1. DSM-5 and its use by chemical dependency professionals
4/7/2017
DSM-5 and its use by chemical dependency professionals
Greg Bauer
Executive Director – Alpine Recovery Services Inc.
President – Chemical Dependency Professionals Washington State (CDPWS)

2. DSM-5 - a brief history 4/7/2017 DSM-5 - a brief history
1943
1952
1968
1980
1987
1994
2000
2013
DSM-5 - a brief history
1943: a list of mental disorders was published by the Office of the Surgeon General for the War Department. it was entitled “Medical 203”. This document was adopted by the Veterans Administration shortly after its publication.
1952: DSM-I was published by the American Psychiatric Association and included 106 mental disorders and was 130 pages in length.
1968: DSM-II was published. number of mental health disorders increased to 182.
1980: DSM-III was published. this publication introduced criteria for diagnostic finding in an attempt to standardize diagnostic criteria in the USA. mental health disorders increased to 265.
1987: DSM-III-R was published. the number of mental health disorders increased to 292.
1994: DSM-IV was published. one major change in this publication was that approximately half of the 297 identified disorders included symptoms that cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.
2000: DSM-IV-TR was published. this was a text revision which included updated information on several diagnostic categories and diagnostic codes were updated to maintain consistency with the ICD.
2013: DSM-5 was published.

3. Diagnostic and Statistical Manual of Mental Disorders
4/7/2017
Diagnostic and Statistical Manual of Mental Disorders
DSM-5

4. overview of changes in the DSM-5
4/7/2017
overview of changes in the DSM-5
removal of Roman numeral to modern Arabic numeral
elimination of multiaxial diagnostic system
elimination of NOS designation
dimensional approach to diagnosis
cultural formulation
overview of changes in the DSM-5
removal of Roman numeral to a modern Arabic numeral. this is an attempt to remove confusion in future revisions of this publication.
elimination of the multiaxial diagnostic system
elimination of the NOS designation and the addition of two options for clinical use:
other specified disorder
unspecified disorder
dimensional approach to diagnosis
cultural formulation

5. changes specific to substance-related and addictive disorders
4/7/2017
changes specific to substance-related and addictive disorders
combines the DSM-IV categories of substance abuse and substance dependence into a single disorder
now have 11 criteria for substance-related disorders
eliminated criteria of recurrent substance related legal issues found in DSM-IV
added criteria of “craving, or strong urge to use”
called substance-related and addictive disorders
DSM-5 changes specific to substance related and addictive disorders
combines the DSM-IV categories of substance abuse and substance dependence into a single disorder
now have 11 criteria for substance related disorders
eliminated criteria of recurrent substance related legal issues found in the DSM-IV
added criteria of “craving, or strong urge to use”
called substance-related and addictive disorders

6. changes specific to substance-related and addictive disorders
4/7/2017
changes specific to substance-related and addictive disorders
substance-related disorders divided into two groups
substance use disorders
substance-induced disorders
each disorder measured on a continuum from mild to severe
addition of first behavioral disorder, “gambling disorder”
DSM-5 changes specific to substance related and addictive disorders
substance-related disorders are divided into two groups:
substance use disorders
substance-induced disorders
each disorder is measured on a continuum from mild to severe.
addition of first behavioral disorder, “gambling disorder”

7. substance use disorder as defined by DSM-5
4/7/2017
substance use disorder as defined by DSM-5
a problematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least two of the following occurring in a 12-month period:
substance use disorder as defined by DSM-5
a problematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least two of the following occurring in a 12 month period:

8. substance use disorder as defined by DSM-5
4/7/2017
substance use disorder as defined by DSM-5
substance is often taken in larger amounts or over a longer period of time than was intended
persistent desire or unsuccessful efforts to cut down or control substance use
great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
craving or strong desire to use the substance
substance use disorder as defined by DSM-5
substance is often taken in larger amounts or over a longer period of time than was intended
persistent desire or unsuccessful efforts to cut down or control substance use
great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
craving or strong desire to use the substance

