelopmental Disorders” DSM IV DSM-5 Communication Disorders ELD and MRELD eliminated and subsumed under new dx “Language Disorder” Stuttering renamed “Childhood Onset Fluency Disorder” PD renamed “Speech-Sound Disorder” Motor Disorders subsection Specifiers added to Stereotypic Movement Dis.-w/ SI, w/out SI, assoc. w/ other known dis./med • Communication Disorders • Expressive Language Disorder (ELD) • Mixed Receptive-Expressive Language Disorder (MRELD) • Stuttering Disorder • Phonologic Disorder (PD) • Motor Skills/Tic Disorders • Tourettes, Dev. Coord Disord • Chronic Vocal & Motor Tics • Stereotypic Movement Disor.

22. More Disorders Moved from “Disorders First Seen” to Other Groups in DSM-5 DSM IV DSM-5 Included in Neurodevelopmental Disorders, all subsumed under Autism Spectrum Disorder except Rett’s which is a genetic disorder SAD & SM moved to Anxiety D. Pica & RD in “ Feeding & Eating Disorders ” & FDI new name “Restrictive Food Intake D” RAD in Trauma & Stress-Related D E & E in “Elimination Disorders” CD/ODD in “Disrupt, Impulse-C & Conduct Disorders” w/ IED • PDD’s (Autistic Disorder, Asperger’s, Childhood Disintegrative Disorder , Rett’s, PDD NOS) • Separation Anxiety D. and Selective Mutism • Pica, Rumination Disorder & Feeding D. of Infancy • Reactive Attachment Dis. • Encopresis & Enuresis • Conduct Disorder & ODD & Intermittent Explosive D.

23. List of Neurodevelopmental Disorders • Include the following disorders: • Intellectual Disability (Intellectual Development Disorder), Global Developmental Delay (children < 5) • Communication Disorders – • Language Disorder, Speech Sound Disorder, Childhood-Onset Fluency Disorder, Social Communication Disorder • Attention Deficit Hyperactivity Disorder • Specific Learning Disorder • Autism Spectrum Disorder • Motor Disorders • Developmental Coordination Disorder, Stereotypic Movement Disorder, Tic Disorders/Tourette’s Disorder

24. Changes in MR: Intellectual Disability • In DSM -5, IQ below 70 is no longer the only criteria • Severity based on functional ability, not IQ, or adaptive functioning in comparison with same age norms has been added as a criteria and must be assessed in 3 domains. (1) Conceptual deficits: language, reading, writing, math, reasoning, knowledge and memory (2) Social deficits: interpersonal communication skills, friendships, social judgment, empathy (3) Practical deficits: personal care, organizing school and work activities, money management, job duties Severity rating scale for each domain is based on the level of support required. Mild, Moderate, Profound

25. Changes in Criteria for ADHD • Required age on onset of sxs changed from 7 to 12 • Greater emphasis on identifying adults ( & sx suited to age) • Addition of sx descriptions more applicable to older teens and adults (“forgetful in keeping appointments or returning calls”) • Symptom threshold reduced to 5 for ages 17 and older, still 6 for children and younger teens • Symptom lists for hyperactive-inattentive and inattentive basically unchanged (sx description more age appropriate) • Cross-situational requirement increased to several symptoms in > 2 settings • Included in Neurodevelopmental Disorders to reflect brain development corrrelates w/ ADHD • Comorbid dx of ADHD & Autism Spectrum D. allowed

26. ADHD (cont) • Subtypes replaced with specifiers “presentations within the past 6 months predominantly_______” • Added duration of 6 months to the specifier “In partial remission” when full criteria were previously met but have not been met for past 6 mos., still evidence of impairment. • Severity ratings • Mild = no symptoms (or few) in excess of number required for diagnosis with minor impairments, • Moderate = functional impairment falls between mild and severe • Severe = more symptoms than required or several symptoms result in marked impairment in social, school or occupational areas

27. Communication Disorders • Language Disorder (new dx =ELD & RELD combined) • Difficulties in language acquisition and use of language across modalities including written, spoken and sign language • Difficulties are not better accounted for by intellectual disability, hearing or sensory impairment • Speech Sound Disorder (phonological disorder renamed) • difficulties with sounds articulation and voice quality impact behavior, ideas and attitudes of others • Childhood Onset Fluency Disorder (stuttering renamed) • Social (Pragmatic) Communication Disorder

28. Social (Pragmatic) Communication Disorder • New diagnosis characterized by difficulty in social uses of verbal and nonverbal communication in naturalistic contexts • Use of communication for greeting and sharing is not appropriate to the context • Impairment in ability to adjust communication to the needs of the listener or the context • Difficulties following the rules for conversation • Difficulties impact development of social relationships and can’t be explained by low abilities in areas of word structure and grammar

