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DSM-5

DSM-5. Jim Messina, Ph.D., CCMHC, NCC Assistant Professor Troy University, Tampa Bay Site. Objectives DSM-5 Workshop. Update status of new DSM-5 Identify categories & changes in DSM-5 Review response to & critique of DSM-5 Suggest impact of DSM-5 for Clinical Mental Health Counselors

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DSM-5

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  1. DSM-5 Jim Messina, Ph.D., CCMHC, NCC Assistant Professor Troy University, Tampa Bay Site

  2. Objectives DSM-5 Workshop • Update status of new DSM-5 • Identify categories & changes in DSM-5 • Review response to & critique of DSM-5 • Suggest impact of DSM-5 for Clinical Mental Health Counselors • Prepare steps to take to be prepared for DSM-5 implementation

  3. Websites on DSM-5 • Official APA DSM-5 site: www.dsm5.org • DSM-5 on: www.coping.us

  4. Timeline of DSM-5 • 1999-2001 Development of Research Agenda • 2002-2007 APA/WHO/NIMH DSM-5/ICD-11 Research Planning conferences • 2006 Appointment of DSM-5 Taskforce • 2007 Appointment of Workgroups • 2007-2011 Literature Review and Data Re-analysis • 2010-2011 1st phase Field Trials ended July 2011 • 2011-2012 2nd phase Field Trials began Fall 2011 • July 2012 Final Draft of DSM-5 for APA review • May 2013 Publication Date of DSM-5

  5. Revision Guidelines for DSM-5 • Recommendations to be grounded in empirical evidence • Any changes to the DSM-5 in the future must be made in light of maintaining continuity with previous editions for this reason the DSM-5 is not using Roman numeral V but rather 5 since later editions or revision would be DSM-5.1, DSM-5.2 etc. • There are no preset limitations on the number of changes that may occur over time with the new DSM-5 • The DSM-5 will continue to exist as a living, evolving document that can be updated and reinterpreted over time

  6. Focus of DSM-5 Changes • DSM-5 is striving to be more etiological-however disorders are caused by a complex interaction of multiple factors and various etiological factors can present with the same symptom pattern • The diagnostic groups have been reshuffled • There is a dimensional component to the categories • Emphasis was to be on developmental adjustment criteria • New disorders were considered and older disorders were to be deleted

  7. Deconstruction Movement • The “deconstruction” movement in schizophrenia (or any of the other categories) seeks to disassemble the existing categorical diagnosis into better-defined working parts, integrating data from genetics, neuroimaging, psychology and other disciplines, and • then group symptoms that cluster together in order to rebuild them into a more valid working definition of schizophrenia.

  8. Grouping of Diagnostic Categories The DSM-5 groups are: • Neurodevelopmental disorders • Schizophrenia and primary psychotic disorders • Bipolar and Related Disorders • Mood Disorders • Anxiety Disorders • Disorders Related to Environmental Stress • Obsessive Compulsive Spectrum • Somatic Symptom Disorder • Feeding and Eating Disorder • Sleep Disorders • Disorders of Sexual Function • Antisocial and Disruptive Disorders • Substance Abuse-Related Disorders • Neurocognitive Disorders • Personality Disorders • Paraphilias • Other Disorders

  9. Obvious Changes in DSM-5 (1) • The DSM-5 will discontinue the Multiaxial Diagnosis, No more Axis I,II, III, IV & V-which means that Personality Disorders will now appear as diagnostic categories and there will be no more GAF score or listing of psychosocial stressor or contributing medical conditions • The Multi-axial model will be replaced by Dimensional component to diagnostic categories

  10. Obvious Changes in DSM-5 (2) • Developmental adjustments will be added to criteria • The goal has been to have the categories more sensitive to gender and cultural differences • Diagnostic codes will change from numeric to alphanumeric e.g., Obsessive Compulsive Disorder will change from 300.3 to F42 • They have done away with the NOS labeling and attempted for specificity with the dimensional categorization

  11. No More NOS what Replaces it CNEC replaces NOS CNEC means: Condition Not Elsewhere Classified

  12. Use for CNEC – First Rationale CNEC is to be used if the diagnosis of a client is too uncertain because of: Behaviorsassociated with a classification are seen but there is uncertainty regarding the diagnostic category due to the fact that a) The client presents some symptoms of the category but a complete clinical impression is not clear b) The client responds to external stimuli with symptoms of psychosis, schizophrenia etc but does not present with a full range of the symptoms need for a complete diagnosis

  13. Use for CNEC – Second Rationale CNEC is to be used if the diagnosis of a client is too uncertain because of: The client has been unwilling to provide information due to an unwillingness to be with the clinician or angry about being brought in to be seen or there is too brief a period of time in which the client has been seen or the clinician is untrained in the classification

  14. Rules for Use of CNEC Rules for use of CNEC CNEC designation can last only six months and after that a specific diagnostic category has to be determined for the diagnosis of the client.

