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UNC-CH School of Social Work Clinical Lecture SeriesDISCLAIMER:These handouts have beenadapted for printing, whichincludes changes to font, color,and format. Because of theseadaptations, please be advisedthat these should NOT beconsidered the official APADSM-5 training slides.1UNC Chapel Hill School of Social WorkClinical Lecture SeriesDSM-5:Navigating changes for Practitionerspresented byMehul Mankad, M.D.Mehul.Mankad@duke.eduSeptember 16, 2013PurposeThis 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 is notintended to be a basic course on DSM-5. DSM-5:Classification, Criteria,and UseICD-8-9 and DSM-II1967-1972US-UK study:demonstrated need for commondefinitions (incorporated in semistructured PSE interview) for clinicians toeliminate wide national variations indiagnosis. DSM-II had glossary in 19681972 Feighner 16 disorders, Renard InterviewCriteria:1977 ICD-9:DSM-5 Revisions:Brief HistoryandConceptual ApproachesICD-9 and DSM-III1978 modified and expanded Feighner toSpitzer create the Research Diagnosticet al. Criteria (RDC) and SADS Interview1980 DSM-III—went beyond glossary ofDSM III symptoms to explicit criteria setsbased on RDCGlossary of symptom definitionsNavigating DSM-5, Mehul Mankad, M.D.Sept 16, 2013

UNC-CH School of Social Work Clinical Lecture SeriesConceptual Development of DSMDSM-IPresumedetiologyDSM-5New ntal, culture,impairment thresholds,living document)DSM-IIIReconceptualizationExplicit criteria(emphasis on reliabilityrather than validity)DSM-IIGlossarydefinitions2Perceived Shortcomings in DSM-IV High rates of comorbidity High use of –NOS category Treatment non-specificity Inability to find a laboratory markers/ testsDSM–IVRequires clinicallysignificant distressor impairmentDSM-III-RCriteria broadenedMost hierarchiesdropped DSM is starting to hinder research progressCopyright 2013. American Psychiatric Association.Strategies for Improving DSMAPA/WHO/NIH Diagnosis Research Planning Conferences: Participant DistributionEastern Mediterranean,5 Incorporate research into the revision andevolution of the classification Move beyond a process of clinicalconsensus and build diagnoses on afoundation of empirical findings fromscientific disciplinesEurope, 119U.S.A., 194South-East Asia, 10Western Pacific, 32Latin Am erica, 16Africa, 9Canada, 12 Seek multidisciplinary, internationalscientific participation in the task ofplanning the DSM-5 revisionAfricaKenya, 2Nigeria, 3South Africa, 4- 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 Disorders Diagnostic Issues in Substance Use Disorders Diagnostic Issues in Dementia Dimensional Approaches in Diagnostic Classification Stress-Induced and Fear Circuitry Disorders Somatic Presentations of Mental Disorders Deconstructing Psychosis Depression and GAD Obsessive-Compulsive Behavior Spectrum Disorders Public Health Aspects of Psychiatric Diagnosis More than 200 journal articles publishedCopyright 2013. American Psychiatric Association.Navigating DSM-5, Mehul Mankad, M.D.DSM-5 Work GroupsChairsADHD & Disruptive BehaviorDisordersDavid Shaffer, M.D.Anxiety, Obsessive-CompulsiveSpectrum, Posttraumatic, andDissociative DisordersKatharine Phillips, M.D.Disorders in Childhood andAdolescenceDaniel Pine, M.D.Eating DisordersTimothy Walsh, M.D.Mood DisordersJan Fawcett, M.D.Neurocognitive DisordersDan Blazer, M.D. & RonPetersen, M.D. // DilipJeste, M.D. [Chair Emeritus]Sept 16, 2013

