DSM-5 Survival Guide Formatted Final PDF
DSM-5 Survival Guide Formatted Final PDF
DSM-5 Survival Guide Formatted Final PDF
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Pre-Release Chatter
• Highly controversial and widely criticized
• The end of multiaxial diagnosis
• Structural reorganization with focus on etiology and
development
• Widespread neurobiological assumptions
• Mandates regarding use of un-validated assessments
• Lowered diagnostic thresholds
• Changes may lead to harm for vulnerable populations
• Questionable engagement in field trials
• Questionable empirical basis for many changes
• Very limited involvement of professional counselors
DSM-5 REVISION PROCESS
13 workgroups
ADHD and Disruptive Behavior
Axiety, OCD, PTSD, and Dissociative
Childhood and Adolescent
Eating
Mood
Neurocognitive
Neurodevelopmental
Personality
Psychotic
Sexual and Gender Identity
Sleep-Wake
Somatic symptoms
Substance-related
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DSM-5 Revision Process
1999-2001 Development of research agenda, 6 workgroups
2002-2007 APA/WHO/NIMH research planning conferences
2006 Appointment of DSM-5 Task Force
2007 Appointment of 13 workgroups
2007-2011 Literature review and data re-analysis
2010-2011 1st phase field trials (large medical/academic)
2010-2012 2nd phase field trials (private practice)
July 2012 Final draft submitted for review
May 2013 DSM-5 released to the public
From DSM-IV-TR to DSM-5
Concerns with DSM-IV Hopes for DSM-5
• Rigid classification system • More dimensional assessment
• Comorbidity • Sound assessments
• Questionable reliability • Reduce comorbidity
• Overuse of NOS • Reduce reliance on NOS
• Controversial diagnoses • Incorporate advances in
psychiatric research, genetics,
neuroimaging, cognitive
science, and pathophysiology
The Reality
Philosophical Change 1
• From phenomenological interpretations (symptoms
and behavioral; medical model) toward
pathophysiological origins (functional changes
associated with disease or injury; biological model)
– New groupings of disorders
– New text coverage within disorders
– Expected to be area of increased attention
Philosophical Change 2
• From categorical groupings toward dimensional
conceptualizations
• Minor compared to proposed
• Capture frequency, duration, and severity of
experience with disorders within diagnosis
– New severity indicators throughout
– New specifiers throughout
– Movement toward specifying assessment measures
Categorical Diagnosis
Advantages Disadvantages
• Discrete clinical criteria • Assumes little variation within
indicating presence or disorder
absence of disorder • Assumes populations
• Common language relatively homogeneous
• Empirically based criteria • Low diagnostic agreement
• Led to development of ESTs • High comorbidity
• Overuse of NOS
Dimensional Diagnosis
Advantages Disadvantages
• Potential to capture • Messy
increased complexity • Administrative burden
• Potential in program and • Lack of consistency
practice evaluation • Lack rigorous validation
• Practice reality – lack
confidence, training, time
• DSM-III severity ratings
largely ignored due to lack
of clinical utility
STRUCTURAL CHANGES
DSM-5 Organization
• Section I • Section III
– Introduction – Emerging measures
– Use of manual – Conditions for
further study
• Section II
– Criteria and codes
Key Structural Changes
DSM-IV-TR DSM-5
16 diagnostic classes, one 3 sections with 20 diagnostic
general section, 11 appendices classes, 2 general sections, 7
appendices
ICD-9-CM Codes ICD-9-CM & ICD-10-CM codes;
ICD-11 harmonization
Multiaxial assessment Nonaxial system
General medical condition Another medical condition
Not otherwise specified Other-specified and
unspecified
DSM-IV Multiaxial System DSM-5 Nonaxial System
Axis I: Clinical d/o & other Combined attention to clinical
conditions that are focus of disorders, including personality
treatment disorders and intellectual
Axis II: Personality disorders and disability; other conditions that are
mental retardation the focus of treatment; and
medical conditions
Axis III: General medical conditions
Reason for visit, psychosocial, and
Axis IV: Psychosocial and contextual factors via expanded list
environmental stressors of V Codes and Z Codes
Disability included in notation.
Axis V: Global assessment of World Health Organization
functioning Disability Assessment Schedule 2.0
(WHODAS 2.0) included as option
Expanded V-Codes
• pp. 715-727
• Include in official diagnosis if a focus of treatment
• Greatly expanded, for example
– Child affected by parental relationship distress
– Problem related to current military deployment status
– Homelessness
– Social exclusion or rejection
– Target of (perceived) adverse discrimination or persecution
– Sex counseling
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Nonaxial Questions
• How will we implement?
• What medical issues should be included? If we
cannot diagnose them, are we qualified to include
them?
• How can we make sure we remember contextual
issues?
• How can we make sure we assess and track
distress/impairment?
• How will 3rd party payers adjust?