9. substance use disorder as defined by DSM-5
4/7/2017
substance use disorder as defined by DSM-5
recurrent use resulting in failure to fulfill major role obligations at work, school, home
continued substance use despite having persistent or recurrent social or interpersonal problems
important social, occupational, or recreational activities are given up or reduced because of substance use
substance use disorder as defined by DSM-5
recurrent use resulting in failure to fulfill major role obligations at work, school, home
continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
important social, occupational, or recreational activities are given up or reduced because of substance use

10. substance use disorder as defined by DSM-5
4/7/2017
substance use disorder as defined by DSM-5
recurrent substance use in situations in which it is physically hazardous
substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
substance use disorder as defined by DSM-5
recurrent substance use in situations in which it is physically hazardous
substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

11. substance use disorder as defined by DSM-5
4/7/2017
substance use disorder as defined by DSM-5
tolerance, as defined by either of the following:
a need for markedly increased amounts of the substance to achieve intoxication or desired effect
a markedly diminished effect with continued use of the same amount of substance
substance use disorder as defined by DSM-5
tolerance, as defined by either of the following:
a need for markedly increased amounts of the substance to achieve intoxication or desire effect
a markedly diminished effect with continued use of the same amount of the substance

12. substance use disorder as defined by DSM-5
4/7/2017
substance use disorder as defined by DSM-5
withdrawal, as manifested by either of the following:
characteristic withdrawal syndrome for the substance
use of the substance or closely related substance is taken to relieve or avoid withdrawal symptoms
substance use disorder as defined by DSM-5
withdrawal, as manifested by either of the following:
characteristic withdrawal syndrome for the substance
use of the substance or closely related substance is taken to relieve or avoid withdrawal symptoms

13. diagnosis of substance use disorder
4/7/2017
diagnosis of substance use disorder
11 identified criteria
impaired control (1 – 4)
social impairment (5 – 7)
risky use (8 – 9)
pharmacological criteria (10 – 11)
a diagnosis of substance use disorder is based on a pathological pattern of behaviors related to the use of the substance
the 11 identified criteria fit within the overall groupings of:
impaired control: this includes criteria 1 – 4
social impairment: this includes criteria 5 – 7
risky use: this includes criteria 8 – 9
pharmacological criteria: this includes criteria 10 – 11

14. significant changes in diagnostic criteria
4/7/2017
significant changes in diagnostic criteria
pharmacological criteria 10 and 11 which include withdrawal occurring during appropriate medical treatment with prescribed medications are specifically NOT counted when diagnosing a substance use disorder
“…the appearance of normal, expected pharmacological tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of addiction even when these were the only symptoms present.”
significant changes in diagnostic criteria
one significant change in the diagnostic criteria is that the pharmacological criteria numbers 10 and 11 which include tolerance, and withdrawal occurring during appropriate medical treatment with prescribed medications are specifically not counted when diagnosing a substance use disorder
the DSM-5 states “the appearance of normal, expected pharmacological tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of addiction even when these were the only symptoms present”

15. significant changes in diagnostic criteria
4/7/2017
significant changes in diagnostic criteria
“however, prescription medications can be used inappropriately, and substance use disorder can be correctly diagnosed when there are other symptoms of compulsive, drug-seeking behavior”
significant changes in diagnostic criteria
the DSM-5 goes on to state “however, prescription medications can be used inappropriately, and substance use disorder can be correctly diagnosed when there are other symptoms of compulsive, drug-seeking behavior”

16. severity and specifiers in the DSM-5
4/7/2017
severity and specifiers in the DSM-5
mild
moderate
severe
severity and specifiers in the DSM-5
mild: presence of two or three symptoms (DSM-IV-TR abuse)
moderate: presence of four or five symptoms
severe: presence of six or more symptoms

17. DSM-5 recommends that in assessing severity clinician uses
4/7/2017
DSM-5 recommends that in assessing severity clinician uses
changes in frequency and/or dose of substance use
individuals own report
report of knowledgeable others
clinician’s observations
biological testing
severity is based on current severity
DSM-5 recommends that in assessing severity clinician uses:
changes in frequency and or dose of substance use
individuals own report
report of knowledgeable others
clinician's observations
biological testing

