June 2013 DSM-5 Changes

Overall Organization Developmental approach to psychiatric disorders Recognition of the influence of culture and gender on how psychiatric illness presents in individual patients Move toward the use of dimensional measures to rate severity and disaggregate symptoms that occur across multiple disorders Harmonization with ICD Integration of genetic and neurobiological findings by grouping clusters of disorders that share these substrates

Organizational Changes Section 1—Basics Organization to DSM-5 with information on how to use the updated manual Section 2—Diagnostic Criteria and ICD codes Outlines the categorical diagnoses according to a revised chapter organization related to developmental stages Section 3—Emerging Measures and Models Includes conditions that require further research before their consideration as formal disorders as well as cultural formulations and the glossary Section 4—Appendix Highlights of changes between DSM-IV and DSM-5 Glossary of technical terms and cultural concepts of distress Listing of DSM-5 diagnoses and codes

Why reorganization? The boundaries between many disorder categories are more fluid over the life course than was previously understood and many symptoms assigned to a single disorder may occur at varying levels of severity in many other disorders.

Overall Changes Chapter order Twenty chapters were restructured based on disorders’ apparent relatedness to one another Similarities in underlying vulnerabilities and symptom characteristics Align with the World Health Organization (WHO) International Classification of Diseases ICD-11 Reduce the utilization of NOS (not otherwise specified) diagnoses to classify patients who do not fit into more explicit diagnostic categories. Reduction in diagnoses—from 172 in DSM-IV to 157 in DSM-5

Overall Changes Removal of multiaxial system Nonaxial documentation of diagnosis Combining the former Axes I, II, III Separate notation for psychosocial and contextual factors—formerly Axis IV disability—ICD-9-CM V Codes now and ICD-10-CM Z Codes in 10/14 Separate notation for disability—formerly Axis V in DSM IV No more GAF Elimination of NOS—Not Otherwise Specified Elimination of Substance Abuse and Substance Dependence Elimination of Sexual Aversion Disorder and Polysubstance related disorder

Example The Criteria for autism spectrum disorder include three levels of severity for the two principal symptoms Deficits in social communication and social interaction Restrictive and repetitive behavior patterns

Chapter Order Reflects a “lifespan” approach with diagnoses diagnosed in childhood at the beginning of the manual and disorders more applicable to older adulthood at the end of the manual Neurodevelopmental disorders Neurocognitive disorders

Chapters Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Obsessive-Compulsive and Related Disorders Trauma and Stressor Related Disorders Dissociative Disorders Somatic Symptom Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions

Chapters Gender Dysphoria Disruptive, Impulse Control and Conduct Disorders Substance Use and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Disorders

Neurodevelopmental Disorders Social communication disorder describes children who exhibit deficits in language and communication but do not have restrictive/repetitive behaviors necessary for ASD. These children would typically receive a DSM-IV diagnosis of pervasive developmental disorder –not otherwise specified

Neurodevelopmental Disorders Specific learning disorder consolidates three DSM-IV learning disorders, but includes specifiers related to deficits in reading, written expression and mathematics Intellectual disability, replacing the DSM-IV category of “mental retardation” requires both adaptive-functioning assessments and IQ scores for diagnosis.

Neurodevelopmental Disorders Attention deficit/hyperactivity disorder has been added to this diagnostic category and is largely unchanged from DSM- IV. However, age of onset was increased from 7 to 12. The subtypes of inattentive, hyperactive and mixed were replaced with presentation specifiers. The threshold for diagnosis in adults was adjusted to five symptoms in either domain to reflect evidence-based impairments.

Neurodevelopmental Disorders Three communication disorders—language disorder, childhood onset fluency disorder (stuttering) and speech sound disorder—replace DSM-IV diagnoses of expressive language disorder, stuttering and phonological disorder respectively Criteria for motor disorders are largely unchanged. DSM-5 criteria for Tourette’s and chronic motor or vocal tic disorder state that tics may “wax and wane in frequency but have persisted for more than a year.”

