DSM-5

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DSM-5

• Jim Messina, Ph.D., CCMHC, NCC
• Assistant Professor
• Troy University, Tampa Bay Site

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Objectives DSM-5 Workshop

• Update status of new DSM-5
• Identify categories changes in DSM-5
• Suggest impact of DSM-5 for Professional
  Counselors
• Using DSM-5 for Improved Clinical Assessment,
  Diagnosis and Treatment Planning

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Websites on DSM-5

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

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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

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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

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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 to be further researched and covered
  in Section III of the DSM-5
• Emphasis was on developmental adjustment
  criteria
• New disorders were considered and older disorders
  were to be deleted
• Special emphasis was made for Substance/Medication
  Induced Disorders and specific classifications
  for them are listed for Schizophrenia Bipolar
  Depressive, Anxiety, Obsessive Compulsive
  Sleep-Wake Sexual Dysfunctions and
  Neurocognitive Disorders.

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Definition of Mental Disorder

• A mental disorder is a syndrome characterized by
  clinically significant disturbance in an
  individual's 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 death of a loved one, is not a
  mental disorder. Socially deviant behavior (e.g.,
  political, religious or sexual) and conflicts
  that are primarily between the individual and
  society are not mental disorders unless the
  deviance or conflict results from a dysfunction
  in the individual, as described above. 
• (American Psychiatric Association
  (2013). Diagnostic and Statistical Manual of
  Mental Disorders-Fifth Edition DSM-5. Arlington
  VA Author, p. 20.)

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Why identify a mental disorder diagnosis?

• The diagnosis of a mental disorder should have
  clinical utility
• Helps to determine prognosis
• Helps in development of treatment plans
• Helps to give an indication of potential
  treatment outcomes
• A diagnosis of a mental disorder is not
  equivalent to a need for treatment. Need for
  treatment is a complex clinical decision that
  takes into consideration
• Symptom severity
• Symptom salience (presence of relevant symptom
  e.g., presence of suicidal ideation)
• The client's distress (mental pain) associated
  with the symptom(s)
• Disability related to the client's symptoms,
  risks, and benefits of available treatment
• Other factors such as mental symptoms
  complicating other illness

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DSM-5 Diagnostic Categories

1. Neurodevelopmental disorders
2. Schizophrenia Spectrum and Other Psychotic
   Disorders
3. Bipolar and Related Disorders
4. Depressive Disorders
5. Anxiety Disorders
6. Obsessive Compulsive and Related Disorders
7. Trauma- and Stressor-Related Disorders
8. Dissociative Disorders
9. Somatic Symptom and Related Disorders
10. Feeding and Eating Disorder
11. Elimination Disorders
12. Sleep-Wake Disorders
13. Sexual Dysfunctions
14. Gender Dysphoria
15. Disruptive, Impulse-Control, and Conduct
    Disorders
16. Substance-Related and Addictive Disorders
17. Neurocognitive Disorders
18. Personality Disorders
19. Paraphilic Disorders

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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

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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
• Diagnostic codes will change from
  numeric ICD-9-CM codes on September 30, 2014 to
  alphanumeric ICD-10-CM codes on October 1,
  2014 e.g., Obsessive Compulsive Disorder will
  change from 300.3 to F42
• They have done away with the NOS labeling and
  replaced it with Other Specified... or
   Unspecified 

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What Replaces NOS?

• NOS is replace by either
• Other specified disorder or Unspecified disorder
  type are to be used if the diagnosis of a client
  is too uncertain because of
• 1. Behaviors which are associated with a
  classification are seen but there is uncertainty
  regarding the diagnostic category due to the fact
  that
• The client presents some symptoms of the category
  but a complete clinical impression is not clear
• 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
• 2. 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 the there is too brief a period of
  time in which the client has been seen or the
  clinician is untrained in the classification
• Rules for use of Other Specific or Unspecified
• This designation can last only six months and
  after that a specific diagnostic category has to
  be determined for the diagnosis of the client.