18. course specifiers in DSM-5
4/7/2017
course specifiers in DSM-5
early remission
sustained remission
in a controlled environment
course specifiers in DSM-5
early remission: after full criteria for substance use disorder were previously met, none of the criteria for substance use disorder have been met for at least three months but for less than 12 months. exception is criteria of craving
sustained remission: after full criteria for substance use disorder were previously met, none of the criteria for substance use disorder have been met at any time during a period of 12 months or longer. exception is criteria of craving
specify if: in a controlled environment

19. 10 classes of substances listed in substance-related disorders
4/7/2017
10 classes of substances listed in substance-related disorders
alcohol
caffeine
cannabis
hallucinogens
inhalants
10 classes of substances listed in substance related disorders
alcohol: includes alcohol use disorder, alcohol intoxication, alcohol withdrawal, other alcohol-induced disorders, unspecified alcohol-related disorder
caffeine: includes caffeine intoxication, caffeine withdrawal, other caffeine induced disorders, unspecified caffeine related disorder. does not include caffeine use disorder. caffeine withdrawal is new to the DSM-5.
cannabis: includes cannabis use disorder, cannabis intoxication, cannabis withdrawal, other cannabis induced disorders, unspecified cannabis related disorder. cannabis withdrawal is new to the DSM-5.
hallucinogens: includes phencyclidine use disorder, other hallucinogen use disorder, phencyclidine intoxication, hallucinogen intoxication, hallucinogen persisting perception disorder, other phencyclidine induced disorders, other hallucinogen induced disorders, unspecified phencyclidine related disorder, unspecified hallucinogen related disorder
inhalants: includes inhalant use disorder, inhalant intoxication other inhalant induced disorders, unspecified inhalant related disorder

20. 10 classes of substances listed in substance-related disorders
4/7/2017
10 classes of substances listed in substance-related disorders
opioids
sedative-hypnotic, or anxiolytics
stimulants
tobacco
other (or unknown)
10 classes of substances listed in substance related disorders
opioids: includes opioid use disorder, opioid intoxication, opioid withdrawal, other opioid induced disorders, unspecified opioid related disorder
sedative-hypnotic, or anxiolytics: includes sedative, hypnotic, or anxiolytic use disorder, sedative, hypnotic, or anxiolytic intoxication, sedative, hypnotic, or anxiolytic withdrawal, other sedative, hypnotic, or anxiolytic induced disorders, unspecified sedative, hypnotic, or anxiolytic related disorder
stimulants: includes stimulant use disorder, stimulant intoxication, stimulant withdrawal, other stimulant induced disorders, unspecified stimulant related disorders.
further, when diagnosing stimulant use disorder under current severity, the clinician would differentiate between
amphetamine type substance
cocaine
other or unspecified stimulant
tobacco: includes tobacco use disorder, tobacco withdrawal, other tobacco induced disorders, unspecified back a related disorder
other (or unknown): includes other or unknown substance use disorder, other or unknown substance intoxication, other or unknown substance withdrawal, other or unknown substance induced disorders, unspecified other or unknown substance related disorder

21. non substance-related disorders
4/7/2017
non substance-related disorders
gambling disorder
only behaviorally based disorder listed in substance related and addictive disorder chapter
has nine specific criteria
non substance-related disorders
gambling disorder
only behaviorally based disorder listed in substance related and addictive disorder chapter
has nine specific criteria

22. 4/7/2017
gambling disorder
needs to gamble with increasing amounts of money in order to achieve the desired excitement
is restless or irritable when attempting to cut down or stop gambling
has made repeated unsuccessful efforts to control, cut back, or stop gambling
is often preoccupied with gambling ( e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble)
DSM-5 defines gambling disorder as: “persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following a 12 month period:”
needs to gamble with increasing amounts of money in order to achieve the desired excitement
is restless or irritable when attempting to cut down or stop gambling
has made repeated unsuccessful efforts to control, cut back, or stop gambling
is often preoccupied with gambling ( e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble)

23. 4/7/2017
gambling disorder
often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed)
after losing money gambling, often returns another date to get even (“chasing” one's losses)
lies to conceal the extent of involvement with gambling
has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
relies on others to provide money to relieve desperate financial situations caused by gambling
gambling disorder continued
often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed)
after losing money gambling, often returns another date to get even (“chasing” one's losses)
lies to conceal the extent of involvement with gambling
has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
relies on others to provide money to relieve desperate financial situations caused by gambling

