Forensic Behavioral Associates DSM 5 Changes: an overview

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Forensic Behavioral AssociatesDSM 5 Changes an
overview

• Presenter James H. Andrews, LCSW, BCD

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SW 2065 HBMH - DSM5 Material

• Diagnostic Statistical Manual

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SW 2065 Human Behavior Mental HealthUse of
the DSM5 in Practice
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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
  

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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

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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..

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DSM5 Changes an overview

• DSM5 Summary of Major Changes
• New disorders in DSM5 (n15)
• 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)

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DSM5 Changes an overview

• DSM5 Summary of Major Changes
• New disorders in DSM5 (n15)
• 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

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DSM5 Changes an overview

• DSM5 Summary of Major Changes
• Combined/merged Disorders in DSM5 (n15)
• 1. Language Disorder (Expressive Language
  Disorder Mixed Receptive Expressive Language
  Disorder)
• 2. Autism Spectrum Disorder (Autistic Disorder,
  Aspergers Disorder, Childhood Disintegrative
  Disorder, Retts disorderPDD-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)

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DSM5 Changes an overview

• DSM5 Summary of Major Changes
• Combined/merged Disorders in DSM5 (n15)
• 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)

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DSM5 Changes an overview

• DSM-IV-TR
• Mental disorder is a syndrome characterized by
  clinically significant disturbance in an
  individuals 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??

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DSM5 Changes an overview

• DSM-IV-TR
• Mental disorder is a syndrome characterized by
  clinically significant disturbance in an
  individuals 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)

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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 GAFGlobal Assessment of Function
• 100 point scale range 100 (superior) thru 1
  Persistent danger harming self or 0 Inadequate
  info

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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 GAFGlobal Assessment of Function
• 100 point scale range 100 (superior) thru 1
  Persistent danger harming self or 0 Inadequate
  info

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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

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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

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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).

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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)

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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

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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
  individuals 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

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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.

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DSM5 Changes an overview

• DSM5 Classification System (new)
• Elements of a diagnosis formerly Axis I, II
  III
• Subtypes Specifiers (contd)
• 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.

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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.

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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.

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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)

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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.

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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

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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 its 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

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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

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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

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DSM5 Changes an overview

• DSM5 Classification System (new)
• Assessment Cross-Cutting Level 1

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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.

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DSM5 Changes an overview

• DSM5 Classification System (new)
• Assessment Cross-Cutting Level 2

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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.

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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

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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.

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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 individuals
  reproductive organs and XX/XY chromosomal
  distribution
• Gender differences variations resulting from
  both an individual's biological sex and
  self-representation of ones perceived gender
• Gender influences illness determines risk,
  moderates risk of development and likelihood of
  particular symptoms being experienced.

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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

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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).

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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

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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)

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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)

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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)

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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.

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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

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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

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DSM5 Changes an overview

• QUESTIONS

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