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Principle Diagnosis

• Principle Diagnosis is to be used when more than
  one diagnosis for an individual is given in most
  cases as the main focus of attention or
  treatment
• In an inpatient setting, the principle diagnosis
  is the condition established to be chiefly
  responsible for the admission of the individual
• In an outpatient setting, the principle diagnosis
  is the condition established as reason for visit
  responsible for care to be received 
• The principle diagnosis is often harder to
  identify when a substance/medication related
  disorder is accompanied by a non-substance-related
  diagnosis such as major depression since both
  may have contributed equally to the need for
  admission or treatment. 
• Principle diagnosis is listed first and the term
  "principle diagnosis" follows the diagnosis name
• Remaining disorders are listed in order of focus
  of attention and treatment 

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Provisional Diagnosis

• Specifier "provisional" can be used when there
  is strong presumption that the full criteria will
  be met for a disorder but not enough information
  is available for a firm diagnosis. It must be
  recorded "provisional" following the diagnosis
  given

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Respect for Age, Gender Culture in DSM-5

• 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

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• Specific Changes
• Per Diagnostic Category
• in DSM-5

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Neurodevelopmental Disorders

• 1. Intellectual Disability (Intellectual
  Developmental Disorder) no longer relies on IQ
  used as specifier because it is the adaptive
  functioning that determines levels of support
  required.
• IQ measures are less valid in the lower end of
  the IQ range
• Still accepted that people with intellectual
  disability have scores two standard deviations or
  more below the population mean, including a
  margin for error which is generally 5 points.
  Thus on tests with standard deviations of 15 and
  mean of 100 the score for mild would involve
  65-75 (705).
• 2. Asperger's Syndrome is lumped into Autism
  Spectrum since it is at the milder end of the
  Spectrum
• 3. Childhood disintegrative disorder, Rett's
  disorder and Pervasive developmental disorder not
  otherwise specified are also now incorporated
  into the Autism Spectrum Disorder
• 4. Autism Spectrum Disorder is now characterized
  by deficits in two domains
• Deficits in social communication and social
  interaction
• Restricted repetitive patterns of verbal and
  nonverbal communication.

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Schizophrenia and Other Psychotic Disorders

• 1.Changes for Criteria A for Schizophrenia were
  made
• 1) elimination of the special attribution of
  bizarre delusions and Schneiderian first-rank
  auditory hallucinations (two or more voices
  conversing), leading to the requirement of at
  least two Criterion A symptoms for any diagnosis
  of schizophrenia
• 2) the addition of the requirement that at least
  one of the Criterion A symptoms must be
  delusions, hallucinations, or disorganized
  speech.
• 2. DSM-IV-TR subtypes of schizophrenia were
  eliminated
• 3. Schizoaffective disorder is reconceptualized
  as a longitudinal rather than a cross sectional
  diagnosis and requires that a major mood episode
  be present for a majority of the total disorder's
  duration after Criterion A has been met
• 4. Schizotypal Personality Disorder is now listed
  in this category

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Bipolar and related disorders

• 1. Bipolar is now a free standing category
• 2. Bipolar was taken out of the mood disorder
  category
• 3. Diagnostic criteria now include both changes
  in mood and changes in activity or energy

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Depressive Disorders

• 1. Dysthymia is now called Persistent Depressive
  Disorder 
• 2. Disruptive Mood Dysregulation Disorder has
  been added for children up to age 18 years who
  exhibit persistent irritability and frequent
  episodes of extreme behaviors
• 3. Premenstrual Dysphoric Disorder has been
  added 

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Anxiety Disorders

• 1. No longer has PTSD in this category
• 2. No longer has OCD in this category
• 3. Social Phobia is now called Social Anxiety
  Disorder
• 4. Panic Disorder and Agoraphobia are unlinked
  and each now have their own separate criteria
• 5. Separation anxiety disorder and selective
  mutism are now classified as anxiety disorders

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Obsessive-Compulsive and Related Disorders

• 1. OCD is now a stand alone category
• 2. Body Dysmorphic Disorder is now listed under
  OCD
• 3. Hoarding has been added under the category of
  OCD
• 3. Trichotillomania (Hair-Pulling Disorder) is
  listed under OCD
• 4. Excoriation (Skin Picking Disorder) is
  listed under OCD

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Trauma and Stressor Related Disorders

• 1 Trauma related disorders are now a stand alone
  category
• 2. Reactive Attachment Disorder is now listed
  here
• 3. Disinhibited Social Engagement Disorder has
  been added
• 4. PTSD is listed here
• 5. PSTD in Preschool Children has been added
• 6. Acute Stress Disorder is listed here and
  requires qualifying traumatic events as explicit
  as to whether they were experienced directly,
  witnessed or experienced indirectly 
• 7. Adjustment Disorders are now listed here and
  conceptualize as a heterogeneous array of
  stress-response syndromes that occur after
  exposure to a distressing (traumatic or
  nontraumatic) event.