24. coding and reporting procedures
4/7/2017
coding and reporting procedures
DSM-5 includes both ICD-9-CM and ICD-10-CM codes
ICD codes are listed as a coding note the following diagnostic criteria
example: mild alcohol use disorder for ICD-9
F10.10 mild alcohol use disorder for ICD-10
coding and reporting procedures
DSM-5 includes both ICD-9-CM and ICD-10-CM codes
ICD codes are listed as a coding note the following diagnostic criteria
example: mild alcohol use disorder, for ICD-9
mild alcohol use disorder, F10.10 for ICD-10

25. coding and reporting procedures
4/7/2017
coding and reporting procedures
please note that if intoxication, withdrawal, or substance induced mental disorders are also present, the comorbid use disorder code is utilized
example: alcohol intoxication and alcohol use disorder mild, F for ICD-10
for classes of substances that have more than one substance, in addition to using the code that applies to the class of substance, also record the name of the specific substance
example: (F13.20) moderate alprazolam use disorder
coding and reporting procedures
please note that if intoxication, withdrawal, or substance induced mental disorders are also present, the comorbid use disorder code is utilized
example: alcohol intoxication and alcohol use disorder mild, F for ICD-10
for classes of substances that have more than one substance such as opioids, sedative, hypnotic and anxiolytics, stimulants, hallucinogens in addition to using the code that applies to the class of substance, also record the name of the specific substance
example: (F13.20) moderate alprazolam use disorder

26. DSM-5 also now includes “provisional diagnosis”
4/7/2017
DSM-5 also now includes “provisional diagnosis”
clinician can indicate diagnostic uncertainty by recording “(provisional)” following the diagnosis
can be used when strong presumption that full criteria will be met but not enough information is available to make firm diagnosis
DSM-5 also now includes “provisional diagnosis”
clinician can indicate diagnostic uncertainty by recording “(provisional)” following the diagnosis
can be used when strong presumption that full criteria will be met but not enough information is available to make firm diagnosis

27. principal diagnosis principal diagnosis:
4/7/2017
principal diagnosis
when more than one diagnosis is given in an inpatient setting, the principal diagnosis is the condition established after study to be chiefly responsible for locating the admission of the individual
when more than one diagnosis is given in an outpatient setting, the reason for the visit is the condition that is chiefly responsible for the ambulatory care medical services received during the visit
in most cases, the principal diagnosis or reason for visit is also the main focus of attention or treatment
principal diagnosis:
when more than one diagnosis is given in an inpatient setting, the principal diagnosis is the condition established after study to be chiefly responsible for locating the admission of the individual
when more than one diagnosis is given in an outpatient setting, the reason for the visit is the condition that is chiefly responsible for the ambulatory care medical services received during the visit
in most cases, the principal diagnosis or reason for visit is also the main focus of attention or treatment

28. DSM-5 - three unique sections
4/7/2017
DSM-5 - three unique sections
section I: introduction/use of the manual
section II: diagnostic criteria and codes
section III: emerging measures and models
DSM-5 - three unique sections
section I: introduction/use of the manual
section II: diagnostic criteria and codes
section III: emerging measures and models
the information up to this point has covered section I and
section II
now, we will briefly review section III

29. section III section III
4/7/2017
section III
includes tools and techniques to enhance clinical decision-making, understand cultural context of mental disorders, and recognize emerging diagnosis for further study
section III
includes tools and techniques to enhance clinical decision-making, understand cultural context of mental disorders, and recognize emerging diagnosis for further study

30. assessment measures assessment measures cross-cutting symptom measure
4/7/2017
assessment measures
cross-cutting symptom measure
adult/child
the adult measure is self rated across 13 domains
the child measure is a parent/guardian rated measure across 12 domains
Clinician rated dimensions of psychosis symptom severity
eight item measure to be completed by the clinician at time of clinical assessment
assessment measures
cross-cutting symptom measure
adult/child
the adult measure is self rated across 13 domains
the child measure is a parent/guardian rated measure across 12 domains
clinician rated dimensions of psychosis symptom severity
eight item measure to be completed by the clinician at time of clinical assessment