  15. Dimensional Specifiers to be used for each diagnostic category • Syntonic vs Dystonic • Correlated Disorders & Suicide Risk • Respect for age, gender & culture • Severity Index Across Time & Circumstances

  16. Syntonic vs Dystonic • The first specifier to be used for each diagnostic category addresses the consideration of the “attitude of the client.” • It will specify on the clients’ eagerness and motivation for counseling/therapy based upon their understanding and insight toward their own mental health disorder. • This is designed to enhance the distinction made between Axis I and Axis II formats in the DSM III and DSM IV.

  17. Syntonic vs Dystonic These terms are borrowed from the terminology used in Motivational Interviewing: • Axis I disorder: is one for which the clients seek help because it causes them distress and this is referred to as DYSTONIC • Axis II disorder: is one for which clients do not seek clinical help because they do not feel any concern about this disorder and this is referred to as SYNTONIC

  18. Syntonic vs Dystonic The rating for this Dimension will be as follows: 1. Good /Fair Insight = Dystonic 2. Poor Insight = Ambivalence 3. Absent Insight = Syntonic

  19. Dystonic Clients Characteristic of Dystonic Conditions: 1. Client is experiencing significant distress, disability or impairment in functioning and such pain helps motivate the client to seek out help 2. Client has no capacity to cope with the condition at the current time 3. Client is motivated for therapy to help with the situation and condition Note: the more Dystonic a client is about disorder helps in case conceptualization & treatment planning & delineates where therapist will begin therapy in situation with client

  20. Characteristics of Syntonic Conditions 1. Client is heavily defended 2. Client rationalizes the behaviors & is reluctant to change 3. Client is angry about being told what to do 4. Client is resigned to his or her fate 5. Client sees benefits to current behaviors 6. Client lacks insight into the condition – typical for children 7. Client is resistant to therapy and often has to be motivated to enter therapy 8. Client has no motivation to change

  21. Correlated Disorders & Suicide Risk • Each diagnostic definition will comment on research based evidence of correlation among disorders (associated features) • There will be comments on each diagnosis as to vulnerability to suicide where appropriate

  22. Respect for Age, Gender & Culture Each diagnostic definition, where appropriate will incorporate: 1. Developmental symptom manifestation – regarding the age of client 2. Gender specific disorders 3. Cultural sensitivity in regards to certain behaviors

  23. Severity Index Across Time & Circumstances • Time and circumstances will be essential specifiers in all diagnostic categories • This will assure that individual does qualify for a mental disorder from definition and that it is a severe impairment • This insures that the clinician will take time in diagnosing • This replaces the Axis V GAF score

  24. Severity Index Across Time & Circumstances There is a need to avoid to rush to certainty given that: “Diagnostics is a process not an event” Rating Scale: Severity Index Across Time & Circumstances 0 = No impairment – Equivalent to GAF 71-100 (Normative Range) 1 = Mild impairment – Equivalent to GAF 61-70 2 = Moderate impairment – Equivalent to GAF 31-60 3 = Severe impairment – Equivalent to GAF 1-30 Specifier must indicate level 1 or 2 or 3 before a diagnosis is validated as a mental disorder

  25. Pathogenic Care Realms 5 Pathogenic Care Realms in the Home, School & Community: Settings in which there is: 1. persistent disregard for the child’s emotional needs 2. persistent disregard for the child’s physical needs 3. repeated changes in primary caregivers 4. limited opportunities for stable attachments for child 5. persistent harsh punishment or types of grossly inept parenting (e.g.: Toxic Homes) It requires one or more of these five essential specifiers for a diagnosis which depends on a pathogenic realm to be fully diagnosed