29. Social (Pragmatic) Communication Disorder • There are no repetitive patterns or restricted interests (i.e. criteria for ASD would not be met). • Language impairment is a common associated feature as is ADHD, behavior problems and specific learning disorders • Symptoms present in early childhood yet may not be fully manifested until social demands exceed capabilities • Replaces the PDD, NOS

30. Autism Spectrum Disorder (ASD) • The change from Pervasive Developmental Disorders (PDD) to Autism Spectrum Disorder and to that one diagnosis, ASD, was justified by the following research: • differentiation between Autism and the other DSM IV PDD’s (including Asperger’s ) as well as among the other PDD’s has been inconsistent, & often associated with severity, language level or IQ instead of features of the disorder. • PDD,NOS – too many, >50% of diagnosed PDD

31. Rationale for ASD: Research on Asperger’s • A key difference in DSM IV to discriminate between Autism and Asperger’s is that an individual with Asperger’s has no general delay in language and there is no significant delay in cognitive development or adaptive skills. • However, individuals with Asperger’s technically do meet the criterion for Autistic Disorder… “in individuals with no language delay, have marked impairment in the ability to initiate or sustain a conversation with others”.

32. DSM 5 Conclusions for ASD • The 3 defining areas of impairment (social deficits; communication deficits; and restricted, repetitive behaviors and interest) were reduced to 2 domains by combining social and communication to “social/communication deficits” and retaining the behavioral impairment domain (RRB’s). • Too difficult to separate social deficits from communication deficits  combine into one unit • Delays in language should be considered factors that influence symptoms rather than define the disorder

33. Reconciling the Changes Individuals previously diagnosed with CDD, Asperger’s or PDD,NOS will meet criteria for ASD. If they do not meet criteria for ASD, they should be evaluated for Social (Pragmatic) Communication Disorder Individual’s currently receiving accommodations in Illinois public schools will continue to receive accommodations

34. Schizophrenia Spectrum and Other Psychotic Disorders • Disorders in this group: • Schizotypal Personality Disorder criteria in Personality Disorders • Delusional Disorder • Brief Psychotic Disorder • Schizophreniform Disorder • Schizophrenia • Schizoaffective Disorder • Substance/Medication-Induced Psychotic Disorder • Psychotic Disorder Due to Another Medical Condition • Catatonia Associated with Another Mental Disorder (Catatonia Specifier) • Other Specified… and Unspecified…

35. Schizophrenia Spectrum/Other Psychotic Disorder, cont. • Major changes. • Elimination of special attribution of certain symptoms (e.g., bizarre delusions, voices talking to each other) in Criterion A of Schizophrenia (only one of these needed in DSM-IV). • Criterion A now requires 2 sx, at least 1 of 3 psychotic sx (Delusions, Hallucinations, or Disorganized Speech). • Schizophrenia subtypes eliminated. • Schizoaffective Disorder now requires that a major mood episode be present for a majority of the disorder’s total duration (not just current episode) after Criterion A met.

36. Schizophrenia Spectrum & Psychotic, cont. • Major changes. • Delusional disorder. Elimination of requirement that delusions be non-bizarre. • Differential diagnosis: if an individual with OCD or Body Dysmorphic Disorder is completely convinced that his/her OCD/BDD beliefs are true, then Delusional Disorder is not diagnosed in addition to OCD or BDD (more on this later). • Criteria for catatonia are same regardless of the context in which it is used as a specifier (Schizophrenia, Bipolar Disorders, Depressive Disorders, or Other Medical Condition).

37. Schizophrenia Spectrum & Psychotic, cont. • Major changes. • Rate symptoms on Clinician-Rated Dimensions of Psychosis Symptom Severity (Section III). • Symptoms (clusters) • Psychotic symptoms: Hallucinations, Delusions, Disorganization • Psychomotor symptoms: Abnormal Psychomotor Behavior • Negative symptoms: Restricted Emotional Expression, Avolition • Cognition: Impaired Cognition • Mood: Depression, Mania • You may still make a diagnosis in this group even without this rating.

38. Bipolar and Related Disorders • Disorders in this group • Bipolar I Disorder • Bipolar II Disorder • Cyclothymic Disorder • Substance/Medication-Induced Bipolar and Related Disorder • Bipolar and Related Disorder Due to Another Medical Condition • Other Specified… • Unspecified...

39. Bipolar and Related Disorders, cont. • Bipolar and Related Disorders are separated from Depressive Disorders and placed between Depressive Disorders and Schizophrenia Spectrum and Other Psychotic Disorders to recognize their place as a bridge in terms of symptoms, family history, and genetics.