UNC-CH School of Social Work Clinical Lecture SeriesDSM-5 Work GroupsNeurodevelopmental DisordersPersonality and PersonalityDisordersPsychotic DisordersSexual and Gender IdentityDisordersSleep-Wake DisordersSomatic Distress DisordersSubstance-Related Disorders3ChairsSusan Swedo, M.D.Andrew Skodol, M.D.William Carpenter, M.D.DSM-5 Classification StructureKenneth Zucker, Ph.D.Charles Reynolds, M.D.Joel Dimsdale, M.D.Charles O’Brien, M.D.,Ph.D.DSM-5 StructureSection I Section I: DSM-5 Basics Brief DSM-5 developmental history Section II: Essential Elements: DiagnosticCriteria and Codes Guidance on use of the manual Section III: Emerging Measures and Models Appendix IndexSection II: Chapter StructureA. Neurodevelopmental DisordersB. Schizophrenia Spectrum and OtherPsychotic DisordersC. Bipolar and Related DisordersD. Depressive DisordersE. Anxiety DisordersF. Obsessive-Compulsive and RelatedDisordersNavigating DSM-5, Mehul Mankad, M.D. Definition of a mental disorder Cautionary forensic statement Brief DSM-5 classification summarySection II: Chapter Structure (cont.)G.H.I.J.K.L.M.N.Trauma- and Stressor-Related DisordersDissociative DisordersSomatic Symptom and Related DisordersFeeding and Eating DisordersElimination DisordersSleep-Wake DisordersSexual DysfunctionsGender DysphoriaSept 16, 2013

UNC-CH School of Social Work Clinical Lecture SeriesSection II: Chapter Structure (cont.)Q. Disruptive, Impulse-Control, and Conduct DisordersR. Substance-Related and Addictive DisordersS. Neurocognitive DisordersT. Personality DisordersU. Paraphilic DisordersV. Other Disorders4Section III: Purpose Serves as a designated location, separate fromdiagnostic criteria, text, and clinical codes, foritems that appear to have initial support interms of clinical use but require furtherresearch before being officially recommendedas part of the main body of the manualOther Conditions That May Be a Focus of ClinicalAttention– This separation clearly conveys to readers that thecontent may be clinically useful and warrantsreview, but is not a part of an official diagnosis of amental disorder and cannot be used as suchSection III: ContentSection III: ContentMedication-Induced Movement Disorders and OtherAdverse Effects of Medication Section III: Emerging Measures and Models– Assessment Measures– Cultural Formulation– Alternative DSM-5 Model for PersonalityDisorders– Conditions for Further Study Section III, Conditions for Further Study– Attenuated Psychosis Syndrome– Depressive Episodes With Short Duration Hypomania– Persistent Complex Bereavement Disorder– Caffeine Use Disorder– Internet Gaming Disorder– Neurobehavioral Disorder Due to Prenatal AlcoholExposure– Suicidal Behavior Disorder– Non-suicidal Self-InjuryAppendix: ContentChanges in Specific DSM Disorder Numbers; Separate from Section III will be an Appendix, with:– Highlights of Changes From DSM-IV to DSM-5– Glossary of Technical Terms– Glossary of Cultural Concepts of Distress– Alphabetical Listing of DSM-5 Diagnoses andCodes (ICD-9-CM and ICD-10-CM)– Numerical Listing of DSM-5 Diagnoses andCodes (ICD-9-CM)– Numerical Listing of DSM-5 Diagnoses andCodes (ICD-10-CM)– DSM-5 Advisors and Other ContributorsCombination of New, Eliminated, and CombinedDisorders(net difference -15)Navigating DSM-5, Mehul Mankad, M.D.Specific MentalDisorders*DSM-IVDSM-5172157*NOS (DSM-IV) and Other Specified/Unspecified (DSM-5)conditions are counted separately.Sept 16, 2013

