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DSM – 5: A Brief Overview

DSM – 5: A Brief Overview. Chuck Pistorio, Ph.D. Laura Tejada, Ph.D. Shedeh Tavakoli, Ph.D. Overview. Outline significant changes Chapter organizations New categories New Diagnoses Eliminated diagnoses Review specific changes for some of the most commonly diagnosed disorders.

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DSM – 5: A Brief Overview

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  1. DSM – 5:A Brief Overview Chuck Pistorio, Ph.D. Laura Tejada, Ph.D. Shedeh Tavakoli, Ph.D.

  2. Overview • Outline significant changes • Chapter organizations • New categories • New Diagnoses • Eliminated diagnoses • Review specific changes for some of the most commonly diagnosed disorders

  3. Changes in Philosophy • Greater emphasis on culture • Cultural Formulation Inventory (CFI) • Awareness of international use • ICD, WHO • Validity rather than reliability • More emphasis on client’s experiences and reported symptoms/needs

  4. Changes to Chapters Chapters reorganized • Organized by common etiologies • More dimensional approach • Diagnosis is ongoing • Reflects developmental lifespan • Removed Disorders Usually Diagnosed in Infancy, Childhood & Adolescence • Individual chapters organized developmentally

  5. Changes to Five-Axis System

  6. Changes to Five-Axis System

  7. Changes to NOS • Not Elsewhere Classified [NEC] • Specific symptoms with code • Other Specified • Allows documentation of why client does not meet specific diagnostic criteria • Unspecified • Significant distress but does not meet criteria • Insufficient information (crisis, ER)

  8. Organization & Content • Section I • Orientation • Historical back ground • Development of DSM-5 • How to use it • Section II • Diagnostic Criteria and codes • “Medication-induced Movement Disorders” • “Other Conditions That May be a Focus of Clinical Attention.”

  9. Organization & Content • Section III • Emerging Measures and Models • Assessment measures http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures • Cultural formulation • Alternative DSM-5 model for personality disorders • “Criteria Sets for Conditions for Further Study” • Appendix • Highlights of changes from DSM-IV to DSM-5 • Glossary of technical terms • Glossary of cultural terms • Alpha & numeric listings of diagnoses and codes • List of advisors and contributors

  10. Structure for Each Diagnosis • Diagnostic Criteria • Subtypes and/or specifiers • Severity • Codes and recording procedures • Explanatory text (new or expanded)

  11. Structure for Each Diagnosis • Diagnostic and associated features • Prevalence • Development and course • Risk and prognosis • Culture- and gender-related factors • Diagnostic markers • Functional consequences • Differential diagnosis • Comorbidity

  12. New Disorders • Social (Pragmatic) Communication Disorder • Disruptive Mood Dysregulation Disorder • Premenstrual Dysphoric Disorder • Hoarding Disorder • Excoriation (Skin‐Picking) Disorder • Disinhibited Social Engagement Disorder (split from Reactive Attachment Disorder) • Binge Eating Disorder

  13. New Disorders • Central Sleep Apnea • Sleep-Related Hypoventilation • Rapid Eye Movement Sleep Behavior Disorder • Restless Legs Syndrome • Caffeine Withdrawal • Cannabis Withdrawal • Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other Medical Conditions) • Mild Neurocognitive Disorder

  14. Eliminated • Sexual Aversion Disorder • Polysubstance-Related Disorder

  15. Diagnostic Changes New categories: • Obsessive-Compulsive and Related Disorders • Trauma- and Stressor-Related Disorders Transformed: • Neurodevelopmental Disorders (Infancy, adolescence, childhood) • Somatic Symptom and Related Disorders

  16. Combined: • Language disorders • Autism spectrum • Specific Learning Disorder • Delusional disorder • Panic Disorder • Dissociative Amnesia • Somatic Symptom • Insomnia Disorder • Alcohol use disorder • Cannabis use disorder • Stimulant Intoxication • Stimulant withdrawal • Substance/medication-induced disorders

  17. Examples of Changes

  18. Trauma and Stress-Related Disorders New chapter in DSM-5 brings together anxiety disorders that are preceded by a distressing or traumatic event • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder (new) • PTSD (includes PTSD for children 6 years and younger) • Acute Stress Disorder • Adjustment Disorders

  19. Posttraumatic Stress Disorder (PTSD) • There are 8 criterion • Criteria (A)- Exposure to actual or threatened death, serious injury, or sexual violence • Four symptom clusters, rather than three • Re-experiencing (B) • Avoidance (C) • Persistent negative alterations in mood and cognition (D) • Arousal- describes behavioral symptoms (E) • Duration of B, C, D, and E is more than 1 month • Causes clinically significant distress • Not attributed to substance use or medical condition

