DSM-5 Overhaul What’s in, out, and relevant in the GP’s world Presented by Jaana Kastikainen, MD, FRCPC SMH General Practitioner Rounds March 31, 2015

disclosures No affiliations, sponsorship, or financial reimbursements to disclose

Objectives Briefly review the history of the DSM Briefly review the changes made (what’s in, what’s out, what didn’t make it) in the newest version of the DSM Review the changes most relevant to our population of medically ill patients and the implications of these changes

Objectives Briefly review the history of the DSM Briefly review the changes made (what’s in, what’s out, what didn’t make it) in the newest version of the DSM Review the changes most relevant to our population of medically ill patients and the implications of these changes

Why the need for a diagnostic manual?

DSM in the making... 1840 Government wanted to collect data on mental illness “idiocy” and “insanity” was terminology used in census 1880 Census expanded to feature seven categories 1917 Census committee embraced Statistical Manual for the Use of Institutions for the Insane Mental illness separated into 22 groups 10 editions over next 25 years

DSM History DSM DSM-II DSM-III DSM-IV Published in 1952 106 disorders, “reactions” Mental disorders were reactions of personality to bio/psycho/social factors on continuum from normalcy  psychosis DSM-II Published in 1968 Glossary of definitions DSM-III Published in 1980 Reconceptualized with research-based criteria, 5 axes Criteria broadened further with DSM-III-R (1987) DSM-IV Published in 1994 Diagnosis required clinically significant distress/functional impairment

Lofty goals of the DSM-5 Eliminate “not otherwise specified” (NOS) diagnoses within categories Remove functional impairments as necessary components of diagnostic criteria Use scientific evidence to justify classifications and criteria

The Current DSM-5 Released at APA annual meeting in May 2013 Represents decade of revision in criteria Standard classification of mental disorders, applicable in wide array of contexts to clinicians and researchers Tool for collecting and communicating accurate public health stats Three major components: classification, criteria sets, and descriptive text Diagnostic guide – not treatment guide

Making the transition... DSM-IV-TR  DSM-5 Traditional roman numerals dropped with intention that subsequent revision processes more at pace with breakthroughs in research with incremental updates until completely new edition required ie. DSM-5.1, DSM-5.2

What defines “mental disorder”? DSM-IV-TR A clinically significant behavioural or psychological syndrome that is associated with present distress, disability, or significantly increased risk of suffering death, pain, disability, loss of freedom DSM-5 A syndrome characterized by significant disturbance in cognition, emotion regulation, or behaviour that reflects dysfunction in bio/psycho/developmental processes and are usually associated with significant distress

Highlights of Changes from IV to 5 Terminology – “general medical condition” replaced with “another medical condition” Neurodevelopmental disorders Intellectual Disability Communication Disorders Autism Spectrum Disorders ADHD Specific Learning Disorder Motor Disorders Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia/Subtypes Schizoaffective Disorder Delusional Disorder Catatonia Bipolar and Related Disorders Bipolar Disorder Anxious Distress Other Specified Bipolar and Related Disorder Depressive Disorders Disruptive Mood Dysregulation Disorder PMDD Persistent Depressive Disorder Bereavement exclusion

Highlights of Changes from IV to 5 Anxiety Disorders Exclusion of OCD, PTSD, acute stress disorder Agoraphobia, Specific Phobia, SAD Panic Attack Panic Disorder and Agoraphobia Separation Anxiety Disorder Selective Mutism Obsessive-Compulsive and Related Disorders Insight specifiers Body Dysmorphic Disorder Hoarding Disorder/Trichotillomania/Excoriation Disorder Trauma- and Stressor-Related Disorders Acute Stress Disorder Adjustment Disorder PTSD Reactive Attachment Disorder Dissociative Disorders Depersonalization/derealization disorder Exclusion of dissociative fugue DID

Highlights of Changes from IV to 5 Somatic Symptom and Related Disorders Exclusion of Somatization Disorder, Hypochondriasis, Pain Disorder Somatic Symptom Disorder Illness Anxiety Disorder Conversion Disorder Feeding and Eating Disorders Pica and Rumination Disorder Avoidant/Restrictive Food Intake Disorder Anorexia Nervosa Bulimia Nervosa Binge-Eating Disorder Elimination Disorders Sleep-Wake Disorders Insomnia Disorder Narcolepsy Breathing-Related Sleep Disorders REM Sleep Behaviour Disorder Restless Legs Syndrome Sexual Dysfunctions Gender-specific sexual dysfunctions Genito-Pelvic Pain/Penetration Disorder