Neurodevelopmental Disorders Autism spectrum disorder (ASD) replaces the four DSM-IV autism diagnoses and includes expanded specifiers and ratings of severity Replaces Autism, Asperger’s, Childhood Disintegrative Disorder and Pervasive Developmental Disorder-not otherwise specified (PDD- NOS) Principal symptoms are a continuum Deficits in social communication and social interaction Repetitive/restrictive behaviors Severity ratings for the principal symptoms indicate the level of supportive services required Requiring support Requiring substantial support Requiring very substantial support Symptoms must be present in the “early developmental period” as the disorder is evident as early as 24 months

Schizophrenia Elimination of the subtypes delineated in previous editions and the creation of a catatonia specifier—no longer a separate subtype of psychosis The catatonia specifier can be used for depressive, bipolar, and psychotic disorders or as a separate diagnosis in the context of a known medical condition

Schizophrenia Two criterion A symptoms will be required for any diagnosis of schizophrenia, at least one of which must be delusions, hallucination or disorganized thinking Delusional disorder no longer has the requirement that the delusions must be nonbizarre

Psychosis and Bipolar Disorders An anxious distress “specifier” will be included for bipolar and for depressive disorders Criteria for bipolar disorder now includes an emphasis on changes in activity and energy—not just mood Eliminates Bipolar Disorder 1—mixed type and instead includes a “mixed state” specifier that can be used when episodes of mania include depressive symptoms and for depression that includes mania or hypomania

Depressive Disorders Reconceptualization of chronicity Mood disorders as a spectrum with different degrees of severity Addition of two new diagnoses Disruptive Mood Dysregulation Disorder (DMDD) Effort to identify children who experience extreme irritability without changes in mood that are characteristic of bipolar disorder and to address what some believe is an overdiagnosis of bipolar disorder in children Premenstrual Dysphoric Disorder (PMDD) Moved from appendix to a new diagnostic entity

Depressive Disorders Dysthymia is now subsumed under the diagnosis of persistent depressive disorder Elimination of the “grief exclusion” for major depression Patients experiencing several and persistent depression related to bereavement can be diagnosed and treated Mixed state specifiers for patients who experience symptoms of mania along with depression

Anxiety Disorders Includes separate diagnostic categories for agoraphobia and panic attack Separation Anxiety Disorder and Selective Mutism are now located in this chapter Severity ratings are included with anxiety PTSD is now in a chapter with trauma, stressor and dissociative disorders Specific phobia and social anxiety disorders require that symptoms persist for at least six months—clinician judgment required as to whether the fears are out of proportion to the danger posed

Obsessive-Compulsive and Related Disorders Includes four new disorders Hoarding Disorder Excoriation (Skin Picking) Disorder Substance/medication induced obsessive-compulsive and related disorder Obsessive-compulsive and related disorder due to another medical condition Body dysmorphic disorder, OCD and trichotillomania are in this chapter

Obsessive Compulsive and Related Disorders Excoriation (Skin-Picking) Disorder is new to DSM-5 Hoarding Disorder is new to DSM-5 Characterize people with persistent difficulty discarding or parting with possessions, regardless of their actual value Significant harmful effects—emotional, physical, social financial and even legal

Trauma and Stressor Related Disorders Groups disorders whose symptoms are preceded by a traumatic or distressing event. Criteria for acute stress disorder and PTSD are not more explicit about how the distressing or traumatic event was experienced Directly experienced Witnessed Experienced indirectly

Post Traumatic Stress Disorder Elimination of the requirement for a subjective response at the time of the event Four symptom clusters: Re-experiencing Avoidance Persistent negative alterations in mood and cognition Arousal Developmentally sensitive—modified for children age 6 or younger

Trauma and Stressor Related Disorders Two distinct diagnoses Reactive Attachment Disorder Disinhibited Social Engagement Disorder Adjustment Disorder has been moved into this chapter More specific diagnosis reconceptualized as a stress-response syndrome following a traumatic or non-traumatic event

Dissociative Disorders “Derealization” is included in the name and symptom structure of what previously was called depersonalization disorder Now called depersonalization/derealization disorder Dissociative fugue is now a specifier of dissociative amnesia rather than a specific diagnosis Criteria for dissociative identity disorder have included a cross-cultural component that recognizes experiences of pathological possession in some cultures consistent with the description of identity disruption

Somatic Systems and Related Disorders Change from somatoform disorders Hypochondriasis has been eliminated Somatic symptom disorder—high health anxiety with somatic symptoms Illness anxiety disorder—high health anxiety without somatic symptoms Psychological factors affecting other medical conditions included in this chapter Symptoms lasting six months including thoughts, feelings and behaviors that are disproportionate

Feeding Disorders Binge eating disorder has been added as a diagnosis for individuals who have persistent episodes, at least once a week, of overeating marked by loss of control and significant clinical distress Criteria for anorexia have been amended, eliminating the requirement for amenorrhea Avoidant/restrictive food intake disorder has replaced feeding disorder of infancy or early childhood Criteria for bulimia nervosa requires a minimum average frequency of once weekly

Sleep-Wake Disorders Insomnia disorder replaces primary insomnia—typically coexists with other medical and psychiatric disorders—with each exacerbating the other and each requiring specific clinical attention Narcolepsy—associated with hypocretin deficiency—is separated from other forms of hypersomnolence

