Overview Of DSM-5 Changes - Aspira Continuing Education

Overview of DSM-5 ChangesChristopher K. Varley, MD

Disclosure to AudienceNo one involved in the planning or presentation of this activity has any relevant financial relationshipswith a commercial interest to discloseThe following are North Star Behavioral Health’s Content Controllers:Christopher K. Varley, MD - PresenterDr. Andy Mayo, CEODr. Ruth Dukoff, System Medical DirectorLaura McKenzie, QIRM DirectorDenise Gleason, CME CoordinatorEvelyn Alsup, Education Resource ManagerMedical Staff:Dr. Phillip NeubergerDr. Arom EvansDr. Manuel RodriguezDr. Elizabeth BaisiDr. David HjellenDr. Judith BautistaDr. Jill AbramEducation Committee:Sabrina Ben, HRDCarla MacGregor, DRTC AdministratorRon Meier, PRTC Clinical DirectorMelanie Nelson, DOSSBrandy Proctor, DONSarah Skeel, PRTC AdministratorBusiness Development Department:Elke Villegas, Director of Business DevelopmentLindsey Fletcher, Clinical Community LiaisonBecky Bitzer, Clinical Community LiaisonAlice Walter, Clinical Community LiaisonSarah Twaddle, Clinical Community Liaison

DSM-5 Revisions DSM-IV’s organizational structure failed toreflect shared features or symptoms ofrelated disorders and diagnostic groups (likepsychotic disorders with bipolar disorders, orinternalizing (depressive, anxiety, somatic)and externalizing (impulse control, conduct,substance use) disorders. DSM-5 restructuring better reflects theseinterrelationships, within and acrossdiagnostic chapters

DSM-5 Revisions DSM-IV does not adequately address thelifespan perspective, including variations ofsymptom presentations across thedevelopmental trajectory, or cultural perspectives DSM-5’s chapter structure, criteria revisions, andtext outline actively address age anddevelopment as part of diagnosis andclassification Culture is similarly discussed more explicitly tobring greater attention to cultural variations insymptom presentations

DSM-5 Revisions DSM-5 represents an opportunity to betterintegrate neuroscience and the wealth offindings from neuroimaging, genetics,cognitive research, and the like, that haveemerged over the past several decades – allof which are vital to diagnosis and treatmentdevelopment DSM-5 will be more amenable to updates inpsychiatry and neuroscience, making it a“living document” and less susceptible tobecoming outdated than its predecessors

DSM-5 Revisions The multiaxial system in DSM-IV is not requiredto make a mental disorder diagnosis and has notbeen universally used DSM-5 has moved to a nonaxial documentationof diagnosis (formerly Axes I, II, and III), withseparate notations for important psychosocialand contextual factors (formerly Axis IV) anddisability (formerly Axis V) This approach is consistent with establishedWHO and ICD guidance to consider theindividual’s functional status separately from hisor her diagnoses or symptom status

Elimination of Multi-Axial Diagnosis Axis IV - psychosocial and environmental factors - arenow covered through an expanded set of V codes. Vcodes allow clinicians to indicate other conditions thatmay be a focus of clinical attention or affect diagnosis,course, prognosis or treatment of a mental disorder Axis V - CGAS and GAF - are replaced by separatemeasures of symptoms severity and disability forindividual disorders. An eventual change to the WorldHealth Organization Disability Assessment Schedule(WHO DAS 2.0) is anticipated for measurement ofdisability, however it is not yet recommended for use byAPA until it has been studied further.

Clustering of Chapters Neurodevelopmental DisordersEmotional (Internalizing) DisordersSomatic DisordersExternalizing DisordersNeurocognitive DisordersPersonality Disorders

DSM-5 ChaptersNeurodevelopmental DisordersSchizophrenia Spectrum and Other Psychotic DisordersBipolar and Related DisordersDepressive DisordersAnxiety DisordersObsessive-Compulsive and Related DisordersTrauma-and Stressor-Related DisordersDissociative DisordersSomatic Symptom DisordersFeeding and Eating Disorders

DSM-5 Chapters (continued)Elimination DisordersSleep-Wake DisordersSexual DysfunctionsGender DysphoriaDisruptive, Impulse Control and Conduct DisordersSubstance Use and Addictive DisordersNeurocognitive DisordersPersonality DisordersParaphilic DisordersOther Disorders

Changes in Terminology Not Otherwise Specified (NOS) has been used as a“catch-all” for patients who didn’t fit into the more specificcategories. NOS language is eliminated in DSM-5. There will now be an option for designating NotElsewhere Classified (NEC) which will typically include alist of specifiers as to why the patient’s clinical conditiondoesn’t meet a more specific disorder. The phrase “general medical condition” is replaced inDSM-5 with “another medical condition” where relevantacross all disorders. These classification changes will help providers with thetransition to ICD-10 in October 2014. DSM-5 includesthe ICD-10 diagnoses in parentheses.

Highlights: Neurodevelopmental DisordersIntellectual Disability(Intellectual Developmental Disorder) Diagnostic criteria for intellectual disability (intellectualdevelopmental disorder) emphasize the need for anassessment of both cognitive capacity (IQ) and adaptivefunctioning. Severity is determined by adaptivefunctioning rather than IQ score. Despite the name change, the deficits in cognitivecapacity beginning in the developmental period, with theaccompanying diagnostic criteria, are considered toconstitute a mental disorder. No longer use of term “mental retardation.”