My Recommendations
• List all relevant diagnoses in order of focus
• Make tentative with “provisional” as necessary
• Increase use of V-codes
• Include medical conditions only if documented and
relevant to conceptualization
Sample Diagnosis
Situation DSM-5 Diagnosis
• Child referred for 314.01 attention-deficit
counseling because of hyperactivity disorder,
numerous disciplinary combined presentation,
problems at school. Upon moderate (principal diagnosis)
assessment, child is found and
to meet criteria for ADHD
V62.3 academic or educational
problem (reason for visit)
Sample Diagnosis
Situation DSM-5 Diagnosis
• Client meets criteria for 296.23 major depressive
depression, uses alcohol disorder, single episode,
excessively, and is unable to severe
control diabetes as a result
of the disturbance 303.90 alcohol use disorder,
moderate
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Self-Rated Level 1 Cross-Cutting
Assessment Measure - Adult
• 23 questions
• 13 domains with 1-3 questions
• Self or informant report
• Past 2 weeks
• 5 point scale
– 0 = none or not at all
– 1 = slight or rare, less than a day or two
– 2 = mild or several days
– 3 = moderate or more than half the days
– 4 = severe or nearly every day
• Thresholds provided for Level 2 follow-up
Other Level 1 Assessments
• Level 1 Cross-Cutting Symptom Measure – Child Age
6-17 (parent/guardian rated)
– In DSM and Online
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SECTION II:
DIAGNOSTIC CRITERIA AND CODES
Section II
• Attempted to change to • Grouping Indicators
empirically-based – shared neural substrates
developmental perspective – family traits
– Grouped by presumed – genetic risk factors
underlying vulnerabilities – environmental risk factors
– Internalizing vs. externalizing – biomarkers
clusters
– temperamental antecedents
– Adjacencies important
– abnormalities of emotional or
– Listed in order of cognitive processing
development within and
between chapters – symptom similarity
– course of illness
– high comorbidity
– shared treatment response
Section II Table of Contents
• Neurodevelopmental • Sexual dysfunctions
• Schizophrenia spectrum and • Gender dysphoria
other psychotic • Disruptive, impulse-control, and
• Bipolar and related conduct
• Depressive • Substance-related and addictive
• Obsessive-compulsive and related • Neurocognitive
• Trauma- and stressor-related • Personality
• Dissociative • Paraphilic
• Somatic symptom and related • Other mental disorders
• Feeding and eating • Medication-induced movement
• Elimination disorders and other adverse
• Sleep-Wake effects of medication
• Other conditions that may be a
focus of clinical attention
Section II Text
• Diagnostic features
• Associated features supporting diagnosis
• Prevalence
• Development and course
• Risk and prognostic features
• Culture-related diagnostic issues
• Gender-related diagnostic issues
• Suicide risk
• Functional consequences
• Differential diagnosis
• Comorbidity
A WHIRLWIND TOUR OF NEW
DISORDERS AND MAJOR CHANGES
Intellectual Disability Becomes Functional
• Elimination of
– Abuse and Dependence distinction
– Physiological dependence specifier
– Partial remission
– Polysubstance disorder
Substance Use Disorder
Over 12-month Period: Severity and Specifiers:
• Larger amounts, longer time • Mild = 2-3 symptoms
• Attempts to cut down
• Time spent to obtain, use, recover • Moderate = 4-5 symptoms
• Craving • Severe = 6 + symptoms
• Failure to fulfill major obligations
• Continued use despite recurrent
problems • Early remission
• Giving up activities
• Use when physically hazardous
• Sustained remission
• Continued use despite physical or • Controlled environment
psychological problems
• Tolerance • Maintenance therapy (for opioid
• Withdrawal use only)
NEW: Gambling Disorder
• The only non-substance-related disorder included in
the DSM-5
• Formerly pathological gambling from the impulse
control disorders not elsewhere specified chapter
• Specifiers:
– Episodic and persistent
– Early remission and sustained remission
OVERHAUL: Neurocognitive Disorders
• Dementia, amnestic, and other cognitive disorders
collapsed into neurocognitive disorder (NCD)
• Delirium remains unchanged
• Evidence of decline within six cognitive domains
– Complex attention
– Executive function
– Learning and memory
– Language
– Perceptual-motor
– Social cognition
OVERHAUL: Neurocognitive Disorders
• Major NCD = significant decline and impairment
– Mild, moderate, severe
– Code by cause
• Mild NCD = modest decline without impairment of
everyday independence
– No further severity or code
• DSM-5 includes operationalized examples for major
and mild NCD in each domain
CONSIDER: Personality Disorders Model
• Controversial
• Largely unchanged in DSM-5
• New model presented in Section III
– Dimensional-categorical model
– Impairments in functioning (level 0-4): identity, self-
direction, empathy, intimacy
– Traits: 5 broad domains and 25 specific facets
• Corresponding assessment tool in DSM-5 website
Lingering Questions
• Will changed criteria result in drastic changes in
some diagnoses?
• Will lowered thresholds lead to increased
– access to services?
– stigma?
– psychotropic treatment?
– costs?
– help-seeking?
– normalization of mental health concerns?
• Will clinicians use assessments and new specifiers?
QUESTIONS AND COMMENTS
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DSM-5 Resources
• DSM-5 change fact sheets
– www.dsm5.org
• Online assessment measures
– http://www.psychiatry.org/practice/dsm/dsm5/online-
assessment-measures
• Insurance
– http://www.psychiatry.org/File%20Library/Practice/DSM/
DSM-5/Insurance-Implications-of-DSM-5.pdf