40. Bipolar and Related Disorders, cont. • Major changes. • Criterion A for manic and hypomanic episodes now includes emphasis on changes in activity and energy as well as mood. (“A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least….” • Removal of Mixed Episode and addition of mixed features specifier that can be added to mania and hypomania if depressive features are present or to episodes of depression when features of mania or hypomania are present (> 3 symptoms from other pole).

41. Bipolar and Related Disorders, cont. • Major changes, cont • Specifiers • With anxious distress (see next slide) • With mixed features • With rapid cycling • With melancholic features • With atypical features • With mood-congruent psychotic features • With mood-incongruent psychotic features • With catatonia. • With peripartum onset (see next slide) • With seasonal pattern (see next slide)

42. Bipolar and Related Disorders, cont. • Major changes: specifiers • Anxious distress: at least two anxiety symptoms during the majority of days of the current/most recent episode of mania, hypomania or depression. • Symptoms: Feeling keyed up or tense, feeling unusually restless, difficulty concentrating because of worry, fear that something awful may happen, feeling that the individual might lose control of himself or herself. • High levels of anxiety have been associated with higher risk of suicide, longer duration of illness, higher risk of poor treatment response. • Specify severity based on number of anxiety symptoms: mild to severe.

43. Bipolar and Related Disorders, cont. • Major changes: Specifiers • Peripartum onset. Can be applied to current/most recent episode of mania, hypomania, or depression in Bipolar I or II if onset of mood symptoms was during pregnancy or in the 4 weeks following delivery. • Seasonal pattern. Regular temporal relationship between onset (and remission) of manic, hypomanic, or depressive episodes and a particular time of year. Does not include cases where there is an obvious psychosocial stressor related to the season.

44. Depressive Disorders • Disorders in this group. • Disruptive Mood Dysregulation Disorder • Major Depressive Disorder • Persistent Depressive Disorder (Dysthymia) • Premenstrual Dysphoric Disorder • Substance/Medication-Induced Depressive Disorder • Depressive Disorder Due to Another Medical Condition • Other Specified Depressive Disorder • Unspecified Depressive Disorder • Specifiers for Depressive Disorders • [Persistent Complex Bereavement Disorder in Section III.] • [Suicidal Behavior Disorder and Nonsuicidal Self-Injury in Section III.]

45. Depressive Disorders, cont. • Major changes • New disorders. • Disruptive Mood Dysregulation Disorder—new. • Persistent Depressive Disorder—replaces Dysthymic Disorder and Chronic Major Depressive Disorder. • Premenstrual Dysphoric Disorder—moved to this group from DSM-IV Appendix B (Criteria Sets…for Further Study). • Mixed features specifier may be added to major depression episode if features (at least three symptoms) of mania or hypomania are present. (Increases probability that the illness is in a bipolar spectrum, though if the person has never had an illness that met criteria for a manic or hypomanic episode the diagnosis of Major Depressive Disorder is retained.)

46. Depressive Disorders, cont. • Major changes, cont. • Bereavement exclusion eliminated. • DSM-IV stated that symptoms that begin within 2 months of loss of a loved one and do not persist beyond these 2 months are “generally considered to result from Bereavement” unless associated with functional impairment, preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. (Note: it did not say major depression could not be diagnosed.) • Implied that bereavement only lasts 2 months, when duration is more commonly 1-2 years (depending on culture and other factors). • Bereavement is severe psychosocial stressor that can precipitate major depression in a vulnerable person, e.g., past history of depression. • Major depression in context of bereavement adds: increased suffering, suicidal ideation; increased risk complex bereavement; and responds to same treatment (meds & verbal) as non-bereavement depression.

47. Comparison of Grief and Depression

48. Depressive Disorders, cont. • Disruptive Mood Dysregulation Disorder • A new diagnosis intended to address concerns of over diagnosis of bipolar disorder in children and unnecessary and potentially harmful treatment • These are children who are described by parents as having “mood swings,” who have explosive outbursts of extreme intensity and duration. Parents have to “walk on eggshells.” • These children present with persistent irritability and outbursts of temper and the sxs overlap sxs of ADHD, may be comorbid w/ ADHD but not w/ Bipolar or ODD

49. ADHD BIPOLAR DMDD More aggressive Morecontinuous More labile Disruptive Behavior Disorders

50. DMDD • Recurrent severe temper outbursts, • verbal and/or behavioral and inappropriate developmentally • frequency of outbursts 3 or more times/week • Symptom duration at least 12 months, no more than 3 months symptom-free • The outbursts are present in at least two settings, severe in at least one setting • Child is at least 6, but no older than 18, & onset before 10 • Criteria never been met for manic or hypomanic episode • Mood between outbursts is persistently irritable or angry most of the day and mood is observable by others • Trajectory is anxiety and/or unipolar mood disorders