Making Sense of the DSM-5: Changes and Changing Perspectives Chasity S. Norris, MLT, MA, FDEX, NCC

Making Sense of the DSM-5 This workshop is designed to cover the basic changes and practical implications of the DSM-5 regarding mental health assessment treatment planning, and evidence-based practice strategy. Particular emphasis is placed on understanding the rationale for the changes and the implications these changes can have on developing best practices. An overview of selected diagnostic categories will be reviewed stressing assessment as it is linked to behavior-based practice strategy. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Who is Your Speaker? Chasity S. Norris, MLT, FDEX, MA, NCC, has a love for therapy and teaching, and has found ways to combine those passions, in ways she hopes will be as meaningful to others as they are to her. She delivers practical information in an entertaining, fast-paced style that is often filled with examples from her experiences both in the classroom, and in mental health. She attended East Tennessee State University from 2002-2013, receiving degrees in the areas of medical laboratory technology, epidemiology, forensic document examination, criminology, and counseling. She has published research and education training manuals including: Psychopathy and Gender: A Comparison Using the PCL-R, and Ethics in Policing: Instructor’s Manual 6th ed.  Her research includes investigations of psychopathy, personality disorders, deviant behaviors, stress and coping, and dialectical behavior therapy. Chasity Norris is currently an adjunct professor of criminology at East Tennessee State University, and primary therapist at the Crisis Stabilization Unit in Johnson City, Tennessee. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris What Is The DSM Used For? –“Primarily designed to assist clinicians in conducting clinical assessment, case formulation, and treatment planning” (pg. 25, DSM-5) To help professionals understand the problem(s) and know how to treat the client. Diagnostic guidelines also provide some criteria for future mental disorder research. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Why a New Edition? We have begun to be more mindful of the language we use to describe our clients in order to help influence the way we think about our clients, the way society thinks about our clients, and ultimately, the way our clients view themselves. The diagnosis we apply, often become “labels’ that can help mold perceptions in positive ways, or negative ways, depending on their intention and delivery. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Why a New Edition? This can influence a client’s willingness to seek help. If a client is fearful of certain diagnoses, or more appropriately, of being “labeled” with a certain disorder, they can be much less likely to seek help when needed. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Why a New Edition? This issue is one of the driving forces behind the movement for a new edition. The DSM-5 now includes many updated diagnostic names that are more sensitive and less stigmatic than previous editions. Ex. (“Mental Retardation” is now titled (“Intellectual Disorder”) Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Why a New Edition? There has been widely inconsistent use of the multiaxial system previously used in the DSM-IV-TR. The DSM must consider as many conditions as possible because insurance companies will not reimburse for conditions not listed in the DSM’s ICD. This factor was a huge influence on the task forces decision to include some previously omitted disorders such as: Gender Dysphoria (previously Gender Identity Disorder) Gambling Disorder Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Why a New Edition? More effective and thorough in judicial proceedings to determine insanity, and competence to stand trial. Aid in determining disabilities for protection against discrimination in the workplace, or for accessing accommodations in work or school settings. Ability to aid in research for medications geared toward specific disorders. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Brief History 28 member task force created in 2007, and worked in working groups for 6 years. Guided by the ideas that the new edition had to be useful for routine clinical practice, and any new changes had to be guided by research evidence. APA developed website in 2010 to gather input from the public and other professionals. Final approval for publication in December 2012 Copyright 2013 Chasity Norris

Cultural Concerns Addressed Section III now contains tools for extensive cultural assessment. Topic of Culture Bound Syndromes addressed Describes three types of culture-bound syndromes: Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Cultural Syndrome- group of symptoms found in specific cultural groups that are not recognized as illness within the culture, but is recognizable to outside observers. Cultural Idiom of Distress- way of talking about suffering among individuals within a group . (“I’ve got nerves”) Cultural Explanations or Perceived Cause- model that provides a culturally determined etiology. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Why a New Edition? To be more culturally aware and considerate Stay current with research Ability to integrate information with social networking DSM-5 online subscription: www.psychiatryonline.org *Also have E-Book and Mobile App Copyright 2013 Chasity Norris