UNC-CH School of Social Work Clinical Lecture SeriesNew and Eliminated Disorders in DSM-55New and Eliminated Disorders in DSM-5New DisordersNew Disorders1. Social (Pragmatic) Communication Disorder2. Disruptive Mood Dysregulation Disorder3. Premenstrual Dysphoric Disorder (DSM‐IVappendix)4. Hoarding Disorder5. Excoriation (Skin‐Picking) Disorder6. Disinhibited Social Engagement Disorder (split fromReactive Attachment Disorder)7. Binge Eating Disorder (DSM‐IV appendix)8. Central Sleep Apnea (split from Breathing‐RelatedSleep Disorder)9. Sleep-Related Hypoventilation (split fromBreathing‐Related Sleep Disorder)10.Rapid Eye Movement Sleep Behavior Disorder(Parasomnia NOS)11.Restless Legs Syndrome (Dyssomnia NOS)12.Caffeine Withdrawal (DSM‐IV Appendix)13.Cannabis Withdrawal14.Major Neurocognitive Disorder with Lewy BodyDisease (Dementia Due to Other MedicalConditions)15.Mild Neurocognitive Disorder (DSM‐IV Appendix)New and Eliminated Disorders in DSM-5Combined Specific Disorders in DSM-5Eliminated Disorders1. Sexual Aversion Disorder2. Polysubstance‐Related Disorder15 disorders added2 disorders eliminated 13 net differenceCombined Specific Disorders in DSM-5 (cont.)6. Dissociative Amnesia (Dissociative Fugue &Dissociative Amnesia)7. Somatic Symptom Disorder (Somatization Disorder,Undifferentiated Somatoform Disorder, & PainDisorder)8. Insomnia Disorder (Primary Insomnia & InsomniaRelated to Another Mental Disorder)9. Hypersomnolence Disorder (Primary Hypersomnia &Hypersomnia Related to Another Mental Disorder)10. Non-Rapid Eye Movement Sleep Arousal Disorders(Sleepwalking Disorder & Sleep Terror Disorder)Navigating DSM-5, Mehul Mankad, M.D.(net difference -28)1. Language Disorder (Expressive Language Disorder &Mixed Receptive Expressive Language Disorder)2. Autism Spectrum Disorder (Autistic Disorder, Asperger’sDisorder, Childhood Disintegrative Disorder, & Rett’sdisorder—PDD-NOS is in the NOS count)3. Specific Learning Disorder (Reading Disorder, MathDisorder, & Disorder of Written Expression)4. Delusional Disorder (Shared Psychotic Disorder &Delusional Disorder)5. Panic Disorder (Panic Disorder Without Agoraphobia &Panic Disorder With Agoraphobia)Combined Specific Disorders in DSM-5 (cont.)11. Genito‐Pelvic Pain/Penetration Disorder (Vaginismus& Dyspareunia)12. Alcohol Use Disorder (Alcohol Abuse and AlcoholDependence)13. Cannabis Use Disorder (Cannabis Abuse and CannabisDependence)14. Phencyclidine Use Disorder (Phencyclidine Abuse andPhencyclidine Dependence)15. Other Hallucinogen Use Disorder (Hallucinogen Abuseand Hallucinogen Dependence)16. Inhalant Use Disorder (Inhalant Abuse and InhalantDependence)Sept 16, 2013