Highlights of Changes from IV to 5 Gender Dysphoria New diagnostic category Disruptive, Impulse-Control, and Conduct Disorders ODD CD IED Substance-Related and Addictive Disorders Substance Use Disorder (exclusion of abuse/dependence) Gambling Disorder Neurocognitive Disorders Mild and Major Neurocognitive Disorder Etiological subtypes Paraphilic Disorders Specifiers “in remission,” “in controlled environment” Addition of “disorder” to diagnostic names

Objectives Briefly review the history of the DSM Briefly review the changes made (what’s in, what’s out, what didn’t make it) in the newest version of the DSM Review the changes most relevant to our population of medically ill patients and the implications of these changes

What’s out Multiaxial Diagnosis Not Otherwise Specified diagnoses I, II, III dropped IV replaced with “with significant psychosocial and contextual features” V dropped, WHODAS recommended Not Otherwise Specified diagnoses Other specified... Unspecified... Disorders usually first diagnosed in infancy, childhood, or adolescence Pervasive Developmental Disorders Autism/Asperger’s/PDD/Rett’s  Autism Spectrum Disorder

What’s out Mood Disorders MDE distinction Distinction between dysthymia and chronic MDD Bereavement exclusion Substance Disorders Distinction between abuse and dependence Psychotic Disorders Bizarre specifier for A criteria in Schizophrenia Subtypes of Schizophrenia

What’s in Dimensions Biomarkers New Terminology Categorical diagnoses stand Indicators of severity throughout Course (partial/full remission, recurrent) Descriptive (with insight, in structured environment) Biomarkers Polysomnography Hypocretin New Terminology “Other specified/Unspecified...” Secondary to “another medical condition” Neurodevelopmental disorders Persistent Depressive Disorder Peripartum Onset Neurocognitive Disorder

New diagnoses Disruptive Mood Dysregulation Syndrome Premenstrual Dysphoric Disorder Hoarding Disorder Trichotillomania Excoriation Disorder Disinhibited Social Engagement Disorder Illness Anxiety Disorder Binge Eating Disorder Central Sleep Apnea Neurocognitive Disorder

What didn’t make the cut Personality disorders revision Major changes proposed Spectrums of personality, trait-focused Attenuated Psychosis Syndrome Mixed Anxiety Depression Posttraumatic Stress Injury Other Substance Use Disorders (additional addictions) New diagnoses Body Integrity Disorder Male-to-Eunuch Disorder Hypersexual Disorder Persistent Complicated Bereavement Olfactory Reference Syndrome

Objectives Briefly review the history of the DSM Briefly review the changes made (what’s in, what’s out, what didn’t make it) in the newest version of the DSM Review the changes most relevant to our population of medically ill patients and the implications of these changes

A lot of changes... But what is actually relevant to you as a family physician?

... All of it!!

Relevant Changes we’ll cover... Neurodevelopmental Disorders Schizophrenia Spectrum Disorders Bipolar Disorders Depressive Disorders Anxiety Disorders Somatic Symptom Disorders Sleep-Wake Disorders Substance-Related Disorders Neurocognitive Disorders

Neurodevelopmental disorders Intellectual Disability Emphasizes assessment of both cognitive capacity (IQ) and adaptive functioning Severity is determined by adaptive functioning rather than IQ Term “mental retardation” eliminated Communication Disorders Language Disorder (DSM-IV’s expressive + mixed receptive-expressive language disorders) Speech Sound Disorder (=phonological disorder) Childhood-onset Fluency Disorder (=stuttering) Social (Pragmatic) Communication Disorder (new diagnosis for persistent difficulties in social uses of communication)

Neurodevelopmental disorders Autism Spectrum Disorder Encompasses Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder, PDD NOS Previously separate disorders actually a single condition w/ different levels of symptom severity 2 core domains Deficits in social communication and interaction Restricted, repetitive behaviours, interests, activities ADHD Neurodevelopmental disorder to reflect developmental correlates Onset criterion changed to <12 yrs (vs onset before age 7) Comorbid ASD diagnosis allowed Change to symptom threshold for diagnosis in adults (5 symptoms vs 6) Specific Learning Disorder Combines Reading Disorder, Mathematics Disorder, Disorder of Written Expression, LD NOS

