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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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
(F84.0)

9. Highlights
Highlighted changes affecting Magellan Complete Care’s targeted diagnoses

10. 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

11. 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.

12. 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.

13. 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

14. 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

15. 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

16. 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.

17. 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

18. 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

19. 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.

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

21. 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

22. 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.

23. Bipolar & Related Disorders
DSM-5 Code
DSM-5 Diagnosis Description
ICD 9 Code
ICD 9 Diagnosis Description
296.XX
(range from to )
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

24. 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
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

25. 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
Unspecified Catatonia
-code first followed by
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

26. 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

27. 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.

28. 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,
Highlights of Changes from DSM-IV-TR to DSM-5
Frequently Asked Questions on the DSM-5
Fact Sheets on What’s New