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Dissociative Disorders

• 1. Dissociative Fugue has been removed from this
  category and is now a specifier of dissociative
  amnesia
• 2. Derealization is included in the name and
  symptom structure of the former depersonalization
  disorder to become Depersonalization/Derealizatio
  n disorder.

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Somatic Symptom Disorder

• 1. Replaced Somatiform Disorders category with
  this category
• 2. Somatization Disorder Pain Disorder
  Hypochondriasis and undifferentiated somatoform
  disorder were eliminated
• 3. Complex Somatic Symptom Disorder was added
• 4. Simple Somatic Symptom Disorder was added
• 5. Illness Anxiety Disorder was added and
  replaces Hypochondriasis
• 6. Conversion Disorders (Functional Neurological
  Disorder) have modified criteria to emphasize
  essential importance of neurological examination,
  in recognition that relevant psychological
  factors may not be demonstrable at time of
  diagnosis
• 7. Psychological factors affecting other medical
  conditions has been added to this category and
  along with Factitious disorder both have been
  placed among the somatic symptom and related
  disorders  because somatic symptoms are
  predominant in both disorders

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Feeding and Eating Disorders

• 1. Pica was moved to this category
• 2. Rumination Disorder was moved to this category
• 3. The "feeding disorder of infancy or early
  childhood has been renamed Avoidant/Restrictive
  Food Intake Disorder 
• 4. Binge Eating Disorder was added

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Elimination Disorders

• 1. This category was created as freestanding
  category
• 2. Enuresis was moved to this category
• 3. Encopresis was move to this category

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Sleep-Wake Disorders

• 1. Primary Insomnia renamed Insomnia Disorder
• 2. Primary Hypersomnia joined with Narcolepsy
  without Cataplexy
• 3. Cheyne-Stokes Breathing added
• 4. Obstructive Sleep Apnea Hypopnea added
• 5. Idiopathic Central Sleep Apnea added
• 6. Congenital Central Alveolar Hypoventilation
  added
• 7. Rapid Eye Movement Behavior Disorder added
• 8. Restless Leg Syndrome added

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Sexual Dysfunctions

• 1. Male orgasmic disorder renamed Delayed
  Ejaculation
• 2. Premature (Early) Ejaculation renamed
• 3. Dyspareunia and Vaginismus were combined into
  Genito-Pelvic Pain/Penetration Disorder
• 4. Sexual Aversion Disorder combined in other
  categories
• 5. For females-sexual desire and arousal
  disorders have been combined into one disorder
  Female sexual interest/arousal disorder

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Gender Dysphoria

• 1 This is a new diagnostic class
• 2. It emphasizes the phenomenon of "gender
  incongruence" rather than cross-gender
  identification per se.
• 3. Posttransition specifier has been added to
  identify individuals who have undergone at least
  one medical procedure or treatment to support new
  gender assignment

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Disruptive, Impulse Control, and Conduct
Disorders

• 1. This is a new diagnostic class and combines
  "Disorders Usually First Diagnosed in Infancy,
  Childhood, or Adolescence" and the
  "Impulse-control Disorders Not Elsewhere
  Classified"2. Oppositional Defiant Disorder was
  added here
• 3. Trichotillomania removed from this category
• 4. Conduct Disorder now in this freestanding
  category
• 5. Antisocial Personality Disorder added to this
  category as well as in Personality Disorders
  Category

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Substance Abuse and Addictive Disorders

• Only 3 qualifiers are used in the category 
• Use - replaces both abuse and dependence
• Intoxication and Withdrawal remain the same
• 2. Nicotine Related renamed Tobacco Use Disorder
• 3. Caffeine Withdrawal added
• 4. Cannabis Withdrawal added
• 5. Polysubstance Abuse categories discontinued
• 6. Gambling added to this category