  26. Diagnoses needing Pathogenic Realm Specifiers Diagnoses in the DSM-5 requiring the 5 Pathogenic Care Realms Specifiers are: G00 Reactive Attachment Disorder G01 Disinhibited Social Engagement Disorder G03 PTSD in Children D00 Disruptive Mood Dysregulation Disorder H00 Dissociative Disorders in Children Q00 Oppositional Defiant Disorder Q06.1 Conduct Disorder (Sociopathy Specifier) Q07 and T04 Dyssocial Personality

  27. Specific Changes Per Diagnostic Category in DSM-5 Neurodevelopmental • IQ no longer used as criteria for Intellectual Developmental Disorder but the IQ still is understood to be below 70 • Asperger's Syndrome will be lumped into Autism Spectrum since it is at the milder end of the Spectrum

  28. Specific Changes Per Diagnostic Category in DSM-5 Schizophrenia and Other Psychotic Disorders • Schizotypal Personality Disorder B01 moved to this category • Added Attenuated Psychosis Syndrome B06

  29. Specific Changes Per Diagnostic Category in DSM-5 Bipolar and related disorders • Bipolar is now a free standing category • Taken out of the mood disorder category

  30. Specific Changes Per Diagnostic Category in DSM-5 Depressive Disorders • Dysthymia now called Chronic Depressive Disorder D03 • Added PrementrualDysphoric Disorder D04 • Added Mixed Anxiety/Depression D05

  31. Specific Changes Per Diagnostic Category in DSM-5 Anxiety Disorders • No longer has PTSD in this category • No longer has OCD in this category • Social Phobia now called Social Anxiety Disorder E04

  32. Specific Changes Per Diagnostic Category in DSM-5 Obsessive-Compulsive and Related Disorders • OCD is now a stand alone category • Body Dysmorphic Disorder listed under OCD as F01 • Added Hoarding under category of OCD as F02 • Trichotillomania now called Hair-Pulling Disorder is listed under OCD as F03 • Skin Picking Disorder moved under OCD as F04

  33. Specific Changes Per Diagnostic Category in DSM-5 Trauma and Stressor Related Disorders • Trauma related disorders are now a stand alone category • Reactive Attachment Disorder is now listed here G00  • Added Disinhibited Social Engagement Disorder G01 • Added PSTD in Preschool Children G03 • Acute Stress Disorder is now listed here G04 • PTSD is now listed here G05 • Adjustment Disorders are now listed here G06

  34. Specific Changes Per Diagnostic Category in DSM-5 Dissociative Disorders • Depersonalization/Derealization Disorder renamed in H00 • Dissociative Fugue has been removed from this category

  35. Specific Changes Per Diagnostic Category in DSM-5 Somatic Symptom Disorder • Replaced Somatiform Disorders with this category • Eliminated the following: Somatization Disorder; Pain Disorder; and Hypochondriasis • Added Complex Somatic Symptom Disorder J00 • Added Simple Somatic Symptom Disorder J01 • Added Illness Anxiety Disorder J02 • Conversion Disorder renamed Functional Neurological Disorder J03

  36. Specific Changes Per Diagnostic Category in DSM-5 Feeding and Eating Disorders • Pica K00 moved to this category • Rumination Disorder K01 moved to this category • Added Avoidant/Restrictive Food Intake Disorder K02 • Added Binge Eating Disorder K05

  37. Specific Changes Per Diagnostic Category in DSM-5 Elimination Disorders • This category was created as freestanding category • Enuresis moved to this category L00 • Encopresis moved to this category L01

  38. Specific Changes Per Diagnostic Category in DSM-5 Sleep-Wake Disorders (1) • Primary Insomnia renamed Insomnia Disorder M00 • Primary Hypersomnia joined with Narcolepsy without Cataplexy M01 • Added Kleine Levin Syndrome M02 (intermittent excessive sleep with behavior change) • Added Obstructive Sleep Apnea Hypopnea Syndrome M03 • Added Primary Central Sleep Apnea M04

  39. Specific Changes Per Diagnostic Category in DSM-5 Sleep-Wake Disorders (2) • Added Primary Alveolar HypoventiationM05 • Added Disorder of Arousal M08 • Added Rapid Eye Movement Behavior Disorder M09 • Added Restless Leg Syndrome M10 • Eliminated: Sleep Terror Disorder & Sleepwalking Disorder

