Understanding the DSM-5

1. Understanding the DSM-5 Crystal Weaver, CRC, MT-BC

2. Terms • Nosology: the branch of medical science dealing with the classification of diseases • Demarcating: separate or distinguish from • Empirical: based on, concerned with, verifiable by observation or experience rather than theory or pure logic • Positivistic: a doctrine contending that sense perceptions are the only admissible basis of human knowledge and precise thought • Psychodynamics: the interaction of various conscious and unconscious mental or emotional processes, especially as they influence personality, behavior, and attitudes • ICD: The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. ICD-10 was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States in 1994. The 11th revision of the classification has already started and will continue until 2015

3. Part One: The History of the DSM

4. Why Learn the History of the DSM? • Understanding the history of the DSM can help practitioners and researchers: • Better understand the diagnostic language they are using • Identify future directions for an improved nosology • Better understand the DSM’s strengths and limitations • For example, many of the diagnostic criteria are not based on empirical research but on expert consensus and, in some cases, political appeasement

5. Before the DSM • Numerous nosologies in North America preceded the development of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) • Having divergent classification systems impeded communication between researchers and practitioners • A standardized classification system was needed to: • Minimize confusion • Create a consensus among the field • Help mental health professionals communicate using a common diagnostic language

6. Precursor to the DSM • The advent of institutionalization provided substantial opportunity to collect data and learn about mental disorders in clinical contexts • Mental disorder began to be viewed through a medical lens • Individual nosologies put forth by psychiatrists in the late 19th and early 20th centuries had the advantage of being holistic and centered on the individual • Challenges of different nosologies: • Different diagnostic languages were spoken, impeding communication between psychiatrists • Prevalence rates of mental disorders could not be determined • Great confusion and variability in diagnoses of mental disorders

7. Precursor to the DSM (cont) • In 1917, the Committee on Statistics of the American Medico-Psychological Association (now the American Psychiatric Association) recommended a uniform classification system of mental disease • This committee feared that having a disordered way of classifying mental diseases would discredit the field of psychiatry • Published the Statistical Manual for the Use of Institutions for the Insane • This manual separated mental disorders into 22 groups • This manual went through 10 editions until 1942

8. Opponents To A Psychiatric Nosology • Adolf Meyer, former president of the APA • Opposed to a nosology demarcating a one-word diagnosis marking the individual • Viewed mental illness in holistic terms and was a proponent of understanding the life histories of patients to understand the etiologies of mental disorders • Believed each psychiatric case was unique and should be studied on its own terms

9. World War II • A significant shift in psychiatric nosology occurred in the U.S. as a result of World War II • Psychiatrists serving in the military found that environmental stressors contribute to mental illness • New terminology focused less on biological bases of behavior and more on developmental, environmental, and relational factors • Therefore, further updates to the Statistical Manual for the Use of Institutions were put on hold and the army made extensive revisions to the standard nomenclature

10. International Statistical Classification • In 1948, the 6th revision of the International Statistical Classification (ICD) was produced • Included a section on mental disorders • At this time, at least three nomenclatures were widely used in North America • None of which were in line with the International Statistical Classification

11. Diagnostic and Statistical Manual of Mental Disorders, First Edition • The first edition of the DSM, published in 1952, was an important development toward a standard nosology of mental disorders • This manual offered: • A new classification in conformity with newer scientific and clinical knowledge • Simpler structure • Easier to use • Virtually identical with other national and international nomenclatures

12. Diagnostic and Statistical Manual of Mental Disorders, First Edition (cont) • DSM-I featured descriptions of 106 disorders, which were referred to as “reactions” • Disorders were split into two groups based on causality • Disorders caused by or associated with impairment of brain tissue function • Acute brain disorders • Chronic brain disorders • Mental deficiency • Disorders of psychogenic origin or without clearly defined physical cause or structural change in the brain • Psychotic disorders • Psychophysiologic autonomic and visceral disorders • Psychoneurotic disorders • Personality disorders • Transient situational personality disorders

13. Diagnostic and Statistical Manual of Mental Disorders, First Edition (cont) • Highly influenced by the prevalence of psychodynamic theory in North America • After its publication, it became necessary to coordinate DSM with future editions of the ICD • Proved to be a daunting task based on the different orientation and purposes of the manuals

