DSM V An overview of notable changes from DSM IV Barika Grayson LMHC, NCC, CCM

DSM-5 Chapter Clustering Neuro-developmental Disorders Emotional (Internalizing) Disorders Somatic Disorders Externalizing Disorders Neurocognitive Disorders Personality Disorders DSM-IV’s organizational structure failed to reflect shared features or symptoms of related disorders and diagnostic groups (like psychotic disorders with bipolar disorders, or internalizing (depressive, anxiety, somatic) and externalizing (impulse control, conduct, substance use) disorders. DSM-5 restructuring better reflects these interrelationships, within and across diagnostic chapters

DSM-5 Chapters Neuro-developmental Disorders Schizophrenia Spectrum & Other Psychotic Disorders Bipolar & Related Disorders Depressive Disorders Anxiety Disorders Somatic Symptom Disorders Obsessive-Compulsive & Related Disorders Trauma -and Stressor- Related Disorders Dissociative Disorders Feeding & Eating Disorders The number of chapters increased to 19 Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse Control & Conduct Disorders The DSM-5 introduces 4 more chapters and is structured so that relevance between related diagnosis groups can be captured Substance Use & Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Disorders The DSM-5 has reclassified chapters to encompass related disorders

Notable Changes in the DSM-5 DSM-IV DSM-5 Did not adequately address the lifespan perspective, including variations of symptom presentations across the developmental trajectory, or cultural perspectives The multiaxial system in DSM-IV is not required to make a mental disorder diagnosis and has not been universally used chapter structure, criteria revisions, and text outline actively address age and development as part of diagnosis and classification Culture is similarly discussed more explicitly to bring greater attention to cultural variations in symptom presentations DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I, II, and III), with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V) This approach is consistent with established WHO and ICD guidance to consider the individual’s functional status separately from his or her diagnoses or symptom status

Multi-Axial Diagnosis Eliminated Axis IV: psychosocial & environmental factors Have been replaced by an expanded set of V codes The V codes will allow clinicians to indicate other conditions that may be a focus of clinical attention or have and a effect on diagnosis, course, prognosis or treatment of a Disorder

Multi-Axial Diagnosis Eliminated Axis V: CGAS and GAF Replaced by separate measures of symptoms severity and disability for individual disorders Replaced by the World Health Organization Disability Assessment Schedule (WHO DAS 2.0) The WHO DAS 2.0 is recommended to measure disability

Terminology/ Language Changes Used as a ”catch-all” for patients who didn’t fit into a more specific catergory General Medical Condition Not otherwise Specified(NOS) DSM-5 was revised to encompass more specific diagnosing Changed to Another medical condition is utilized where relevant across all disorders Whic will generally include a list of specfiers as to why the patient’s clinical condition doesnot meet criteria for a more specific disorder. Not Elsewhere Classified (NEC) Another Medical Condition

Implications of Terminology/ Language Changes The classification changes in the DSM-5 will assist providers with the transition to ICD-10 in October 2015. The DSM-5 includes the ICD-10 diagnosis in parenthesis 299.00 (F84.0)

Highlights Highlighted changes affecting Magellan Complete Care’s targeted diagnoses

Schizophrenia Spectrum Disorders The DSM-IV TR subtypes of Schizophrenia have been eliminated due to their limited diagnostic stability, low reliability, and poor validity. An individual must have at least one of these three positive symptoms: Delusions Hallucinations Disorganized Speech Two “Criterion A” symptoms are now required for any diagnosis of Schizophrenia in DSM-5 Subtypes- paranoid disorganized, catatonic, undifferentiated, and residual

Schizoaffective Disorder This change makes Schizoaffective disorder longitudinal instead of a cross-sectional diagnosis-more comparable to Schizophrenia, Bipolar, and Major Depressive disorder, which are now bridged by the connection. The primary change to Schizoaffective disorder is the requirement that a major mood episode be present for a majority of the disorder’s total duration after “Criterion A” has been met The change was also made to improve the reliability, diagnostic stability, and validity of this disorder, while recognizing that the characterization of patients with both psychotic and mood symptoms, either concurrently or at different points in their illness, has been a clinical challenge.

Catatonia can be utilized as an other specified diagnosis In DSM-5 all contexts require three catatonic symptoms (from a total of 12 characteristic symptoms) Catatonia may be diagnosed as a specifier for Depressive, Bipolar, & Psychotic disorders Catatonia can be used as a separate diagnosis in the context of another medical condition Catatonia can be utilized as an other specified diagnosis The same criteria are used to diagnose catatonia whether the context is a psychotic, bipolar, depressive, or other medical disorder, or an unidentified medical condition. In DSM-IV, two out of five symptom clusters were required if the context was a psychotic or mood disorder, whereas only one symptom cluster was needed if the context was a general medical condition. In DSM-5, all contexts require three catatonic symptoms (from a total of 12 characteristic symptoms). In DSM-5, catatonia may be diagnosed as a specifier for depressive, bipolar, and psychotic disorders; as a separate diagnosis in the context of another medical condition; or as an other specified diagnosis.