UNC-CH School of Social Work Clinical Lecture SeriesCombined Specific Disorders in DSM-5 (cont.)17. Opioid Use Disorder (Opioid Abuse & Opioid Dependence)18. Sedative, Hypnotic, or Anxiolytic Use Disorder (Sedative,Hypnotic, or Anxiolytic Abuse and Sedative, Hypnotic, orAnxiolytic Dependence)19. Stimulant Use Disorder (Amphetamine Abuse;Amphetamine Dependence; Cocaine Abuse; CocaineDependence)20. Stimulant Intoxication (Amphetamine Intoxication andCocaine Intoxication)21. Stimulant Withdrawal (Amphetamine Withdrawal andCocaine Withdrawal)22. Substance/Medication-Induced Disorders (aggregate ofMood ( 1), Anxiety ( 1), and Neurocognitive (-3))6Changes from NOS toOther Specified/Unspecified(net difference 24)NOS (DSM-IV) and OtherSpecified/Unspecified (DSM-5)DSM-IV DSM-54165Other Specified and Unspecified Disorders in DSM-5 replaced theNot Otherwise Specified (NOS) conditions in DSM-IVto maintain greater concordance with the official InternationalClassification of Diseases (ICD) coding system.This statistical accounting change does not signify any new specificmental disorders.Autism Spectrum Disorder (ASD)Highlights of Specific Disorder Revisionsand Rationales(Neurodevelopmental Disorders) ASD replaces DSM-IV’s autistic disorder,Asperger’s disorder, childhood disintegrationdisorder, and pervasive developmental disordernot otherwise specified– Rationale: Clinicians had been applying the DSM-IVcriteria for these disorders inconsistently and incorrectly;subsequently, reliability data to support their continuedseparation was very poor.– Specifiers can be used to describe variants of ASD (e.g.,the former diagnosis of Asperger’s can now be diagnosedas autism spectrum disorder, without intellectualimpairment and without structural language impairment).Intellectual Disability(Intellectual Developmental Disorder) Mental retardation was renamed intellectual disability(intellectual developmental disorder)– Rationale: The term intellectual disability reflects the wordingadopted into U.S. law in 2010 (Rosa’s Law), in use in professionaljournals, and endorsed by certain patient advocacy groups. Theterm intellectual developmental disorder is consistent withlanguage proposed for ICD-11. Greater emphasis on adaptive functioning deficits ratherthan IQ scores alone– Rationale: Standardized IQ test scores were over-emphasized asthe determining factor of abilities in DSM-IV. Consideration offunctioning provides a more comprehensive assessment of theindividual.Navigating DSM-5, Mehul Mankad, M.D.Attention-Deficit/Hyperactivity Disorder Age of onset was raised from 7 years to 12 years– Rationale: Numerous large-scale studies indicate that,in many cases, onset is not identified until after age 7years, when challenged by school requirements. Recallof 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 made based on longitudinal studiesshowing that patients tend to have fewer symptoms inadulthood than childhood. This should result in aminimal increase in the prevalence of adult ADHD.Sept 16, 2013

UNC-CH School of Social Work Clinical Lecture Series7SchizophreniaSchizophrenia (cont’d)(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 Deletion of specific subtypes– Rationale: DSM-IV’s subtypes were shown tohave very poor reliability and validity. They alsofailed to differentiate from one another based ontreatment response and course.– Rationale: This will improve reliability and preventindividuals with only negative symptoms and catatoniafrom being diagnosed with schizophrenia.CatatoniaSchizoaffective Disorder Now based on the lifetime (rather than episodic)duration of illness in which the mood and psychoticsymptoms described in Criterion A occurRationale:The criteria in DSM-IV have demonstrated poor reliabilityand clinical utility, in part because the language in DSM-IVregarding the duration of illness is ambiguous.This revision is consistent with the language in schizophreniaand in mood episodes, which explicitly describe alongitudinal rather than episodic course.Similarly applying a longitudinal course to schizoaffectivedisorder will aid in its differential diagnosis from theserelated disorders.Mania and Hypomania(Bipolar and Related Disorders) Inclusion of increased energy/activity as aCriterion A symptom of mania and hypomaniaRationale:This will make explicit the requirement of increasedenergy/activity in order to diagnose bipolar I or IIdisorder (which is not required under DSM-IV) andwill improve the specificity of the diagnosis.Navigating DSM-5, Mehul Mankad, M.D. Now exists as a specifier for neurodevelopmental,psychotic, mood and other mental disorders; as well asfor other medical disorders (catatonia due to anothermedical condition)Rationale:As represented in DSM-IV, catatonia was under-recognized,particularly in psychiatric disorders other thanschizophrenia and psychotic mood disorders and in othermedical disorders.It was also apparent that inclusion of catatonia as a specificcondition that can apply more broadly across the manualmay help address gaps in the treatment of catatonia.Mania and Hypomania “Mixed episode” is replaced with a “withmixed features” specifier for manic,hypomanic, and major depressive episodesRationale:DSM-IV criteria excluded from diagnosis the sizeablepopulation of individuals with subthreshold mixedstates who did not meet full criteria for majordepression and mania, and thus were less likely toreceive treatment.Sept 16, 2013

