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

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

Part One: The History of the DSM

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 DSMs 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

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

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 19 th and early 20 th 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

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

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

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

International Statistical Classification In 1948, the 6 th 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

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

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

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

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

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

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 Kraepelins 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

Neo-Kraepelinians (cont) Kraepelins 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

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

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

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 responsibilityThe efficacy of various treatment modalities can be compared only if patient groups are described using diagnostic terms that are clearly defined.

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

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

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

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

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

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

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

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Predictions (cont) Other proposed changes for the DSM-5: Autistic disorder, Aspergers 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)

Part Two: The DSM-5

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

The Basics The DSM-5 was released at the American Psychiatric Associations 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

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

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

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

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

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

Diagnostic Groupings 1.Neurodevelopmental Disorders 2.Schizophrenia Spectrum and Other Psychotic Disorders 3.Bipolar and Related Disorders 4.Depressive Disorder 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 Disorders 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

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

Autism Spectrum Disorder (ASD) Aspergers disorder is now absorbed into Autism Spectrum Disorder (ASD) Aspergers, Childhood Disintegrative Disorder, Retts 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

Autism Spectrum Disorder (cont) People with a well-established DSM-IV diagnosis of ASD, Aspergers, 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)

Autism Spectrum Disorder (cont) Three domains in DSM-IV will become two domains in the DSM-5: DSM-IV 1.Qualitative impairment in social interaction 2.Qualitative impairment in communication 3.Restricted repetitive and stereotyped patterns of behavior, interests, and activities DSM-5 1.Social and communication deficits 2.Restricted repetitive behaviors, interests, and activities (RRBs)

Autism Severity (Severity specifiers should not be used to determine eligibility for services) Severity LevelSocial Communication Restricted Interests, Repetitive Behaviors Level 3 Requiring very substantial support Severe deficits in verbal and nonverbal communication, limited social interaction Preoccupations interfere with functioning in all areas. Distress when rituals are interrupted Level 2 Requiring substantial support Marked deficits even with supports, limited initiation of social interactions, abnormal responses Rituals appear frequently enough that a casual observer notices. Some interference with function Level 1 Requiring support Without support, deficits cause impairment. Difficulty with social interaction Repetitive behaviors interfere with some functioning. Resists redirection

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

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%: Tourettes/tic disorders

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

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)

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

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

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

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

Disruptive Mood Dysregulation Disorder (cont) Severe recurrent temper outbursts: Verbal or behavioral Inconsistent with developmental level Mood between outbursts is persistently irritable or angry Present in a least 2 settings, severe in at least one Frequency: at least 3 times weekly Duration: 12 months, no more than 3 months symptom- free Can not diagnosis before age 6 or after age 18

Anxiety Disorders Post-Traumatic Stress Disorder (PTSD) and Obsessive Compulsive Disorder (OCD) are no longer in this category Panic attack is now just a specifier, not a diagnosis Category includes: Separation Anxiety Disorder Can diagnose with adult onset Selective Mutism Specific Phobia Social Anxiety Disorder Panic Disorder Agoraphobia Now a stand-along diagnosis, does not need to be linked with Panic Disorder Generalized Anxiety Disorder

Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder (OCD) is a stand alone category Category includes: OCD Body Dysmorphic Disorder (now listed under OCD instead of Somatoform Disorders) Hoarding Disorder (new) Trichotillomania Excoriation (new)

Obsessive-Compulsive and Related Disorders (cont) Insight specifier with OCD, Hoarding, and Body Dysmorphic Disorder DSM-IV required the person with OCD to realize the obsessions and compulsions were unreasonable, that is not required in the DSM-5 30% have a Tic Disorder 25% of OCD starts by age 14 Suicide and OCD: Ideation in 50% Attempts in 25%

Trauma and Stressor-Related Disorders Category includes: Reactive Attachment Disorder Disinhibited Social Engagement Disorder Post-Traumatic Stress Disorder (PTSD) Acute Stress Disorder Adjustment Disorders

Post Traumatic Stress Disorder (PTSD) Specifically includes sexual violence as a trigger event PTSD no longer requires that an individual have a subjective experience of fear or horror Well-trained emergency workers and military personnel often do not report subjective feelings of fear and horror At one year, 14% have dissociative symptoms Military leaders through that the word disorder made military people resistant to asking for help they wanted to rename PTSD to Post-Traumatic Stress Injury The task force felt that injury was imprecise and that the military environment needs to change