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Neurocognitive Disorders

• 1. Category replaces Delirium, Dementia, and
  Amnestic and Other Cognitive Disorders Category
• 2. Now distinguishes between Minor and Major
  Disorders
• 3. Replace wording of Dementia "due to"
   with Neurocognitive Disorder "Associated with"
  for all the conditions listed
• 4. Added new Neurocognitive Disorders 
• Fronto-Temporal Lobar Degeneration
• Traumatic Brain Injury
• Lewy Body Disease
• 5. Renamed Head Trauma to Traumatic Brain Injury
• 6. Renamed Creutzfeldt-Jakob Disease to Prion
  Disease

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Personality Disorders

• Cluster A Personality Disorders
• 301.0 (F60.0) Paranoid Personality Disorder
• 301.20 (F60.1) Schizoid Personality Disorder
• 301.22 (F21) Schizotypal Personality Disorder
• Cluster B Personality Disorders
• 301.7 (F60.2) Antisocial Personality Disorder
• 301.83 (F60.3) Borderline Personality Disorder
• 301.50 (F60.4) Histrionic Personality Disorder
• 301.81 (F60.81) Narcissistic Personality Disorder
• Cluster C Personality Disorders
• 301.82 (F60.6) Avoidant Personality Disorder
• 301.6 (F60.7) Dependent Personality Disorder
• 301.4 (F60.5) Obsessive-Compulsive Personality
  Disorder
• Other Personality Disorders
• 310.1 (F07.0) Personality Change Due to Another
  Medical Condition Specify whether Labile type
  Disinhibited Type Aggressive Type Apathetic
  Type Paranoid Type Other Type Combined Type
  Unspecified Type
• 301.89 (F60.89) Other Specified Personality
  Disorder
• 301.9 (F60.9) Unspecified Personality Disorder

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Paraphilic Disorders

• 1. They all carried over to DSM-5
• 2. New names for them all but the category
  remains the same
• 3. Overarching change is the addition of course
  specifiers
• in a controlled environment
• in remission
• 4. Distinction between paraphilias and paraphilic
  disorder was made
• Paraphilic disorder is a paraphilia that is
  currently causing distress or impairment to the
  individual or a paraphilia whose satisfaction has
  entailed personal harm, or risk of harm, to
  others. 
• Paraphilia is a necessary but not a sufficient
  condition for having a paraphilic disorder, and a
  paraphilia by itself does not automatically
  justify or require clinical intervention

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Conditions Designated for Further Study in
DSM-5 in Section III

• Attenuated Psychosis Syndrome
• Depressive Episodes with Short-Duration Hypomania
• Persistent Complex Bereavement Disorder
• Caffeine Use Disorder
• Internet Gaming Disorder
• Neurobehavioral Disorder Associated with Prenatal
  Alcohol Exposure
• Suicidal Behavior Disorder
• Nonsuicidal Self-Injury

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Possible  Disorders Discussed But Not Included in
Section III of DSM-5

• Dissociative Trance Disorder
• Anxious Depression
• Factitious disorder imposed on another
• Hypersexual Disorder
• Olfactory Reference Syndrome
• Paraphilic Coercive Disorder

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Other Conditions That May Be a Focus of Clinical
Attention (V Codes and TZ Codes)

• Relational Problems
• Problems Related to Family Upbringing
• Other Problems Related to Primary Support Group
• Abuse and Neglect
• Child Maltreatment and Neglect Problems
• Child Physical Abuse Child Sexual Abuse Child
  Neglect Child Psychological Abuse
• Adult Maltreatment and Neglect Problems
• Spouse or Partner Violence, Physical Spouse or
  Partner Violence, Sexual Spouse or Partner
  Neglect Spouse or Partner Abuse, Psychological
  Adult Abuse by Nonspouse or Nonpartner Adult
  Sexual abuse by nonspouse or nonpartner Adult
  Psychological abuse by nonspouse or nonpartner

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Other Conditions That May Be a Focus of Clinical
Attention Continued

• Educational and Occupational Problems
• Housing and Economic Problems
• Other Problems Related to Social Environment
• Problems Related to Crime or Interaction with
  Legal System
• Other Health Services Encounters for Counseling
  and Medical Advice
• Problems Related to Other Psychosocial, Persons
  and Environmental Circumstances
• Other Circumstance of Personal History
• Problems Related to Access to Medical and Other
  Health Care
• Nonadherence to Medical Treatment

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Steps to formulate an initial tentative diagnosis

1. Do a thorough Psychosocial History
2. Do a Mental Status Examination
3. Develop a Diagnosis using DSM-5

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• STEP 1
• Complete Psychosocial History

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First Establish - WHY NOW?