UNC-CH School of Social Work Clinical Lecture Series8Mania and HypomaniaBereavement Exclusion “With anxious distress” also added as aspecifier for bipolar (and depressive) disorders Eliminated from major depressive episode (MDE)Rationale:The co-occurrence of anxiety with depression is oneof the most commonly seen comorbidities in clinicalpopulations.Will allow clinicians to indicate the presence ofanxiety symptoms that are not reflected in the corecriteria for depression and mania but nonethelessmay be meaningful for treatment planning.(Depressive Disorders)Rationale:In some individuals, major loss – including but not limitedto loss of a loved one – can lead to MDE or exacerbatepre-existing depression.Individuals experiencing both conditions can benefit fromtreatment but are excluded from diagnosis under DSM-IV.Further, the 2-month timeframe required by DSM-IVsuggests an arbitrary time course to bereavement that isinaccurate. Lifting the exclusion alleviates both of theseproblems.Disruptive Mood Dysregulation DisorderAnxiety Disorders(DMDD) Newly added to DSM-5Rationale:Addresses disturbing increase in pediatric bipolar diagnoses overthe past two decades, due in large part to incorrect characterizationof non-episodic irritability as a hallmark symptom of mania.Provides a diagnosis for children with extreme behavioraldyscontrol but persistent, rather than episodic, irritability andreduces the likelihood of such children being inappropriatelyprescribed antipsychotic medication.Criteria do not allow a dual diagnosis with oppositional-defiantdisorder (ODD) or intermittent explosive disorder (IED), but can bediagnosed with conduct disorder (CD). Children who meet criteriafor DMDD and ODD would be diagnosed with DMDD only.Panic Attacks Specifier Now a specifier for any mental disorder Separation of DSM-IV Anxiety Disorders chapterinto four distinct chaptersRationale:Data from neuroscience, neuroimaging, and geneticstudies suggest differences in the heritability, risk,course, and treatment response among fear-basedanxiety disorders (e.g., phobias); disorders ofobsessions or compulsions (e.g., OCD); trauma-relatedanxiety disorders (e.g., PTSD); and dissociativedisorders.Thus, four anxiety-related classifications are present inDSM-5, instead of two chapters in DSM-IV.Hoarding Disorder(Obsessive-Compulsive and Related Disorders) Newly added to DSM-5Rationale:Rationale:Panic attacks can predict the onset, severity andcourse of mental disorders, including anxietydisorders, bipolar disorder, depression, psychosis,substance use disorders, and personality disorders.Clinically significant hoarding is prevalent and canhave direct and indirect consequences on the healthand safety of patients as well as that of others (e.g.,dependents, neighbors).Inclusion will increase the chances of theseindividuals receiving treatment.Navigating DSM-5, Mehul Mankad, M.D.Sept 16, 2013

UNC-CH School of Social Work Clinical Lecture SeriesBody Dysmorphic Disorder (BDD) Now classified as an OCD-related disorderrather than as a somatic disorder9BDD and OCD Both now include expanded specifiers toindicate the degree of insight present:– “good or fair,” “poor” and absent/delusional”Rationale:Rationale:This reflects the fact that repetitive behaviors (e.g.,mirror checking) are a key characteristic of thisdisorder and are prominent targets of intervention(e.g., response prevention).This allows for indication of delusional variants of OCDand BDD while permitting them to remain classifiedhere rather than with the psychotic disorders.Posttraumatic Stress Disorder(Trauma- and Stress-Related Disorders) The stressor criterion (Criterion A) is more

familiar with DSM-IV-TR, its content, and its use. This presentation is solely to facilitate transition from DSM-IV-TR to DSM-5 and is not intended to be a basic course on DSM-5. DSM-5:Classification, Criteria, and Use DSM-5 Revisions: Brief History and Conceptual Approaches ICD-8-9 and DSM-II 1967-1972 US-UK study:

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