Criteria: Neurodevelopmental DisordersIntellectual Disability (Intellectual DevelopmentalDisorder)A. Deficits in intellectual functions, such as reasoning, problem solving,planning, abstract thinking, judgment, academic learning, and learningfrom experience, confirmed by both clinical assessment andindividualized, standardized intelligence testing.B. Deficits in adaptive functioning that result in failure to meetdevelopmental and socio-cultural standards for personal independenceand social responsibility. Without ongoing support, the adaptive deficitslimit functioning in one or more activities of daily life, such ascommunication, social participation, and independent living, acrossmultiple environments, such as home, school, work, and community.C. Onset of intellectual and adaptive deficits during the developmentalperiod.Specify severity (based on adaptive function, not IQ): Mild, Moderate,Severe, Profound

Criteria: Neurodevelopmental DisordersGlobal Developmental DelayDiagnosed reserved for individuals under 5 when clinical severity levelcannot be reliably assessed. Diagnosed when an individual fails tomeet expected developmental milestones in several areas ofintellectual functioning, and applies to individuals who are unable toundergo systematic assessments of intellectual functioning, includingchildren who are too young to participate in standardized testing.Requires reassessment after a period of time.Unspecified Intellectual DisabilityDiagnosed in individuals over 5 when assessment of the degree ofintellectual disability by means of locally available procedures isdifficult or impossible because of associated sensory or physicalimpairments, as in blindness or prelingual deafness; locomotordisability; or presence of severe problem behaviors or co-occurringmental disorder. Should only be used in exceptional circumstancesand requires reassessment after a period of time.

Criteria: Neurodevelopmental DisordersCommunication DisordersThe DSM-5 communication disorders include new and revisedconditions: Language Disorder (which combines DSM-IV expressive and mixedreceptive-expressive language disorders) Speech Sound Disorder (a new name for phonological disorder) Childhood-Onset Fluency Disorder (a new name for stuttering) Social (pragmatic) Communication Disorder, a new condition forpersistent difficulties in the social uses of verbal and nonverbalcommunication (ASD is an obligate rule-out).

DSM-5:Autistic DisorderAsperger’s DisorderPDD-NOSAutism Spectrum DisorderCDD

3 become 2Impairment in Social InteractionDeficits in social communicationand social interactionQualitative impairment incommunicationRestricted repetitive andstereotyped patterns of behavior,interests, and activitiesRestricted, repetitive patterns ofbehavior, interests, or activities

A. Persistent deficits in social communication and social interactionacross multiple contexts, manifested by the following, currently or byhistory (examples are illustrative not exhaustive; see text):1.Deficits in social-emotional reciprocity; ranging, for example, fromabnormal social approach and failure of normal back-and-forth conversation;to reduced sharing of interests, emotions, or affect; to failure to initiate orrespond to social interactions.2. Deficits in nonverbal communicative behaviors used for socialinteraction, ranging, for example, from poorly integrated verbal andnonverbal communication; to abnormalities in eye contact and bodylanguage or deficits in understanding and use of gestures; to a total lack offacial expressions and nonverbal communication.3. Deficits in developing, maintaining, and understanding relationships,ranging, for example, from difficulties adjusting behavior to suit varioussocial contexts; to difficulties in sharing imaginative play or in makingfriends, to absence of interest in peers.

B. Restricted, repetitive patterns of behavior, interests, or activities, asmanifested by at least two of the following, currently or by history(examples are illustrative, not exhaustive; see text):1.Stereotyped or repetitive motor movements, use of objects, or speech(e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia,idiosyncratic phrases).2.Insistence on sameness, inflexible adherence to routines, or ritualizedpatterns of verbal or nonverbal behavior (e.g., extreme distress at smallchanges, difficulties with transitions, rigid thinking patterns, greeting ritualsneed to take same route or eat same food every day).3.Highly restricted, fixated interests that are abnormal in intensity or focus(e.g., strong attachment to or preoccupation with unusual objects, excessivelycircumscribed or perseverative interests).4.Hyper- or hypo-reactivity to sensory input or unusual interest in sensoryaspects of the environment (e.g., apparent indifference to pain/temperature,adverse response to specific sounds or textures, excessive smelling ortouching of objects, visual fascination with lights or movement).

C. Symptoms must be present in the early developmentalperiod (but may not become fully manifest until socialdemands exceed limited capacities; or may be masked bylearned strategies in later life).D. Symptoms cause clinically significant impairment insocial, occupational, or other important areas of currentfunctioning.E. These disturbances are not better explained by intellectualdisability (intellectual developmental disorder) or globaldevelopmental delay. Intellectual disability and autism spectrumdisorder frequently co-occur; to make comorbid diagnoses ofautism spectrum disorder and intellectual disability, socialcommunication should be below that expected for generaldevelopmental level.

Note: Individuals with a well-establishedDSM-IV TR diagnosis of Autisticdisorder, Asperger’s disorder, orPervasive Developmental Disorder NotOtherwise Specified should be given thediagnosis of Autism Spectrum Disorder.

Autism Spectrum Disorder: Specifiers With/without accompanying intellectual impairment. With/without accompanying language impairment. Associated with a known medical or genetic condition orenvironmental factor. Associated with another neurodevelopmental, mental, orbehavioral disorder. With catatonia.Autism Spectrum Disorder: Severity Severity is based on social communication impairmentsand restricted, repetitive patterns of behavior (see Table2 in text).