31. 4/7/2017
World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)
36 item measure that assesses disability in adults over age 18
assesses disability across six domains:
understanding and communicating
getting around
self-care
getting along with people
life activities
participation in society
World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)
36 item measure that assesses disability in adults over age 18
assesses disability across six domains:
understanding and communicating
getting around
self-care
getting along with people
life activities
participation in society

32. cultural formulation 4/7/2017 cultural formulation
“understanding the cultural context of illness experience is essential for effective diagnostic assessment and clinical management.”
culture: systems of knowledge, concepts, rules and practices that are learned and transmitted across generations
cultures are open, dynamic systems that undergo continuous change over time
race: a culturally constructed category of identity that divides humanity into groups based on a variety of superficial physical traits
ethnicity: a culturally constructed group of identity used to define peoples and communities
culture, race, and ethnicity are related to economic iniquities, racism, and discrimination that resulted health disparities
cultural formulation
“understanding the cultural context of illness experience is essential for effective diagnostic assessment and clinical management”
culture: systems of knowledge, concepts, rules and practices that are learned and transmitted across generations. culture includes language, religion and spirituality, family structures, life cycle changes, ceremonial rituals, and customs, as well as moral and legal systems
cultures are open, dynamic systems that undergo continuous change over time, in the contemporary world, most individuals are exposed to multiple cultures which they used to fashion their own identities and make sense of experience
race: a culturally constructed category of identity that divides humanity into groups based on a variety of superficial physical traits attributed to some hypothetical intrinsic, biological characteristics
ethnicity: a culturally constructed group of identity used to define peoples and communities. It may be rooted in a common history, geography, language, religion, or shared characteristics of a group, which distinguish that group from others
culture, race, and ethnicity are related to economic iniquities, racism, and discrimination that resulted health disparities. cultural, ethnic, and racial identities can be sources of strength and group support and enhance resilience, but they may also lead to psychological, interpersonal, and intergenerational conflict or difficulties in adaptation that require diagnostic assessment

33. outline for cultural formulation
4/7/2017
outline for cultural formulation
cultural identity of the individual
cultural conceptualizations of distress
psychosocial stressors and cultural features of vulnerability and resilience
cultural features of the relationship between the individual and clinician
overall cultural assessment
outline for cultural formulation
cultural identity of the individual
cultural conceptualizations of distress
psychosocial stressors and cultural features of vulnerability and resilience
cultural features of the relationship between the individual and clinician
overall cultural assessment

34. cultural formulation interview
4/7/2017
cultural formulation interview
16 questions clinicians may use to obtain information during assessment regarding impact of culture on key aspects of the individual’s clinical presentation and care
cultural formulation interview
16 questions clinicians may use to obtain information during assessment regarding impact of culture on key aspects of the individual’s clinical presentation and care

35. cultural concepts of distress
4/7/2017
cultural concepts of distress
refers to ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions
cultural concepts of distress
cultural concepts of distress refers to ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions

36. 4/7/2017
cultural concepts are important to psychiatric diagnosis for several reasons:
to avoid misdiagnosis
to obtain useful clinical information
to improve clinical rapport and engagement
to improve therapeutic efficacy
to guide clinical research
to clarify the cultural epidemiology
cultural concepts are important to psychiatric diagnosis for several reasons:
to avoid misdiagnosis
to obtain useful clinical information
to improve clinical rapport and engagement
to improve therapeutic efficacy
to guide clinical research
to clarify the cultural epidemiology

37. 4/7/2017
DSM-5 has also placed in section III proposed criteria and diagnostic features for the following
caffeine use disorder
internet gaming disorder
neurobehavioral disorder associated with prenatal alcohol exposure
conditions for further study specific to substance use and addictive disorders
DSM-5 has also placed in section III proposed criteria and diagnostic features for the following:
caffeine use disorder
internet gaming disorder
neurobehavioral disorder associated with prenatal alcohol exposure

38. for more information further information on DSM-5 available at:
4/7/2017
for more information
DSM-5 diagnostic criteria mobile app also available for IOS and android operating systems
further information on DSM-5 available at:
DSM-5 diagnostic criteria mobile app also available for IOS and android operating systems

39. Thank you for listening and for attending.
4/7/2017
Thank you for listening and for attending.
Greg Bauer
Alpine Recovery Services Inc.