Sleep-Wake Disorders Breathing related sleep disorders are divided into three relatively distinct disorders Obstructive sleep apnea hypopnea Central sleep apnea Sleep related hypoventilation Circadian rhythm sleep-wake disorders have been expanded to include Advanced sleep phase syndrome Irregular sleep-wake type Non 24-hour sleep-wake type Jet lag type has been removed

Sexual Dysfunctions Addition of gender-specific sexual dysfunctions Combined female sexual interest/arousal disorder Require a minimum duration of approximately 6 months

Gender Dysphoria New category/diagnostic class replacing gender identity disorder Reflects a new conceptualization of individuals who seek treatment for problems related to gender Emphasizes gender incongruence rather than cross-gender identification Intent to decrease stigma Separate criteria based upon age

Gender Dysphoria Specifiers to indicate whether the individual’s condition is related to a disorder of sex development (DSD) such as congenital adrenal hyperplasia For adolescents and adults, a specifier is also included for individuals who have transitioned to full-time living in the desired gender For children, “a strong desire to be of the other gender or an insistence that he or she is the other gender” is now necessary but not sufficient to meet the diagnosis

Disruptive, Impulse Control and Conduct Disorders Brings together disorders marked by problems with emotional and behavioral self-control Replaces the “Disorders Usually First Diagnoses in Infancy, Childhood or Adolescent” Oppositional Defiant Disorder Conduct Disorder Intermittent Explosive Disorder

Disruptive, Impulse-Control and Conduct Disorders Also includes: Antisocial personality disorder Pyromania Kleptomania Oppositional Defiant Disorder symptom classification— covers emotional and behavioral focus Angry/irritable mood Argumentative/defiant behavior Vindictiveness

Disruptive, Impulse-Control and Conduct Disorders ODD and Conduct Disorder may be diagnosed at the same time Criteria indicates that symptoms must be present more than once a week to distinguish the diagnosis from normal development Severity rating must reflect the degree of pervasiveness of symptoms

Disruptive, Impulse-Control and Conduct Disorders Intermittent Explosive Disorder changes: Type of aggressive outbursts can include physical aggression, verbal aggression and nondestructive/noninjurious physical aggression Aggressive outbursts are impulsive and/or anger and must cause marked distress, cause impairment in occupation or interpersonal functioning, or associated with negative financial or legal consequences A minimum age of 6 is required

Disruptive, Impulse-Control and Conduct Disorders Conduct Disorder is largely unchanged with the exception of a descriptive specifier addressing deficiencies in “pro social behaviors.”

Substance Use Disorder Combines the categories of substance abuse and dependence Criteria has been strengthened Includes gambling disorder Cannabis withdrawal and caffeine withdrawal is included Early remission from a substance use disorder is defined as at least three but less than 12 months without criteria

Substance-Related and Addictive Disorders Severity rating—two or three criteria indicate a mild disorder; four or five criteria indicate a moderate disorder and six or more, a severe disorder

Neurocognitive Disorders Mild neurocognitive disorder, previously included in the appendix of DSM-IV, is intended to describe individuals who have cognitive impairment but do not meet previous DSM-IV criteria for dementia. Its inclusion in Section II of the manual reflects the movement within the Alzheimer’s community toward earlier diagnosis and treatment. Dementia is subsumed under the newly named entity “major neurocognitive disorder.” Criteria for mild and major neurocognitive disorder include etiological subtypes having their own separate criteria Continued on next slide

Neurocognitive Disorders Alzheimer’s disease NCD Vascular NCD Frontotemporal NCD Lewy bodies NCD Traumatic brain injury NCD Parkinson’s disease NCD HIV infection NCD Substance/medication induced NCD Huntington’s disease NCD Prion Disease NCD NCD due to another medical condition Unspecified NCD

Personality Disorders Will maintain the categorical model and criteria for the 10 personality disorders from DSM-IV and will include the new trait-specific methodology in a separate area of Section 3 to encourage further study This chapter addresses the considerable overlap of symptoms across disorders and the overuse of “not otherwise specified” (NOS) Focus is on dimension Personality types, traits and disorders are on a continuous spectrum

Personality Disorders Six (6) types remain Antisocial Avoidant Borderline Narcissistic Obsessive-Compulsive Schizotypal New diagnosis of Personality Disorder—Trait Specified Meet general criteria for a PD but do not have one of the six specified disorders By utilizing trait specifiers, symptoms can be noted from previous PD diagnoses—paranoid, schizoid, histrionic and dependent