Changes from DSM-IV-TR To DSM-5 Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

Major Structural Changes: Discontinuation of Multiaxial System Axis I: Clinical Disorders Other Conditions that May Be a Focus of Clinical Attention Axis II: Personality Disorders Mental Retardation Axis III: General Medical Conditions Axis IV: Psychosocial & Environmental Problems Axis V: Global Assessment of Functioning Copyright 2013 Chasity Norris

Discontinuation of Multiaxial System Instead of using the prior system of organization, the DSM-5 actually combines the first three axes (mental disorders, intellectual disabilities, and personality disorders) into section II. They are now all regarded as equally important in achieving a correct diagnosis, so they are listed together, in the particular order the clinician feels they are affecting the client. Copyright 2013 Chasity Norris

Discontinuation of Multiaxial System The axis system was originally used to separate out the disorders that had been heavily researched and confirmed (organic disorders) from those needing more research to be acknowledged (personality disorders), however, the APA now agrees there is no fundamental difference between the disorders on Axis I and Axis II. Copyright 2013 Chasity Norris

Discontinuation of Multiaxial System Section II also contains much of the information formerly listed under Axis IV. Any of the environmental factors or other conditions in life that could hinder treatment are now listed at the end of this section, instead of being separated. The rational for this change is that all of these factors are equally important when making and treating a specific diagnosis, so they should all be listed and considered together, forming a more holistic picture of the presenting issues. Copyright 2013 Chasity Norris

Discontinuation of Multiaxial System Global Assessment Functioning Score (GAF) dropped completely from DSM-5 Physicians and Clinicians are still encouraged to assess suicidal and homicidal behavior with standard assessments for severity, according to symptoms. Disability now measured using the World Health Organization’s Disability Assessment Schedule (WHODAS). Can also use other information under section III of DSM-5 Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

Integrational Approach to Diagnosis Rather than the prior Axis system, the new chapter order is organized in “Clusters”. This allows for disorders that are relatable or share similar symptoms and characteristics to be looked at together. Copyright 2013 Chasity Norris

Neurodevelopmental Cluster This includes all Neurodevelopmental Disorders and Schizophrenia Spectrum & Psychotic Disorders Copyright 2013 Chasity Norris

Internalizing Cluster Includes: Bipolar Disorder Depressive Disorder Obsessive-Compulsive and Related Disorders Anxiety Disorder Trauma & Stressor Disorders Dissociative Disorder Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Somatic Cluster Includes: Somatic Symptom Disorders Feeding & Eating Disorders Gender Dysphoria Sexual Dysfunctions Elimination Disorders Sleep Disorders Copyright 2013 Chasity Norris

Externalizing Cluster Disruption, Conduct, and Impulse-Control Disorders Substance and Addictive Disorders Copyright 2013 Chasity Norris

Neurocognitive Disorders Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Personality Cluster Personality Disorders Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Other Paraphilias Medication-Induced Movement Disorders Conditions for Further Study Copyright 2013 Chasity Norris

Sensitivity to Stability of Disorders Chapter in DSM-IV-TR describing “Disorders Usually Diagnosed During Infancy, Childhood, and Adolescence has been eliminated and the subsequent disorders have been divided up into the chapters they relate to by symptomology. This is due to research showing most of these disorders are stable into adulthood, and can also present during adulthood, not just childhood. (Pica, ADHD). Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris No More NOS! The NOS (not otherwise specified) category has been eliminated all together. Options now include: Other Specified Disorder Unspecified Disorder *Condition deferred still available, but is not listed. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

DSM-5 Specific Disorders Neurodevelopmental Disorders including: Internalizing Cluster Somatic Cluster Externalizing Cluster Neurocognitive Cluster Personality Cluster Other Cluster Copyright 2013 Chasity Norris

