Wake AHEC & UNC Chapel Hill School Of Social Work Clinical .
Wake AHEC & UNC Chapel HillSchool of Social WorkClinical Lecture SeriesTransition to DSM-5:Navigating changes forPractitionerswebinar presented byMehul Mankad, M.D.mehul.mankad@duke.eduSeptember 18, 2013
DSM-5:Classification, Criteria, and Use
PurposeThis course is for clinicians who are alreadyfamiliar with DSM-IV-TR, its content, and itsuse. This presentation is solely to facilitatetransition from DSM-IV-TR to DSM-5 and isnot intended to be a basic course on DSM-5.Copyright 2013. American Psychiatric Association.
DSM-5 Revisions: Brief History andConceptual Approaches
ICD-8-9 and DSM-II 1967-1972 US-UK study: demonstratedneed for common definitions (incorporated insemi-structured PSE interview) for cliniciansto eliminate wide national variations indiagnosis. DSM-II had glossary in 1968 1972: Feighner Criteria—16 disorders,Renard Interview 1977 ICD-9:Glossary of symptom definitionsCopyright 2013. American Psychiatric Association.
ICD-9 and DSM-III 1978 Spitzer et al. modified andexpanded Feighner to create theResearch Diagnostic Criteria (RDC)and SADS Interview 1980 DSM-III—went beyond glossaryof symptoms to explicit criteria setsbased on RDCCopyright 2013. American Psychiatric Association.
Conceptual Development of DSMDSM-IPresumedetiologyDSM-5New ntal, culture,impairment thresholds,living ualizationExplicit criteria(emphasis on reliabilityrather than validity)DSM–IVRequires clinicallysignificant distressor impairmentDSM-III-RCriteria broadenedMost hierarchiesdroppedCopyright 2013. American Psychiatric Association.
Perceived Shortcomings in DSM-IV High rates of comorbidity High use of –NOS category Treatment non-specificity Inability to find a laboratory markers/tests DSM is starting to hinder researchprogressCopyright 2013. American Psychiatric Association.
Strategies for Improving DSM Incorporate research into the revisionand evolution of the classification Move beyond a process of clinicalconsensus and build diagnoses on afoundation of empirical findings fromscientific disciplines Seek multidisciplinary, internationalscientific participation in the task ofplanning the DSM-5 revisionCopyright 2013. American Psychiatric Association.
APA/WHO/NIH Diagnosis Research Planning Conferences: Participant DistributionEastern Mediterranean,5AfricaKenya, 2Nigeria, 3South Africa, 4Europe, 119U.S.A., 194South-East Asia, 10Western Pacific, 32Latin Am erica, 16Africa, 9Canada, 12- 397 Participants- 39 Countries- 16 Developing Nations- 51% Non-US Participants- 10% Developing Nation PaticipantsLatin Am ericaArgentina, 2Brazil, 4Chile, 3Mexico, 5Puerto Rico, 2EasternMediterraneanBahrain, 1Israel, 3Lebanon, 1EuropeBelarus, 1Belgium, 2Denmark, 4Estonia, 1France, 3Germany, 11Europe (Cont)Greece, 1Hungary, 1Italy, 5Luxembourg, 1Netherlands, 12Norw ay, 2Russia, 4Spain, 5Sw eden, 4Sw itzerland, 21UK, 41South-East AsiaIndia, 5Pakistan, 2Sri Lanka, 1Thailand, 2Western PacificAustralia, 9China, 9Japan, 8Korea, 3New Zealand, 3Copyright 2013. American Psychiatric Association.
DSM-5 Conference Output 13 Conferences (2003-08)10 monographs published Dimensional Models of Personality DisordersDiagnostic Issues in Substance Use DisordersDiagnostic Issues in DementiaDimensional Approaches in Diagnostic ClassificationStress-Induced and Fear Circuitry DisordersSomatic Presentations of Mental DisordersDeconstructing PsychosisDepression and GADObsessive-Compulsive Behavior Spectrum DisordersPublic Health Aspects of Psychiatric DiagnosisMore than 200 journal articles publishedCopyright 2013. American Psychiatric Association.