  20. PTSD • DSM 5 more clearly defines what constitutes traumatic event • Sexual assault is specifically included • Recurring exposure, that could apply to first responders • Recognition of PTSD in young children • Developmentally sensitive: • Criteria have been modified for children 6 and younger • Thresholds- number of symptoms in each cluster have been lowered • Risk and Prognostic actors: • Pretraumatic factors • Per traumatic factors • Posttraumatic factors

  21. Substance-Related and Addictive Disorders DSM-5 consolidates substance abuse and dependence into one disorder: substance use disorder accompanied by criteria for: intoxication, withdrawal, substance-induced disorders, and unspecified related disorders. Criteriaare nearly identical to DSM-IV w/ exception of: -Recurrent substance-related legal problems criterion has been deleted from DSM-5. -And new criterion: craving, or a strong desire or urge to use a substance added. The threshold is set at 2 or more criteria vs. 1 or more for abuse and 3 or more for dependence in the DSM-IV.

  22. Substance-Related and Addictive Disorders New disorders in substance-related & addictive disorders chapter of DSM-5: Gambling Disorder (non-substance related disorder) Cannabis Withdrawal Caffeine Withdrawal * The dx of polysubstance dependence has been eliminated.

  23. Substance-Related and Addictive Disorders Specifiers: In DSM-5 severity for substance use disorders is based on the number of criteria endorsed: -mild= 2-3 criteria -moderate = 4-5 criteria -Severe= 6 or more criteria The DSM-IV specifier for psychological subtype has been eliminated.

  24. Substance-Related and Addictive Disorders In DSM-5 early remission is defined as at least 3 but less then 12 months without substance use disorder criteria (except craving). Sustained remission is defined as at least 12 months without criteria (except craving). New specifiers include: -in a controlled environment -on maintenance therapy

  25. Neurodevelopmental Disorders • DSM-IV TR – “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” • Intellectual Disability (vs mental retardation) – Rosa’s Law • Assess cognitive capacity (IQ) and adaptive functioning (the primary determinant of severity). • Autism Spectrum Disorder (gone – Asperger’s, childhood disintegrative disorder, pervasive developmental disorder) • Addition – Social (Pragmatic) Communication Disorder

  26. Neurodevelopmental Disorders • Attention-Deficit/Hyperactive Disorder (prior to age 12 vs age 7, less symptoms for adults, option for comorbid with ASD) • Specific Learning Disorder (DSM-IV TR = Academic Skills Disorders; greater detail in diagnosis, e.g., word reading, fluency, comprehension; clarify requirements for Low Achievement criterion) • Specifiers – greater detail on severity (e.g., ID – mild, moderate, severe, profound; ASD – Levels 1, 2, 3) • Removed – Separation Anxiety Disorder, Pica and Rumination Disorder, Feeding Disorder of Infancy or Early Childhood, Oppositional Defiant Disorder, Conduct Disorder

  27. Personality Disorders • Criteria for PD’s in Section II of DSM-5 not changed from DSM-IV • No longer exist as an Axis II disorder (i.e., dropped multiaxial evaluation system) • PD now coded at same level as other mental disorders • No longer marginalized and treated differently

  28. Personality Disorders • NOS dropped in favor of: (1) Other specified PD and (2) Unspecified PD • New, alternative approach to diagnosing PD developed for further study and included in separate section (Section III) • Personality Change Due to Another Medical Condition included in PD chapter (vs. DSM-IV’s Mental Disorders Due to a General Medical Condition)

  29. Alternative DSM-5 Model for Personality Disorders • New model for assessment of personality disorders and traits • Includes Categorical and Dimensional approaches • Model not accepted by APA for inclusion in Section II • Decision –include in Section III as the “Alternative DSM-5 Model for Personality Disorders” • Rationale: the model “preserve(s) continuity with current clinical practice, while also introducing a new approach that aims to address numerous shortcomings of the current approach to personality disorders.” • Six PDs (vs. ten) – antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal)

  30. Alternative DSM-5 Model for Personality Disorders • Based on Five Factor model of personality (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness) • PD Model (Negative affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism) • Negative Affectivity Neuroticism • Detachment Introversion • Antagonism Antagonism • Disinhibition Low Conscientiousness • Psychoticism Openness • 25 Facets (traits): e.g., Anxiousness, Attention Seeking, Depressivity, Emotional Lability, Hostility, Impulsivity, Separation Insecurity, Withdrawal

  31. QUESTIONS? ? QUESTIONS? ? QUESTIONS?

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