14. Diagnostic and Statistical Manual of Mental Disorders, Second Edition • Both the DSM-I and the DSM-II held similar theoretical stances, which were grounded in psychodynamics • Noteworthy differences between the DSM-I and the DSM-II • In the DSM-II nomenclature was carefully selected to avoid terms implying causality • The term “reaction” was removed from diagnostic labels in the DSM-II because it implied causality and referred to psychoanalysis • The DSM-II increased the number of disorders to 182

15. Between the Second and Third Editions of the DSM • By the 1960s, psychiatry as a profession was predominantly psychodynamic • Which resulted in some unrealistic thinking • Success in returning soldiers to the front in World War II created perhaps an unrealistic expectation of the curability of mental illness • The reliability of diagnosis came under scrutiny • There was growing public contempt in the U.S. • Particularly over conflicting testimonies of psychiatrists in insanity defense pleas

16. Neo-Kraepelinians • The profession of psychiatry underwent significant theoretical changes toward an empirical, positivistic orientation • The field reverted to an orientation based on the ideas of Emil Kraepelin • Kraepelin’s core ideas include: • Relating psychiatry with medicine • Using descriptive language • Observing psychiatry through an empirical lens • Biology and genetics play a key role in mental disorders • Distinguishing between schizophrenia and bipolar disorder

17. Neo-Kraepelinians (cont) • Kraepelin’s influence on psychiatry reemerged in the 1960s, about 40 years after his death, with a small group of psychiatrists at Washington University in St. Louis, MO, who were dissatisfied with psychodynamically oriented American psychiatry • They were dissatisfied with: • The lack of clear diagnoses and classification • Low interrater reliability among psychiatrists • Blurred distinction between mental health and illness • To address these fundamental concerns and to avoid speculating on etiology, these psychiatrists advocated descriptive and epidemiological work in psychiatric diagnosis • In 1972, John Feighner and his “neo-Kraepelinian” colleagues published a set of diagnostic criteria based on a synthesis of research, pointing out that the criteria were not based on opinion or tradition

18. Diagnostic and Statistical Manual of Mental Disorders, Third Edition • The DSM-III appeared to adopt a neo-Kraepelinian standpoint and in the process revolutionized psychiatry in North America • The DSM-III, published in 1980, dropped the psychodynamic perspective in favor of empiricism • The DSM-III expanded to 494 pages with 265 diagnostic categories

19. Diagnostic and Statistical Manual of Mental Disorders, Third Edition (cont) • The DSM-III: • Presented psychiatry in a medical model • Emphasized follow-up • Emphasized family histories • Sought to increase the reliability of diagnosis • Sought to facilitate communication among mental health professionals

20. Diagnostic and Statistical Manual of Mental Disorders, Third Edition (cont) • The introduction of the DSM-III emphasizes the importance of having a common diagnostic language: • “Clinicians and researchers must have a common language with which to communicate about the disorders for which they have professional responsibility…The efficacy of various treatment modalities can be compared only if patient groups are described using diagnostic terms that are clearly defined.”

21. Diagnostic and Statistical Manual of Mental Disorders, Third Edition (cont) • The DSM-III featured a multiaxial format, which addressed: • Mental disorder • Personality • Medical causes • Environmental factors • General functioning in diagnoses • Contrary to a neo-Kraepelinian standpoint, expert consensus was often used to inform diagnostic criteria • Empirical research was used when possible, but much of the categorization was based on clinical judgment

22. Diagnostic and Statistical Manual of Mental Disorders, Third Edition (cont) • A revised edition of the DSM-III was published in 1987, which included: • Some revised descriptions of diagnostic criteria • Descriptions of field trials assessing the validity and reliability of disorders • An appendix of “Proposed Diagnostic Categories Needing Further Study”

23. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition • The structure and theoretical orientation of the DSM-IV was largely unchanged from the DSM-III • The number of mental disorders increased to more than 300 in the DSM-IV • The threshold for approval or a diagnosis in the DSM-IV was more conservative, requiring more empirical backing • The DSM-IV-TR was published to ensure that information in the DSM-IV remained up-to-date • No substantive changes were made to the diagnostic criteria set out in the DSM-IV • No new disorders nor new subtypes were considered

24. The DSM-IV-TR and the ICD • The DSM-IV-TR and ICD-10 represented the dominant diagnostic languages in the world • Traditionally, revisions to the DSMs and ICDs have occurred relatively independently • Most disorders in both manuals have differences between them • 21% having conceptually based differences • Differences in these two manuals can undermine the credibility of the field of psychiatry, and having two different classification systems can impede international collaboration effects

25. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Predictions • The initial phase of the DSM-5 planning process began in 1999 with a series of conference cosponsored by APA and the National Institute of Mental Health • Task force of 28 people • Work groups had over 130 people in 13 workgroups • 400 advisors • Strong international representation (39 countries) • Harmonization of the DSM and ICD was identified as an important goal of the revisions of both manuals • One step that had been proposed for the DSM-5 was the amalgamation of Axes I, II, and III into one axis that contains all psychiatric and general medical conditions • This would bring the DSM more in line with ICD approach

26. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Predictions (cont) • Perhaps the most revolutionary idea is to adopt a dimensional rather than categorical approach to classification • In contrast with the categorical approach used in the DSM-IV-TR, where dichotomous diagnostic decisions regarding the presence/absence of a disorder are made based on meeting a certain number/pattern of criteria, a dimensional approach would involve quantitative ratings of patients on characteristics or features of the disorder • Using this method, important clinical information can be communicated for patients above and below current diagnostic thresholds

27. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Predictions (cont) • In February 2010, the APA released Proposed Draft Revisions to DSM Disorders and Criteria. Many of these proposed changes reflected a shirt toward etiologically based, dimensional diagnoses • One proposed change was the inclusion of an anxiety dimension across all mood disorders • In the categorical approach in DSM-III and DSM-IV, anxiety is identified as a separate and distinct construct from other mood disorders, whereas the proposed changes in DSM-5 suggest that anxiety may be a common underlying factor

28. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Predictions (cont) • Other proposed changes for the DSM-5: • Autistic disorder, Asperger’s disorder, and PDD-not otherwise specified (NOS) were distinct categories in the DSM-IV-TR. The proposed changes would eliminate these categories and place these disorders within the classification “autism spectrum disorder” • With Personality Disorders, diagnoses may be based on underlying traits (which requires a dimensional approach)

29. Part Two: The DSM-5

30. Why Are Clients Diagnosed? • To provide better treatment for the client • To obtain reimbursement • To stimulate research • To guide treatment • To better understand the client

31. The Basics • The DSM-5 was released at the American Psychiatric Association’s annual conference in San Francisco in May, 2013 • There are criticisms and controversies surrounding the DSM-5 • Pathology-based, not strengths-based • Concerns about overprescribing medications • No treatment suggestions • Electronic version available

32. Development • Task force of 28 people • Work groups had over 130 people in 13 workgroups • 400 advisors • International representation (39 countries) • Process began in 1999

33. Goals and Purpose • Goals: • Improve diagnostic accuracy • Add severity scales • Add dimensional assessments • Reduce not otherwise specified (NOS) usage • Align with ICD (International Classification of Diseases) • Purpose: • Tool for clinicians • Educational resource for students • Reference for researchers • Provide a common language • Assist in compiling public health statistics • Help assess people objectively

34. Defining Mental Disorder • The definition of mental disorder is essentially the same as the DSM-IV definition: • A syndrome of clinically significant disturbance in cognition, emotion regulation, or behavior, that is associated with distress, disability, or significant impairment in important areas of functioning • Several categories give the option of medication-induced __________ disorder or substance-induced __________ disorder

35. Guidance on Use • A diagnosis should not be made for behaviors that are an expected or culturally sanctioned response to a particular event • Consider cultural context: Section 3 has a chapter on cultural formulation with a structured interview • These are conditions a person may have but the conditions should not define the person • These disorders are often early life coping or defense mechanisms that are now dysfunctional and causing distress • Conditions may or may not be medical or biological illnesses

36. No More Multiaxial System • No more Axis I- V • No more GAF • No listing of psychosocial and environmental problems • No listing of contributing medical conditions

37. Diagnostic Groupings • Neurodevelopmental Disorders • Schizophrenia Spectrum and Other Psychotic Disorders • Bipolar and Related Disorders • Depressive Disorder • 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 • Sleep-Wake Disorders • Sexual Dysfunctions • Gender Dysphoria • Disruptive, Impulse Control, and Conduct Disorders • Substance-Related and Addictive Disorders • Neurocognitive Disorders • Personality Disorders • Paraphilic Disorders

38. Neurodevelopmental Disorders • Category includes: • Intellectual Disability • Global Developmental Delay (under age 5) • Communication Disorders • Autism Spectrum Disorder • ADHD • Specific Learning Disorder • Motor Disorders