DSM-5 Work Groups and Chairs ADHD & Disruptive Behavior Disorders (David Shaffer, M.D.)Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, andDissociative Disorders (Katharine Phillips, M.D.)Disorders in Childhood and Adolescence (Daniel Pine, M.D.)Eating Disorders (Timothy Walsh, M.D.)Mood Disorders (Jan Fawcett, M.D.)Neurocognitive Disorders (Dan Blazer, M.D.; Ron Petersen, M.D.[Co-Chair]; Dilip Jeste, M.D. [Chair Emeritus])Neurodevelopmental Disorders (Susan Swedo, M.D.)Personality and Personality Disorders (Andrew Skodol, M.D.)Psychotic Disorders (William Carpenter, M.D.)Sexual and Gender Identity Disorders (Kenneth Zucker, Ph.D.)Sleep-Wake Disorders (Charles Reynolds, M.D.)Somatic Distress Disorders (Joel Dimsdale, M.D.) Substance-Related Disorders (Charles O’Brien, M.D., Ph.D.) Copyright 2013. American Psychiatric Association.
Cross-Cutting Study Groups and Chairs Diagnostic Spectra (Steven Hyman, M.D.) Life Span Developmental Approach Study Group(Susan K. Schultz, M.D.) Gender and Cross-Cultural Study Group(Kimberly Yonkers, M.D.) Psychiatric/General Medical Interface Study Group(Lawson Wulsin, M.D.) Impairment and Disability Assessment(Jane S. Paulsen, Ph.D.) Diagnostic Assessment Instruments(Jack D. Burke, Jr., M.D., M.P.H.)Copyright 2013. American Psychiatric Association.
DSM-5 Classification Structure
DSM-5 Structure Section I: DSM-5 BasicsSection II: Essential Elements: DiagnosticCriteria and CodesSection III: Emerging Measures andModelsAppendixIndexCopyright 2013. American Psychiatric Association.
Section I BriefDSM-5 developmental history Guidance on use of the manual Definition of a mental disorder Cautionary forensic statement Brief DSM-5 classification summaryCopyright 2013. American Psychiatric Association.
Section II:Chapter StructureA. Neurodevelopmental DisordersB. Schizophrenia Spectrum and Other PsychoticDisordersC. Bipolar and Related DisordersD. Depressive DisordersE. Anxiety DisordersF. Obsessive-Compulsive and Related DisordersG. Trauma- and Stressor-Related DisordersH. Dissociative DisordersCopyright 2013. American Psychiatric Association.
Section II:Chapter StructureJ. Somatic Symptom and Related DisordersK. Feeding and Eating DisordersL. Elimination DisordersM. Sleep-Wake DisordersN. Sexual DysfunctionsP. Gender DysphoriaCopyright 2013. American Psychiatric Association.
Section II:Chapter StructureQ. Disruptive, Impulse-Control, and Conduct DisordersR. Substance-Related and Addictive DisordersS. Neurocognitive DisordersT. Personality DisordersU. Paraphilic DisordersV. Other DisordersMedication-Induced Movement Disorders and OtherAdverse Effects of MedicationOther Conditions That May Be a Focus of ClinicalAttentionCopyright 2013. American Psychiatric Association.
Section III: Purpose Section III serves as a designated location,separate from diagnostic criteria, text, andclinical codes, for items that appear to haveinitial support in terms of clinical use butrequire further research before beingofficially recommended as part of the mainbody of the manual This separation clearly conveys to readers that thecontent may be clinically useful and warrants review,but is not a part of an official diagnosis of a mentaldisorder and cannot be used as suchCopyright 2013. American Psychiatric Association.
Section III: Content Section III: Emerging Measures andModels Assessment Measures Cultural Formulation Alternative DSM-5 Model for PersonalityDisorders Conditions for Further StudyCopyright 2013. American Psychiatric Association.
Section III: Content Section III, Conditions for Further Study Attenuated Psychosis SyndromeDepressive Episodes With Short Duration HypomaniaPersistent Complex Bereavement DisorderCaffeine Use DisorderInternet Gaming DisorderNeurobehavioral Disorder Due to Prenatal AlcoholExposureSuicidal Behavior DisorderNon-suicidal Self-InjuryCopyright 2013. American Psychiatric Association.
Appendix: Content Separate from Section III will be an Appendix,which will include Highlights of Changes From DSM-IV to DSM-5Glossary of Technical TermsGlossary of Cultural Concepts of DistressAlphabetical Listing of DSM-5 Diagnoses and Codes(ICD-9-CM and ICD-10-CM)Numerical Listing of DSM-5 Diagnoses and Codes(ICD-9-CM)Numerical Listing of DSM-5 Diagnoses and Codes(ICD-10-CM)DSM-5 Advisors and Other ContributorsCopyright 2013. American Psychiatric Association.