Bipolar & Related Disorders Enhancements have been made to increase accuracy of diagnosis and allow for earlier detection in clinical settings. Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood. The DSM-IV TR diagnosis of Bipolar I Disorder, mixed episode requiring that the individual simultaneously meet full criteria for both mania and major depressive episode, has been removed. Instead a new specifier, “with mixed features.” has been added that can be applied to episodes of mania or hypomania when depressive features are present, and to episodes of depression in the context of Major Depressive Disorder or Bipolar Disorder when features of mania/ hypomania are present. Bipolar Disorders

Bipolar & Related Disorders DSM-5 allows the specification of particular conditions for other specified bipolar and related disorders, including categorization for individuals with a past history of Major Depressive disorder who meet all criteria for hypomania except the duration criterion (ie., at least 4 consecutive days) A second condition constituting an Other Specified Bipolar and related disorder is that too few symptoms of hypomania and present to meet criteria for the full Bipolar II syndrome, although the duration is sufficient at 4 or more days. Other Specified Bipolar and Related Disorders

Anxious Distress Specifier The specifier of Anxious Distress has been added to Bipolar & Related disorders and Depressive Disorders This specifier is intended to identify patients with anxiety symptoms that are not part of the Bipolar diagnostic criteria

Depressive Disorders Depressive Disorders Persistent Depressive Disorder Contains the DSM-IV diagnosis of Dysthymia The category includes both Chronic Major Depressive disorder and previous Dysthimic disorder Depressive Disorders Now includes Premenstrual Dysphonic Disorder as a distinct diagnosis To address over diagnosis and treatment of Bipolar in children Disruptive Mood Dysregulation Disorder was added for children up to age 18 exhibiting persistent irritability and frequent episodes of extreme behavioral dyscontrol.

Major Depressive Disorder Neither the core criterion symptoms applied to the diagnosis of MD episode nor the requisite duration of a least 2 weeks has changed DSM-IV to DSM- 5 As is the requirement for clinically significant distress or impairment in social, occupational, or other important areas of life. Criterion C is relabeled Criterion B in DSM-5 The coexistence within a major depressive episode of at least three manic symptoms(insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier “with mixed features.” The presence of mixed features in an episode of MDD increases the likelihood that the illness exists in a bipolar spectrum; however, if the individual concerned has never met criteria for a manic or hypomanic episode, the diagnosis of MDD is retained. DSM-5

Specifiers for Depressive Disorders Suicidality represents a critical concern in psychiatry the clinician is given guidance on assessment of suicidal thinking, plans, and the presence of other risk factors in order to make a determination of the prominence of suicide prevention in treatment planning for a given individual Mixed Symptoms added across both the bipolar and the depressive disorders allowing for the possibility of manic features in individuals with a diagnosis of unipolar depression With Anxious Distress research conducted over the last two decades points to the importance of anxiety as relevant to prognosis and treatment decision making specifier gives the clinician an opportunity to rate the severity of anxious distress in all individuals with bipolar or depressive disorders

Obsessive-Compulsive & Related Disorders This chapter has been developed to include OCD along with four new disorders: Hoarding Disorder Excoriation Disorder Substance-medication induced OC and related disorder Obsessive-Compulsive and related disorder due to another medical condition Disorders added to Obsessive-Compulsive and Related Disorders Body Dysmorphic Disorder Trichotillomania Specifiers Insight specifiers have been refined to distinguish between levels of insight in patients diagnosed with these disorders emphasizes that the presence of absent insight/delusional beliefs warrants a diagnosis of the relevant obsessive-compulsive or related disorder, rather than a schizophrenia spectrum and other psychotic disorder The “with poor insight” specifier for obsessive-compulsive disorder has been refined in DSM-5 to allow a distinction between individuals with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compulsive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). Analogous “insight” specifiers have been included for body dysmorphic disorder and hoarding disorder. These specifiers are intended to improve differential diagnosis by emphasizing that individuals with these two disorders may present with a range of insight into their disorder-related beliefs, including absent insight/delusional symptoms. This change also emphasizes that the presence of absent insight/delusional beliefs warrants a diagnosis of the relevant obsessive-compulsive or related disorder, rather than a schizophrenia spectrum and other psychotic disorder. The “tic-related” specifier for obsessive-compulsive disorder reflects a growing literature on the diagnostic validity and clinical utility of identifying individuals with a current or past comorbid tic disorder, because this comorbidity may have important clinical implications.