PTSD: Symptom Clusters DSM-IV: 3 symptom clusters Re-experiencing and intrusive symptoms Avoidance and numbing Arousal and reactivity DSM-5: 4 symptom clusters Re-experiencing and intrusive symptoms Avoidance and numbing Arousal and reactivity Negative alterations in cognitions and mood

PTSD: Symptom Clusters (cont) Negative cognitions and mood: Inability to remember important aspects of the trauma Negative beliefs about self, others, or the world Persistent distorted blame of self or others Pervasive negative emotional state Diminished interest in significant activities Feeling detachment from others Inability to experience positive emotions

PTSD: Symptom Clusters (cont) Re-experiencing and intrusive symptoms: Recurrent memories of the traumatic event Recurrent distressing dreams related to the trauma Flashbacks or other intense prolonged psychological distress Avoidance: Avoiding distressing memories, thoughts, feelings, or external reminders of the event Arousal and reactivity: Aggressive, reckless, or self-destructive behavior Sleep disturbance Hypervigilance Irritability and anger

Substance Use and Addictive Disorders This is by far the largest category in the DSM-5 Only three qualifiers are used in the category Use (replaces both abuse and dependence) Intoxication Withdrawal Nicotine-related renamed tobacco use Polysubstance categories discontinued Gambling added to this category

Substance Use and Addictive Disorders (cont) Substance use disorder replaces both abuse and dependence Dependence was misused when describing the normal physical reactions that can occur during appropriate medication use, such as antidepressant discontinuation syndrome Abuse was more reliably assessed than dependence Nicotine was changed to tobacco Do not want people on nicotine replacement to get confused and think they are doing something risky Tobacco is the harmful agent with significant health risks

Substance Use and Addictive Disorders (cont) Symptoms: 1.Taken in larger amounts or for a longer period than intended 2.Persistent desire or unsuccessful efforts to cut down or control use 3.Great deal of time is spent obtaining, using, or recovering 4.Craving or a strong desire or urge to use 5.Recurrent use results in failure to fulfill major role obligations at work, school, or home 6.Continued use in spite of social or interpersonal problems 7.Important activities are given up or reduced because of use 8.Recurrent use when it is physically hazardous 9.Continued use in spite of physical problems 10.Tolerance 11.withdrawal

Substance Use and Addictive Disorders (cont) Severity: Mild = 2-3 symptoms Moderate = 4-5 symptoms Severe = 6 or more symptoms

Gambling Moved to substance use and addictive disorders section from disruptive, impulse control, and conduct disorders section Only behavioral addiction in the manual Individuals who are pathological gamblers: show tolerance, dependence, and withdrawal The brains reward system and neural circuits react in similar ways Similar to substance use disorders in: Clinical expression Brain origin Comorbidity Frontal lobe dysfunction Treatment (Cognitive-Behavioral Therapy, 12-step program, motivational, brief) Impulse dysregulation Genetics

In Conclusion The DSM has frequently been referred to as the gold standard for psychiatric diagnosis The DSM is used in clinical and research contexts throughout the world, and few texts match its influential power There are a number of factors that spurred the development of the first edition of the DSM, with perhaps the most important being the need for a common diagnostic language From the beginning, there were fundamental differences between the DSM and the ICD As international collaboration becomes increasingly more common, continued harmonization of the DSM and ICD is needed

In Conclusion (cont) The development of DSM, from beginning to present, resembles a historic pendulum, from DSM-I on the one hand emphasizing psychodynamics and causality to DSM-III and DSM-IV emphasizing empiricism and logical positivism Etiological- and dimensional-based classification for DSM-5 appear to represent a shift toward the center

References Sanders, J. L. (2011). A distinct language and a historic pendulum: The evolution of the diagnostic and statistical manual of mental disorders. Archives of Psychiatric Nursing, 25, 394-403. Teater, M. (2013). Using the DSM-5 for Revolutionizing Diagnosis & Treatment. Eau Claire, Wisconsin: CMI Education. DSM-5 Press Briefing at the APA Annual Meeting in San Francisco May 18, 2013 Speaker: DSM Task Force Chair David Kupfer, MD American Psychiatric Association: www.dsm5.org www.psychiatry.org/dsm5

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