Changes in Specific DSM Disorder Numbers;Combination of New, Eliminated, and CombinedDisorders(net difference -15)Specific Mental Disorders* *NOSDSM-IVDSM-5172157(DSM-IV) and Other Specified/Unspecified (DSM-5) conditions are countedseparately.Copyright 2013. American Psychiatric Association.
New and Eliminated Disorders in DSM-5New Disorders(net difference 13)1.2.3.4.5.6.7.8.9.10.11.12.13.14.Social (Pragmatic) Communication DisorderDisruptive Mood Dysregulation DisorderPremenstrual Dysphoric Disorder (DSM‐IV appendix)Hoarding DisorderExcoriation (Skin‐Picking) DisorderDisinhibited Social Engagement Disorder (split from Reactive Attachment Disorder)Binge Eating Disorder (DSM‐IV appendix)Central Sleep Apnea (split from Breathing‐Related Sleep Disorder)Sleep-Related Hypoventilation (split from Breathing‐Related Sleep Disorder)Rapid Eye Movement Sleep Behavior Disorder (Parasomnia NOS)Restless Legs Syndrome (Dyssomnia NOS)Caffeine Withdrawal (DSM‐IV Appendix)Cannabis WithdrawalMajor Neurocognitive Disorder with Lewy Body Disease (Dementia Due to OtherMedical Conditions)15. Mild Neurocognitive Disorder (DSM‐IV Appendix)Eliminated Disorders1.2.Sexual Aversion DisorderPolysubstance‐Related DisorderCopyright 2013. American Psychiatric Association.
Combined Specific Disorders in DSM-5(net difference -28)1.Language Disorder (Expressive Language Disorder & Mixed Receptive ExpressiveLanguage Disorder)2.Autism Spectrum Disorder (Autistic Disorder, Asperger’s Disorder, ChildhoodDisintegrative Disorder, & Rett’s disorder—PDD-NOS is in the NOS count)3.Specific Learning Disorder (Reading Disorder, Math Disorder, & Disorder of WrittenExpression)4.Delusional Disorder (Shared Psychotic Disorder & Delusional Disorder)5.Panic Disorder (Panic Disorder Without Agoraphobia & Panic Disorder With Agoraphobia)6.Dissociative Amnesia (Dissociative Fugue & Dissociative Amnesia)7.Somatic Symptom Disorder (Somatization Disorder, Undifferentiated SomatoformDisorder, & Pain Disorder)8.Insomnia Disorder (Primary Insomnia & Insomnia Related to Another Mental Disorder)9.Hypersomnolence Disorder (Primary Hypersomnia & Hypersomnia Related to AnotherMental Disorder)10.Non-Rapid Eye Movement Sleep Arousal Disorders (Sleepwalking Disorder & SleepTerror Disorder)Copyright 2013. American Psychiatric Association.
Combined Specific Disorders in DSM-5 (Continued)(net difference -28)11.Genito‐Pelvic Pain/Penetration Disorder (Vaginismus & Dyspareunia)12.Alcohol Use Disorder (Alcohol Abuse and Alcohol Dependence)13.Cannabis Use Disorder (Cannabis Abuse and Cannabis Dependence)14.Phencyclidine Use Disorder (Phencyclidine Abuse and Phencyclidine Dependence)15.Other Hallucinogen Use Disorder (Hallucinogen Abuse and Hallucinogen Dependence)16.Inhalant Use Disorder (Inhalant Abuse and Inhalant Dependence)17.Opioid Use Disorder (Opioid Abuse and Opioid Dependence)18.Sedative, Hypnotic, or Anxiolytic Use Disorder (Sedative, Hypnotic, or Anxiolytic Abuse andSedative, Hypnotic, or Anxiolytic Dependence)19.Stimulant Use Disorder (Amphetamine Abuse; Amphetamine Dependence; Cocaine Abuse;Cocaine Dependence)20.Stimulant Intoxication (Amphetamine Intoxication and Cocaine Intoxication)21.Stimulant Withdrawal (Amphetamine Withdrawal and Cocaine Withdrawal)22.Substance/Medication-Induced Disorders (aggregate of Mood ( 1), Anxiety ( 1), andNeurocognitive (-3))Copyright 2013. American Psychiatric Association.