DSM-5 to ICD 9 Providing a bridge between the two for Magellan Complete Care Target Diagnoses

Bridging DSM-5 & ICD 9 for Psychiatric Disorders This bridge is designed to assist providers match DSM-5 and ICD 9 diagnosis codes which are currently used for billing. Under the Health Insurance Portability and Accessibility Act (HIPAA): Insurance companies are only required to accept ICD 9 diagnosis The descriptions in ICD 9 do not always match directly to descriptions in the DSM 5 In the following slides options are provided under ICD 9 Diagnosis Description to assist providers in choosing the best match

Diagnostic Code Changes: DSM-5 and ICD 9 Interface New and revised DSM-5 diagnosis need to be mapped to an existing ICD 9 code. This will cause some disorders to share codes for recording and billing purposes Because there may be several disorders associated with a DSM-5/ICD 9 code, as a best practice the DSM-5 diagnosis description should always be recorded by name in the medical records in addition to listing the code.

Bipolar & Related Disorders DSM-5 Code DSM-5 Diagnosis Description ICD 9 Code ICD 9 Diagnosis Description 296.XX (range from 296.41 to 296.56) Bipolar I Disorder -see DSM 5 for specifiers for severity, manic or depressed, psychotic features, and remission status 296.89 Bipolar II Disorder 301.13 Cyclothymic Disorder 293.83 Bipolar and Related Disorder Due to Another Medication Condition Mood Disorder Due to a General Medical Condition Other Specified Bipolar and Related Disorder 296-89 Other and Unspecified Bipolar Disorders 296.80 Unspecified Bipolar and Related Disorder Bipolar Disorder, Unspecified

Depressive Disorders 296.99 296.21-296.26 300.4 625.4 293.83 311 DSM-5 Code DSM-5 Description ICD 9 Code ICD 9 Description 296.99 Disruptive Mood Dysregulation Disorder Other Specified Episodic Mood Disorder 296.21-296.26 Major Depressive Disorder, Single and Recurrent Episodes Persistent Depressive Disorder (Dysthymia) 300.4 Dysthymic Disorder 625.4 Premenstrual Dysphoric Disorder 293.83 Depressive Disorder Due to Another Medical Condition Mood Disorder Due to a General Medical Condition 311 Other Specified Depressive Disorder Depressive Disorder, Not Elsewhere Classified Unspecified Depressive Disorder

Schizophrenia Spectrum & Other Psychotic Disorders DSM-5 Code DSM-5 Diagnosis Description ICD9 Code ICD 9 Diagnosis Description 301.22 Schizotypical Personality Disorder (also found in Personality Disorder chapter) 297.1 Delusional Disorder 298.8 Brief Psychotic Disorder 295.40 Schizophreniform Disorder 295.90 Schizophrenia 295.70 Schizoaffective Disorder (specify Bipolar Type or Depressive Type) 293.81 293.82 Psychotic Disorder Due to Another Medical Condition -with delusions -with hallucinations 293.89 Catatonia Associated with Another Mental Disorder (Catatonia Specifier) Catatonic disorder due to known physiological condition Catatonic Disorder Due to Another Medical Condition Catatonic disorder in conditions classified elsewhere 781.99+293.89 Unspecified Catatonia -code first 781.99 followed by 293.89 Catatonia Other Specified Transient Mental Disorders Due to Conditions Classified Elsewhere Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Other and Unspecified Reactive Psychosis 298.9 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder Unspecified Psychosis

Obsessive-Compulsive & Related Disorders DSM-5 Code DSM-5 Diagnosis Description ICD 9 Code ICD 9 Description 300.3 Obsessive-Compulsive Disorder 300.7 Body Dysmorphic Disorder Hoarding Disorder Obsessive-Compulsive Disorders 312.39 Trichotillomania (Hair-Pulling Disorder) 698.4 Excoriation (Skin-Picking) Disorder Excoriation, neurotic 294.8 Obsessive-Compulsive and Related Disorder Due to Another Medical Condition Other Persistent Mental Disorders Due to Conditions Classified Elsewhere Other Specified Obsessive-Compulsive and Related Disorder Unspecified Obsessive-Compulsive and Related Disorder

Insurance Implications Despite the DSM-5 removal of the multi-axial diagnosis terminology, not all insurance companies have updated their forms and systems: This creates a situation requiring providers to continue to utilize the multi-axial diagnosis terminology when submitting claims.

References & Resources American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, Fifth Edition. Arlington, VA: American Psychiatric Association. American Psychiatric Association, DSM-5 Resources, www.dsm5.org Highlights of Changes from DSM-IV-TR to DSM-5 http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf Frequently Asked Questions on the DSM-5 http://www.dsm5.org/about/Pages/faq.aspx Fact Sheets on What’s New http://www.dsm5.org/