Neurodevelopmental Disorders Intellectual Disability (formerly “Intellectual Development Disorder”) Global Developmental Delay Unspecified Intellectual Disability (formerly “Intellectual Development Disorder) Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris A federal state statute “Rosa’s Law” (public Law 111-256), determined “mental retardation” was now to be termed “intellectual disability” Copyright 2013 Chasity Norris

Neurodevelopmental cont. Communication Disorders Language Disorder- a combo of DSM-IV’s expressive and mixed-receptive expressive language disorders. Speech Sound Disorder- Previously Phonological Disorder. Copyright 2013 Chasity Norris

Neurodevelopmental cont. A new diagnosis of Social Communication Disorder has been added. SCD- is persistent difficulty in the social use of verbal and nonverbal communication that is not caused by low cognitive ability. Copyright 2013 Chasity Norris

Neurodevelopmental cont. Autism Spectrum Disorder Combines: Autistic Disorder Asperger's Childhood Disintegrative Disorder Pervasive Developmental Disorder **Requires both social communication and social interaction, and restricted repetitive behaviors, interests, and activities. Copyright 2013 Chasity Norris

Neurodevelopmental cont. Attention Deficit Hyperactivity Disorder Now has symptoms added to help diagnose in adults Children still need to have at least 6 symptoms, but older adolescents and adults need 5 Symptoms must have presented before age 12, not age 7 as previously held in DSM-IV Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Schizophrenia Schneiderian first-rank auditory hallucinations eliminated. Symptom threshold raised form 1 to 2 specific symptoms to qualify for diagnosis Includes requirements for symptoms of delusions, hallucinations, or disorganized speech. Also eliminated subtypes (paranoid, disorganized, catatonic, undifferentiated, etc. ) Copyright 2013 Chasity Norris

Schizoaffective Disorder Now must have presence of a mood dysregulation for the majority of time the schizophrenic symptoms present. Makes it more longitudinal DX. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Delusional Disorder Criteria for delusions to be “non-bizarre” eliminated. Shared Delusional Disorder no longer separated from delusional disorder Now is “other specified schizophrenia spectrum and other psychotic disorder” Copyright 2013 Chasity Norris

Bipolar and Related Disorders Now includes changes in activity level or energy level, not just mood. BP I, mixed episode has been removed Replaced with ‘With Mixed Features” Qualifier can be used in either BP I or II “with anxious distress” also new qualifier for those exhibiting anxiety along with BP symptoms. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Depressive Disorders New diagnoses added: Disruptive Mood Dysregulation Disorder – violent temper outbursts manifested verbally Premenstrual Dysphoric Disorder Copyright 2013 Chasity Norris

Persistent Depressive Disorder Combines Chronic Major Depressive Disorder and Dysthymic Disorder. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Anxiety Disorders Disorders no longer included in this section include: Obsessive-Compulsive Disorder Post Traumatic Stress Disorder Acute Stress Disorder Now listed under new chapter (obsessive-compulsive and trauma-stressor disorders) Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Panic Disorder and Agoraphobia are now tow-separate disorders under the DSM-5. If there is a co-occurrence of panic and agoraphobia, they are coded as two separate diagnoses. Copyright 2013 Chasity Norris

Social Anxiety Disorder (social phobia) Now has “generalized” and “performance only” qualifiers. Copyright 2013 Chasity Norris

Separation Anxiety Disorder Now moved out of section describing childhood or adolescent disorders, and is now in with the anxiety disorders This is due to research showing it can occur after age 18 Must still be present for >6 months Selective Mutism also moved to anxiety disorders for same reason. Copyright 2013 Chasity Norris

Obsessive-Compulsive & Related Disorders New chapter to the DSM includes: Obsessive-Compulsive Disorder Body Dysmorphic Disorder Trichotillomania (hair-pulling) Excoriation (skin-picking) Hoarding Disorder Substance-Medication Induced OCD OCD related to other medical conditions Copyright 2013 Chasity Norris