• You must be able to describe the presenting
  problem
• Listing specific symptoms and complaints which
  would justify diagnosis
• You must be able to list the duration of the
  symptoms or at least estimate the duration

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Second Review clients mental health history

• Previous treatment for mental health problems?
• Hospitalization for psychiatric conditions?
• As child involved in family therapy?
• Treatment for substance abuse problems-outpatient
  or inpatient?

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Third Determine if client is on any
psychotropic medications

• What medications?
• Level of prescription?
• Who prescribed medications?
• For what are the medications prescribed?

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Fourth Review clients relevant medical history

• What is current overall physical health of
  client?
• When was last physical?
• Is there anything currently or in the past
  medically accounting for this current mental
  health complaint?

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Fifth Review clients family history

• Do a genogram of the family
• Identify psychosocial stressors within the family
  structure
• Mental health and/or substance abuse history with
  in the family and if successfully treated

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Sixth Review clients social history

• School history Failed grades? Academic success?
  Social interaction with peers? Highest academic
  level attained?
• Community history Peer group? Current network of
  social support? Activities and interests sports,
  hobbies, social functioning?

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Seventh Review clients vocational history

• Level of current employment and commitment to
  current job?
• Relevant past employment history length of
  tenure on past jobs, job hopping, relationships
  with work peers?
• Level of satisfaction with current employment?

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Eighth List clients strengths

• Identify those strengths which make the client a
  good candidate for successful therapy to address
  the here and now mental health problem
• How motivated for therapy is client?
• How insightful to symptoms?
• How psychologically minded is client?
• How verbal and intelligent?

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Ninth List liabilities client bringsto therapy

• Level of present social support system?
• Mandated for freely coming to therapy?
• Perceptual problems which could interfere e.g.
  hearing, vision, etc.
• Risk of decompensating (relapsing) if not treated

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Tenth Rate Client on ACE Scale

• Identify Relevant ACE (Adverse Childhood
  Experiences)
• Abuse
• 1. Emotional Abuse
• 2. Physical Abuse
• 3. Sexual Abuse
• Neglect
• 4. Emotional Neglect
• 5. Physical Neglect
• Household Dysfunction
• 6. Mother was treated violently
• 7. Household substance abuse
• 8. Household mental illness
• 9. Parental separation or divorce
• 10. Incarcerated household member

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• Step 2
• Mental Status Examination

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Mental Health Status ExamMental Health Status
Exam Rates Clients

• Mood
• Concentration
• Activity level
• Thoughts
• Memory
• Judgment

• Appearance
• Consciousness
• Orientation to person, place time
• Speech
• Affect

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• Step 3
• Formulate Tentative Diagnosis

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Formulate Tentative Diagnosis

• You are ready to make a tentative Diagnosis using
  DSM-5 Including
• Principle Diagnoses
• Any Provisional Diagnosis
• Any relevant Other Conditions That May Be a Focus
  of Clinical Attention

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DSM-5 Single Diagnosis

• Use DSM-5 Most Appropriate Classification
• Include relevant rule-out diagnoses
• Compare clients symptoms lists with those
  contained in DSM-5 to get to most appropriate
  tentative Principle diagnosis
• Then list any and all secondary diagnosis if the
  clients symptoms match up for such
  classifications
• Also list Provisional diagnoses if the clients
  presentation allows for these additional
  diagnoses
• List all relevant V (T,Z) Code Conditions
• Each must be listed with number description
  just like the principal diagnosis

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It is important to remember

• The Diagnosis given a client is tentative
  dependent on gathering more data in future
  anticipated treatment
• Diagnoses can ALWAYS be changed to address
  changes with the individuals presentation
  functioning