Changes from NOS toOther Specified/Unspecified(net difference 24)NOS (DSM-IV) and her Specified and Unspecified Disorders in DSM-5 replacedthe Not Otherwise Specified (NOS) conditions in DSM-IV tomaintain greater concordance with the official InternationalClassification of Diseases (ICD) coding system. This statisticalaccounting change does not signify any new specific mentaldisorders.Copyright 2013. American Psychiatric Association.
Highlights of Specific DisorderRevisions and Rationales
Autism Spectrum Disorder (ASD)(Neurodevelopmental Disorders) ASD replaces DSM-IV’s autistic disorder,Asperger’s disorder, childhood disintegrationdisorder, and pervasive developmentaldisorder not otherwise specified Rationale: Clinicians had been applying the DSM-IVcriteria for these disorders inconsistently andincorrectly; subsequently, reliability data to supporttheir continued separation was very poor. Specifiers can be used to describe variants of ASD(e.g., the former diagnosis of Asperger’s can now bediagnosed as autism spectrum disorder, withoutintellectual impairment and without structurallanguage impairment).Copyright 2013. American Psychiatric Association.
Intellectual Disability (IntellectualDevelopmental Disorder) Mental retardation was renamed intellectualdisability (intellectual developmental disorder) Rationale: The term intellectual disability reflects thewording adopted into U.S. law in 2010 (Rosa’s Law), inuse in professional journals, and endorsed by certainpatient advocacy groups. The term intellectualdevelopmental disorder is consistent with languageproposed for ICD-11.Greater emphasis on adaptive functioning deficitsrather than IQ scores alone Rationale: Standardized IQ test scores were overemphasized as the determining factor of abilities in DSMIV. Consideration of functioning provides a morecomprehensive assessment of the individual.Copyright 2013. American Psychiatric Association.
Attention-Deficit/Hyperactivity Disorder Age of onset was raised from 7 years to 12years Rationale: Numerous large-scale studies indicate that,in many cases, onset is not identified until after age 7years, when challenged by school requirements.Recall of onset is more accurate at 12 years.The symptom threshold for adults age 17 yearsand older was reduced to five Rationale: The reduction in symptom threshold was foradults only and was made based on longitudinal studiesshowing that patients tend to have fewer symptoms inadulthood than in childhood. This should result in aminimal increase in the prevalence of adult ADHD.Copyright 2013. American Psychiatric Association.
Schizophrenia(Schizophrenia Spectrum and Other Psychotic Disorders) Elimination of special treatment of bizarredelusions and “special” hallucinations in CriterionA (characteristic symptoms) Rationale: This was removed due to the poor reliabilityin distinguishing bizarre from non-bizarre delusions.At least one of two required symptoms to meetCriterion A must be delusions, hallucinations, ordisorganized speech Rationale: This will improve reliability and preventindividuals with only negative symptoms and catatoniafrom being diagnosed with schizophrenia.Copyright 2013. American Psychiatric Association.
Schizophrenia (cont’d) Deletion of specific subtypes Rationale: DSM-IV’s subtypes were shownto have very poor reliability and validity. Theyalso failed to differentiate from one anotherbased on treatment response and course.Copyright 2013. American Psychiatric Association.
Schizoaffective Disorder Now based on the lifetime (rather thanepisodic) duration of illness in which the moodand psychotic symptoms described in CriterionA occur Rationale: The criteria in DSM-IV have demonstratedpoor reliability and clinical utility, in part because thelanguage in DSM-IV regarding the duration of illnessis ambiguous. This revision is consistent with thelanguage in schizophrenia and in mood episodes,which explicitly describe a longitudinal rather thanepisodic course. Similarly applying a longitudinalcourse to schizoaffective disorder will aid in itsdifferential diagnosis from these related disorders.Copyright 2013. American Psychiatric Association.
Catatonia Now exists as a specifier forneurodevelopmental, psychotic, mood andother mental disorders; as well as for othermedical disorders (catatonia due to anothermedical condition) Rationale: As represented in DSM-IV, catatonia wasunder-recognized, particularly in psychiatricdisorders other than schizophrenia and psychoticmood disorders and in other medical disorders. Itwas also apparent that inclusion of catatonia as aspecific condition that can apply more broadly acrossthe manual may help address gaps in the treatmentof catatonia.Copyright 2013. American Psychiatric Association.
Mania and Hypomania(Bipolar and Related Disorders) Inclusion of increased energy/activity as aCriterion A symptom of mania andhypomania Rationale: This will make explicit therequirement of increased energy/activity inorder to diagnose bipolar I or II disorder (whichis not required under DSM-IV) and will improvethe specificity of the diagnosis.Copyright 2013. American Psychiatric Association.