Schizophrenia-spectrum disorders Elimination of attribution of bizarre delusions (poor reliability) and Schneiderian first-rank AH (non-specificity) 1 of 3 core positive symptoms must be present: hallucinations, delusions, disorganization Elimination of subtypes (paranoid, disorganized, catatonic, undifferentiated, residual)due to limited stability, reliability, validity Dimensional approach to rating severity instead DSM-IV – if present, only required one of these in Criteria A (vs two other sx) to make diagnosis

Schizophrenia-spectrum disorders Schizoaffective Disorder Major mood episode must be present for majority of disorders’ total duration after Criterion A met Longitudinal versus cross-sectional (DSM-IV-TR) diagnosis, comparable to other SPMIs Delusional Disorder No longer requirement that delusions must be non-bizarre (specifier exists) New exclusion from OCD, BDD with absent insight/delusional beliefs No longer separated from shared delusional disorder Catatonia Same criteria regardless of context (psychotic/bipolar/depressive/AMC) All require 3 of 12 characteristic symptoms May be diagnosed as separate diagnosis (AMC) or as specifier

Bipolar disorders Criteria A for manic/hypomanic episodes now include changes in activity/energy as well as mood Addition of “with mixed features” specifier to manic/hypomanic episodes with depressive features, and vice versa Elimination of need to meet full criteria for manic/hypomanic/depressive episodes simultaneously Other specified bipolar and related disorder Individuals with hx of MDD with all but time criteria for hypomanic episode, or time criteria but too few symptoms for bipolar II diagnosis Anxious distress specifier Identifies patients with anxiety symptoms not part of bipolar disorder criteria Also included as new specifier in depressive disorders To enhance accuracy of diagnosis and earlier detection

Depressive disorders Several new disorders Disruptive Mood Dysregulation Disorder Addresses concerns of overdiagnosis/overtx of bipolar disorders in children < age 18 with persistent irritability and frequent episodes of extreme behaviour dyscontrol Premenstrual Dysphoric Disorder Moved from DSM-IV-TR “criteria sets for further study” to main body Persistent Depressive Disorder Includes both chronic MDD and dysthymia No scientifically meaningful differences Add with peripartum onset = during pregnancy or with onset within four weeks postpartum

Depressive disorders MDE no longer separate diagnostic criteria set (captured within MDD) Bereavement exclusion Recall DSM-IV – MDE could not be diagnosed if symptoms fell within two months of death of loved one Bereavement typically lasts 1-2 years Bereavement is severe psychosocial stressor that can precipitate MDE Bereavement-related MDD more likely to occur in those with personal/family hx of MDD Treatment approach and response is same Addition of “with mixed features” specifier Change in specifier from “w/ postpartum onset” to “w/ peripartum onset”

Anxiety disorders No longer encapsulates OCT, PTSD, Acute Stress Disorder Agoraphobia, Specific Phobia, Social Anxiety Disorder Deletion of requirement that >18 yrs must recognize excessive nature of fear 6 month duration (previously only for <18 yrs) now extended to all ages Panic Attack Complicated subtypes (DSM-IV) replaced with “expected” or “unexpected” Can now be listed as specifier for all DSM diagnoses Panic Disorder and Agoraphobia Now two separate diagnoses with own criteria At least two agoraphobic situations, at least 6 months duration required for agoraphobia

Anxiety disorders Social Anxiety Disorder Separation Anxiety Disorder “Generalized” specifier removed “Performance only” specifier added Separation Anxiety Disorder Reclassified as anxiety disorder Wording of criteria modified to include adults Attachment figures can include children of adults affected Avoidance behaviours can occur in the workplace No longer specify age of onset must be <18 yrs Duration of at least 6 months Selective Mutism

Somatic symptom disorders Recall DSM-IV-TR – significant overlap and lack of clarity across somatoform disorders  nonpsychiatric MDs found them problematic to use Removal of somatization disorder, pain disorder, hypochondriasis Somatic Symptom Disorder Somatic symptoms with abnormal thoughts, behaviours, feelings may or may not have a diagnosed medical condition Arbitrarily high symptom count (SD) did not accommodate spectrum of relationship btw somatic sx and psychopathology SSD has no specific number of sx required Medically unexplained symptoms not overemphasized