  40. Specific Changes Per Diagnostic Category in DSM-5 Sexual Dysfunction • Male orgasmic disorder renamed Delay Ejaculation N02 • Premature Ejaculation renamed Early Ejaculation N03 • Dyspareunia and Vaginismus combined into Genito-Pelvic Pain/Penetraion Disorder N06 • Sexual Aversion Disorder combined in other categories

  41. Specific Changes Per Diagnostic Category in DSM-5 Disruptive Impulse Control and Conduct Disorders • Gambling removed from this category • Oppositional Defiant Disorder Q00 was moved • Trichotillomania removed from this category • Conduct Disorder Q06 was moved • Antisocial Personality Disorder renamed Dyssocial Personality Disorder Q07 moved to this category

  42. Specific Changes Per Diagnostic Category in DSM-5 Substance Abuse and Addictive Disorders • Only 3 qualifiers are used in the category: Use - replaces both abuse and dependence while Intoxication and Withdrawal remain the same • Nicotine Related renamed Tobacco Use Disorder R09 • Added Caffeine Withdrawal R24 • Added Cannabis Withdrawal R25 • Polysubstance Abuse categories discontinued • Added Gambling R31 added to category

  43. Specific Changes Per Diagnostic Category in DSM-5 Neurocognitive Disorders • Category replaces Delirium, Dementia, and Amnestic and Other Cognitive Disorders Category • Now distinguishes between Minor and Major Disorders • Replace wording of Dementia due to ... with Neurocognitive Disorder Associated with for all the conditions listed • Added Fronto-Temporal Lobar Degeneration S15/S27; Traumatic Brain Injury S16/S28; Lewy Body Disease S17/S29 • Renamed Head Trauma to Traumatic Brain Injury • Renamed Creutzfeldt-Jakob Disease to Prion Disease

  44. Specific Changes Per Diagnostic Category in DSM-5 Paraphilias • They all carry over to the DSM-5 new names • U00 Exhibitionistic Disorder; U01 Fetishistic Disorder; U02 Frotieuristic Disorder; U03 Pedophilic Disorder; U04 Sexual Masochism Disorder; U05 Sexual Sadism Disorder; U06 Tranvestic Disorder; U07 Voyeuristic Disorder

  45. Specific Changes Per Diagnostic Category in DSM-5 Personality Disorders • Only six Personality Disorders remain in this category: Borderline T00; Obsessive-Compulsive T01; Avoidant T02; Schizotypal T03; Antisocial T04; Narcissistic T05 • Schizotypal Personality Disorder T03 also under Schizophrenia and Other Psychotic Disorders B02 • Antisocial Personality Disorder T04 also under Disruptive Impulse Control and Conduct Disorders as Dyssocial Personality Disorder Q07 • This category no longer stands alone as another AXIS II but rather as a diagnosed category with dimensions

  46. Personality Disorders T00-06. Personality Disorders Classifications T00   Borderline Personality Disorder T01   Obsessive-Compulsive Personality Disorder T02   Avoidant Personality Disorder T03   Schizotypal Personality Disorder T04 Dyssocial   Personality Disorder (Antisocial Personality Disorder) T05   Narcissistic Personality Disorder T06   Personality Disorder Trait Specified

  47. Three Measures to Assess Personality Pathology 1. Core Impairments in Personality Functioning 2. Pathological Personality Traits 3. Overall Measure of Severity

  48. 1. Core Impairments in Personality Functioning 1. Self-Functioning includes: a. Identity: individual experiences oneself as unique, has boundaries, stable self-esteem, and can regulate emotions b. Self-direction: individual has vocational, occupational, relational and social goals also has internal standards and displays a “moral compass” 2. Interpersonal Functioning includes: a. Empathy: listens, appreciates others’ experiences and advice, tolerance and acceptance and understands how one’s behaviors affect others b. Intimacy: positive connection to others, a desire and capacity for closeness and is emotionally responsive

  49. 2. Pathological Personality Traits 1. Negative Affectivity: labile moods & emotional dysregulation 2. Detachment: emotional constriction & intimacy avoidance 3. Antagonism: manipulative 4. Disinhibition or Compulsivity: perfectionism &controlling 5. Psychoticism: unusual beliefs

  50. 3. Overall Measure of Severity of Personality Functioning 0 = very little 1 = Mild 2 = Moderate 3 = Extreme The severity level is an assessment of how the behavior impacts on the therapeutic relationship

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