Mania and Hypomania “Mixed episode” is replaced with a “withmixed features” specifier for manic,hypomanic, and major depressiveepisodes Rationale: DSM-IV criteria excluded fromdiagnosis the sizeable population ofindividuals with subthreshold mixed stateswho did not meet full criteria for majordepression and mania, and thus were lesslikely to receive treatment.Copyright 2013. American Psychiatric Association.
Mania and Hypomania “With anxious distress” also added as aspecifier for bipolar (and depressive)disorders Rationale: The co-occurrence of anxiety withdepression is one of the most commonly seencomorbidities in clinical populations. Additionof this specifier will allow clinicians to indicatethe presence of anxiety symptoms that are notreflected in the core criteria for depressionand mania but nonetheless may bemeaningful for treatment planning.Copyright 2013. American Psychiatric Association.
Bereavement Exclusion(Depressive Disorders) Eliminated from major depressive episode(MDE) Rationale: In some individuals, major loss –including but not limited to loss of a loved one –can lead to MDE or exacerbate pre-existingdepression. Individuals experiencing bothconditions can benefit from treatment but areexcluded from diagnosis under DSM-IV. Further,the 2-month timeframe required by DSM-IVsuggests an arbitrary time course tobereavement that is inaccurate. Lifting theexclusion alleviates both of these problems.Copyright 2013. American Psychiatric Association.
Disruptive Mood Dysregulation Disorder(DMDD) Newly added to DSM-5 Rationale: This addresses the disturbing increase inpediatric bipolar diagnoses over the past two decades,which is due in large part to the incorrectcharacterization of non-episodic irritability as a hallmarksymptom of mania. DMDD provides a diagnosis forchildren with extreme behavioral dyscontrol butpersistent, rather than episodic, irritability and reducesthe likelihood of such children being inappropriatelyprescribed antipsychotic medication. These criteria donot allow a dual diagnosis with oppositional-defiantdisorder (ODD) or intermittent explosive disorder (IED),but it can be diagnosed with conduct disorder (CD).Children who meet criteria for DMDD and ODD wouldbe diagnosed with DMDD only.Copyright 2013. American Psychiatric Association.
Anxiety Disorders Separation of DSM-IV Anxiety Disorderschapter into four distinct chapters Rationale: Data from neuroscience,neuroimaging, and genetic studies suggestdifferences in the heritability, risk, course, andtreatment response among fear-based anxietydisorders (e.g., phobias); disorders ofobsessions or compulsions (e.g., OCD);trauma-related anxiety disorders (e.g., PTSD);and dissociative disorders. Thus, four anxietyrelated classifications are present in DSM-5,instead of two chapters in DSM-IV.Copyright 2013. American Psychiatric Association.
Panic Attacks Specifier Now a specifier for any mental disorder Rationale: Panic attacks can predict the onsetseverity and course of mental disorders,including anxiety disorders, bipolar diso
ASD replaces DSM-IV’s autistic disorder, Asperger’s disorder, childhood disintegration disorder, and pervasive developmental disorder not otherwise specified Rationale: Clinicians had been applying the DSM-IV criteria for these disorders inconsistently and incorrectly; subsequently, reliability data to support
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Rebecca J. Macy, PhD, MSW University of North Carolina at Chapel Hill, School of Social Work 325 Pittsboro Street, CB #3550 Chapel Hill, NC 27599 rjmacy@email.unc.edu . Professor, UNC at Chapel Hill, School of Social Work L. Richardson Preyer Distinguished Chair for Strengthening Families, UNC at Chapel Hill, School of Social Work .
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Welcome to UNC-Chapel Hill! The information presented in this document (the Clinical Psychology Program Handbook) has been prepared by faculty, staff, and students to help you as you progress through the UNC-Chapel Hill Clinical Psychology graduate program. Note: For the rest of this document, we'll use "UNC" to refer to "UNC-Chapel .
TODD M. JENSEN, MSW, LCSWA Curriculum Vitae University of North Carolina at Chapel Hill School of Social Work 325 Pittsboro Street, CB# 3550 Chapel Hill, NC 27599-3550 801-376-8410 toddm.jensen@gmail.com jensent@live.unc.edu EDUCATION 2017 (expected) PhD University of North Carolina at Chapel Hill, Chapel Hill, NC Field: Social Work