Somatic symptom disorders Illness Anxiety Disorder Hypochondriasis eliminated – pejorative, not conducive to effective therapeutic relationship Most “hypochondriacs” now fit into Somatic Symptom Disorder, unless no somatic sx present Conversion Disorder Emphasize essential importance of neuro exam Recognizes potential absence of psychological factors at time of diagnosis Psychological Factors Affecting Other Medical Conditions

Sleep-wake disorders Reconceptualized to emphasize sleep disorders as their own entity requiring independent clinical attention Elimination of sleep disorders related to another mental disorder/GMC Primary Insomnia renamed Insomnia Disorder Narcolepsy distinguished because of hypocretin deficiency (part of criteria) REM Sleep Behaviour Disorder and RLS added as own diagnoses

Substance-related disorders Substance Use Disorder No distinction between substance abuse and dependence  combined into one symptom list requiring at least 2 criteria Recurrent legal problems criterion deleted Craving or strong desire/urge to use added Severity specifiers (2-3 = mild; 4-5 = mod; 6+ = severe) New: Tobacco Use Disorder, Cannabis Withdrawal, Caffeine Withdrawal Gambling Disorder On premise that behaviour activates same reward centres in brain

Neurocognitive disorders APA president, at time of DSM-5’s release, called for a movement among psychiatrists to retire the term “dementia” for stigmatic reasons, as the literal Latin translation is “without mind” Old habits die hard

Neurocognitive disorders Mild and Major Neurocognitive Disorder DSM-IV-TR diagnoses of dementia and amnestic disorder subsumed under newly named major NCD Evidence of significant decline from previous level of performance in one or more domains based on concern and substantial impairment in performance Interference with independence in everyday activities Mild NCD is new disorder of less disabling syndrome Evidence of modest decline from previous level of performance in one or more domains based on concern and modest impairment in performance Do not interfere with independence in everyday activities

Neurocognitive disorders Etiological Subtypes Major/mild vascular NCD criteria retained Major/mild NCD due to Alzheimer’s disease retained New separate criteria for major or mild NCD due to frontotemporal NCD, Lewy Bodies, TBI, Parkinson’s disease, HIV, Huntington’s disease, prion disease, AMC

What we didn’t cover... Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Dissociative Disorders Feeding and Eating Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse-Control, and Conduct Disorders Paraphilic Disorders

A note on Personality disorders Criteria have not changed in DSM-5  but... PDs have: Poor inter-rater reliability (except BPD) Poor stability over time Poor discriminate validity Poor clinical utility Extensive work done on alternative approach Maintain 6/10 PDs (BPD, OCPD, APD, NPD, ASPD, SPD) Move from categorical to trait-based, dimensional classification system Captures nuances of human personality by measuring traits on continuum ++ labour-intensive approach in the end with ++ pushback from psychiatric community  ultimately voted down! Available in Section 3 of DSM-5

Dsm-5 top ten DSM-5 is reorganized into a new series of chapters that either reflect common clinical features or seem to fall in the same spectrum. The multiaxial system has been eliminated. There is now no such thing as Axis II – personality disorders are considered in the same way as other categories. With the elimination of Axis V, levels of functioning can be rated using scores of severity or disability. The criteria for several categories have been expanded, which will probably lead to more frequent diagnosis. The grief exclusion for diagnosis of major depression has been eliminated.

Dsm-5 top ten 6. Substance use disorders no longer distinguish between abuse and dependence. 7. Overly aggressive children can now be diagnosed with disruptive mood dysregulation disorder. 8. Autism spectrum disorder now captures both classical autism and Asperger’s disorder. 9. Dementias are now classified as neurocognitive disorders, rated by severity. 10.Somatic symptom disorders replace somatoform disorders and are classified differently.

Closing remarks Have there been sufficient advances in the pathophysiologic, phenomenologic, and therapeutic understanding of mental illness to warrant a revised DSM? Ultimate aim (in all of medicine) is to base diagnoses mostly on objective and, ideally, biologically measurable criteria  psychiatry is still far from this goal

Change we can believe in...

Thank you!

references American Psychiatric Association. Desk reference to the diagnostic criteria from DSM-5. American Psychiatric Publishing. 2013. American Psychiatric Association. Highlights of changes from DSM-IV-TR to DSM-5. May 2013. http://www.dsm5.org/Documents/changesfromdsm-iv-trtodsm-5.pdf Paris, J. The intelligent clinician’s guide to the DSM-5. Oxford University Press. March 2013.