Personality Disorders Criterion A—Impairment in self or interpersonal functioning Self—Identify, self direction Interpersonal functioning--empathy and intimacy Criterion B—Pathological personality traits in five broad areas Negative affectivity Detachment Antagonism Disinhibition Psychoticism

Personality Disorders Alternate model in Section III includes a scale for measuring the level of impairment ranging from 0 (no impairment) to 4 (severe impairment) A diagnosis of one of the personality disorders would require at least a level 2 (moderate) category of impairment

Paraphilic Disorders Separate and distinct chapter with no alterations to criteria but does entail some important conceptual reformulations. Paraphilias are defined as atypical sexual—not a diagnosis Paraphilic disorders are defined as distress or impairment in functioning—a paraphilia is necessary for the diagnosis Specifiers are included such as “in remission” or “in a controlled environment” to indicate course of illness “In a controlled environment” would be someone who is incarcerated with a diagnosis of pedophilic disorder Criterion A and Criterion B are required Criterion B indicates that the paraphilia causes distress or impairment in functioning or that the sexual practice inherently involves nonconsenting individuals

Section III Disorders that require more research Attenuated psychosis syndrome—patients who experience distress and impairment from symptoms that do not rise to the clinical threshold of psychosis—may lead to earlier identification of individuals before they become actively psychotic Internet gaming disorder Non-suicidal self-injury Suicidal behavioral disorder Depressive episodes with short-duration hypomania Persistent complex bereavement disorder Caffeine use disorder Neurobehavioral disorder due to prenatal alcohol exposure

Section III— Emerging Measures and Models Not an “appendix” but includes tools to enhance diagnosis, as well as models for an evolving DSM of the future Includes patient-rated and clinician-rated measures of symptoms that cut across all DMS diagnoses, measures of disability, information about how cultural context can influence the presentation of mental illnesses and an alternative model for diagnosis of personality disorders Includes the World Health Organizations Disability Assessment Schedule as a replacement for the GAF Amenable to the use of EHR’s

Additional Features Appendix Contains a glossary of terms and the names of the individuals who participated in the development of the manual Listing of diagnoses and codes Highlights of changes from DSM-IV to DSM-5

Frequently Asked Questions When can DSM-5 be used for insurance purposes? It is compatible with the HIPAA approved ICD-9-CM coding system now in use by insurance companies The revised criteria can be used immediately for diagnosing The change in format from a multi-axial system may results in a brief delay while insurance companies update their claim forms and reporting procedures

Frequently Asked Questions How will the previous multi-axial conditions be coded? DSM-5 combines the first three axes into one list that contains all mental disorders including personality disorders, intellectual disability and other medical diagnoses. Contributing psychosocial and environmental factors are now represented through an expanded selected set of ICD-9-CM-V codes. DSM-5 contains these codes.

Frequently Asked Questions ICD-10-CM is adopted 10/1/2014. How will diagnoses be coded then? DSM-5 contains both ICD-9-CM codes for immediate use and ICD-10-CM codes in parentheses. No separate training will be required. Psychosocial and environmental factors will be called Z-codes in ICD-10-CM Includes other conditions or problems that may be a focus of clinical attention or otherwise affect the diagnosis, course, prognosis or treatment of a mental disorder

Frequently Asked Questions With the removal of the multiaxial system in DSM-5, how will disability and functioning be assessed? The DSM-5 includes separate measures of symptom severity and disability for individual disorders rather than the GAF. This is consistent with the WHO recommendations to be consistent between ICD and ICF—International Classification of Functioning, Disability and Health. Details about these measures are included in Section III of the manual

Frequently Asked Questions Different disorders or subtypes share the same diagnostic code—is this an error? No. It is occasionally necessary to use the same code for more than one disorder. The relationship is with DSM-5 and ICD. The APA is working with the CDC and CMS to include new DSM-5 terms in the ICD-10-CM and will inform clinicians and insurance companies when modifications are made. The disorders should be recorded by name and not by number.

Frequently Asked Questions The names of some DSM-5 disorders do not match the names of the ICD disorders. Why? DSM-5 diagnostic codes are limited to those contained in the ICD, new DSM-5 disorders were assigned the best available codes. The DSM-5 diagnosis should always be recorded by name in the medical record in addition to listing the code.

Frequently Asked Questions How are DSM-5 and ICD related? Companion publications Can clinicians continue to use the DSM-IV-TR diagnostic criteria? May use the DSM-5 starting in May. Transition details are still being developed with CDC-NCHS, CMS and private insurance agencies. The APA is working with these groups with the expectation that a transition to DSM-5 by the insurance industry can be made by December 31, 2013

Additional Resources Located at Look for articles in the on-line Psychiatric News Additional resources located in the DSM 5 section of the Clinical Services SharePoint site