Body Dysmorphic Disorder Somatic disorder with repetitive behaviors and mental acts responding to their preoccupation with their perceived physical defects or flaws. Now has “with muscle dysmorphia” and “absent insight/ delusional” specifiers. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Hoarding Disorder NEW!! Related to OCD, but not a variant of Patient presents with persistent difficulty discarding or parting with possessions and noted distress associated with discarding them. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Excoriation Disorder NEW!! Skin Picking causing dermatological damage Copyright 2013 Chasity Norris

Trauma & Stressor Related Disorders New Category! PTSD now has a list of traumatic event qualifiers and “second-hand exposure” allowance (first-responders collecting human remains) Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Includes: Reactive Attachment Disorder as a distinct disorder Also includes Disinhibited Social Engagement Disorder Both outcome of social neglect and denial of healthy attachment Copyright 2013 Chasity Norris

Somatic Symptom and Related Disorders Previously called “Somatoform Disorders” Reduced subcategories Copyright 2013 Chasity Norris

Somatic Symptom Disorder Combines previous “somatization disorder’ and “undifferentiated somatoform disorder”. Designed to diagnose those with maladaptive thoughts, feelings, and behaviors with somatic symptoms that may or may not be related to medical conditions. Requirement that medically unexplained symptoms be present removed. Psychological stress more important. Copyright 2013 Chasity Norris

Hypochondriasis and Illness Anxiety Disorder Hypochondriasis removed from DSM-5 Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Sexual Dysfunctions Genito-Pelvic Pain/ Penetration Disorder- NEW!! Replaces Vaginismus and Dyspareunia Sexual Aversion Disorder Removed Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Gender Dysphoria NEW!! No longer associated with sexual dysfunction. “strong desire to be the other gender” replaces “repeatedly stated desire to be the other gender” in children. Copyright 2013 Chasity Norris

Disruptive, Impulse-Control, & Conduct Disorders NEW CHAPTER!! Characterized by difficulties in behavioral and emotional self-control. Due to high co-morbidity, antisocial personality disorder is listed here and in personality disorder chapter. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Includes: Oppositional Defiant Disorder Conduct Disorder (limited pro-social emotions”) Intermittent Explosive Disorder Copyright 2013 Chasity Norris

Substance-Related & Addictive Disorders NEW Disorder!! Gambling Disorder Substance Abuse and Substance Dependence Disorders now combined into “Substance Use Disorder” Cannabis Withdrawal & Caffeine Withdrawal also added! Copyright 2013 Chasity Norris

Neurocognitive Disorders Delirium now all listed together instead of being 5 different diagnoses. Dementia and Amnestic Disorders now combined into “Major and Mild Neurocognitive Disorders” Copyright 2013 Chasity Norris

Personality Disorders (Section II) Updates in terminology Added “Personality Change Due to Another Medical Condition” Now listed alongside other mental disorders rather than separately Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris PD (Section III) Replaces NOS with Personality Disorder-Trait Specified (PD-TS) Provides more specific, individual diagnosis Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Criterion A -Level of personality functioning Shows disturbances of self (identity), and interpersonal functioning (empathy & intimacy) Criterion B -one or more pathological personality traits Criterion C -inflexibility and pervasiveness of impairment and traits. Criterion D: -Stability of impairment and traits Criterion E: -not better accounted for by another mental disorder Criterion F: -Not due to the effects of a substance Criterion G: - not normal for their developmental stage or socioculurall environment. Copyright 2013 Chasity Norris

Paraphilias and Paraphilic Disorders Distinction made between the two Paraphilic Disorders causing “marked distress and impairment”. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Controversy Copyright 2013 Chasity Norris

What Should You Know if You’re a Social Worker? No social workers were formally invited to participate in the Task Force or Work Groups for the fifth edition of the DSM!! This is not a recent occurrence There was only one social worker on the Task Force for the DSM-IV-TR. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris Bibliography Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington, D.C.: American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. (4th ed.). (2000). Washington, DC: American Psychiatric Association. Copyright 2013 Chasity Norris

Copyright 2013 Chasity Norris