39. Autism Spectrum Disorder (ASD) • Asperger’s disorder is now absorbed into Autism Spectrum Disorder (ASD) • Asperger’s, Childhood Disintegrative Disorder, Rett’s Disorder, and Pervasive Developmental Disorder (PDD) are gone • The reliability and validity of these disorders are very poor • There is no evidence to support their continued separation

40. Autism Spectrum Disorder (cont) • People with a well-established DSM-IV diagnosis of ASD, Asperger’s, or PDD will probably qualify for the diagnosis of ASD • If the person does not meet criteria, an evaluation for Social (Pragmatic) Communication Disorder may be done • Dramatic rise in the prevalence of ASD: • 2007 (1 in 150) • 2009 (1 in 110) • 2013 (1 in 88)

41. Autism Spectrum Disorder (cont) • Three domains in DSM-IV will become two domains in the DSM-5: • DSM-IV • Qualitative impairment in social interaction • Qualitative impairment in communication • Restricted repetitive and stereotyped patterns of behavior, interests, and activities • DSM-5 • Social and communication deficits • Restricted repetitive behaviors, interests, and activities (RRB’s)

42. Autism Severity(Severity specifiers should not be used to determine eligibility for services)

43. Autism Spectrum Disorder (cont) • Typical presentation includes: • Inappropriate responses in conversation • Misreading nonverbal interactions • Difficulty building friendships appropriate to age • Overly dependent on routines • Highly sensitive to changes in environment • Intensely focused on inappropriate items • Core features are usually obvious by age 2 • Regression or plateau in language or social development is present in 20-30% by age 2 • There is no blood test or biological marker

44. Autism Spectrum Comorbidities • 71%: Oppositional Defiant Disorder (ODD) • 62%: Anxiety • 50-73%: Significant motor delays (especially handwriting) • 40-85%: Sleep problems (10x higher rate of insomnia) • 41%: ADHD • 37%: Obsessive-Compulsive Disorder (OCD) • 22-70%: GI complaints • 13%: Depression • 10%: Speech problems • 9%: Tourette’s/tic disorders

45. Autism Spectrum Disorder (cont) • 70% have one other mental health diagnosis • 41% have two or more other mental health diagnoses • Parents may have increased stress and poorer health • Siblings may have more anxiety and depression • There is no link between vaccines and autism • Conclusive studies done by: • Centers for Disease Control and Prevention • Food and Drug Administration • Institute for Medicine • World Health Organization • American Academy of Pediatrics

46. Depressive Disorder • Category includes: • Disruptive Mood Dysregulation Disorder (new) • Major Depressive Disorder • Symptom list has not changed • Persistent Depressive Disorder (new) • Premenstrual Dysphoric Disorder (new)

47. Anxious Distress Specifier • Depression/anxiety link: • 29% have history of panic attacks • 62% have moderate anxiety • Anxious Distress Specifier: • Keyed up/tense • Unusually restless • Decreased concentration • Fear of something awful happening • Fear of losing control • Depression with Anxious Distress Specifier: • Takes longer to recover from • Greater suicide risk • More complaints of medication side effects • Greater recurrence • Greater impairment

48. Bereavement Exclusion • Beginning in DSM-III, if someone is grieving the loss of a loved one, they can not be diagnosed with depression for the first 2 months • Prognosis is bad if someone has bereavement and major depression at the same times • Bereavement can induce great suffering, but does not typically induce major depression • Grief vs. Depression: • Less psychomotor retardation • Less worthlessness or self-loathing • Less suicidal ideation • Fewer symptoms • People see symptoms as normal and expected given the loss

49. Bereavement Exclusion (cont) • Grief: • Painful feelings come in waves, often mixed with positive memories of the deceased • Prominent feelings of emptiness and loss • Person feels that symptoms are due to the loss • Depression: • Mood and ideation are almost constantly negative • Mood is persistently depressed with an inability to anticipate happiness or pleasure • Person may not have any idea why they feel so bad

50. Disruptive Mood Dysregulation Disorder (DMDD) • New diagnosis • Similar to Bipolar Disorder with extreme temper and rage • Prevalence: 2-5% more in males than females • Similar to Oppositional Defiant Disorder (ODD), but more severe: • DMDD requires impairment across two settings, once of which is severe • DMDD has higher symptom threshold than ODD