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8/25/14Redefining Mental Illness:History, DSM-5 Updates, &Clinical ImplicationsTNP 26th Annual Conference San Antonio, TX,September 5, 2014Donna Rolin-Kenny, PhD, APRN, PMHCNS-BCDirector of Family Psychiatric Mental Health Nurse Practitioner ProgramAssistant Professor, UT Austin School of Nursingdrolin@mail.nur.utexas.eduJaime Nelson, MSN, APRN, PMHNP-BCInstructor FPMHNP Program, UT Austin School of Nursingjnelson@mail.nur.utexas.eduOBJECTIVESReview the historical context ofclassification of mental illness Outline interviewing and diagnosticstructure utilizing DSM-5 Survey major changes by diagnosticcategory With emphasis on Depressive, Anxiety,ADHD and Addictive Disorders Apply diagnostic changes to case studiesHISTORICAL VIEW OFMENTAL ILLNESSCLASSIFICATION1

8/25/14Diagnoses: What’s in a Name? What is the meaning of a psychiatricdiagnosis? What does it mean to give a person adiagnosis?" Why do (DSM) diagnoses change? Are we getting sicker? Better at identifying pathology? Are diagnoses merely social constructions?Why Classify Mental Illness? Common language provides:" A better understanding of global epidemiology" Refinement of disease statistics"" Improved interprofessional collaboration"" Facilitation of early diagnosis (& treatment?)"Early Attempts to Classify Mental Illness1840 U.S. Census" First attempt at statistically identifying mentally ill individuals" Asked for the number of insane and idiotic persons in public orprivate charge" No definitions of insane or idiotic for for census workers"1880 U.S. CensusPrimitive classification of mental illness included:"§ Mania"§ Melancholia"§ Monomania"§ Dementia"§ Dipsomania"§ Epilepsy"2

8/25/14Kraepelin’s Compendium der Psychiatrie-- 1883§ Foundation of modern psychiatric classification"§ Kraepelin advocated for a systematic investigation of mentalillness"§ Psychiatric problems comparable to physical problems"§ Evidence-based"Kraepelinian Dichotomy of Mental Illness!Exogenous" Manic-depression" Depression"Endogenous" Dementia Praecox (Schizophrenia)"o Catatonic "o Excessive or lack of motor activity"o Hebephrenic "o Emotional lability/inappropriate affect"o Paranoid "o Delusions of grandeur or persecutionInternational Classification of Disease (ICD)1893: Bertillon introduces the Classification of Causes of Death!1898: The American Public Health Association recommendsadoption of Bertillon’s system and a revision every decade"!1938: 5th edition! Included mental illness" Diagnoses: Mental deficiency, dementia praecox, manicdepressive psychosis and alcoholism. "1948: 6th edition! Published by the World Health Organization" Name changed to International Statistical Classification ofDiseases, Injuries and Causes of Death. ! Greatly expanded section on mental disorders, including:"o Psychoses and psychoneuroses (10 categories)"o Disorders of character (7 categories)"o Disorders of intelligence"U.S. Censusincludescensus for"idiots" and"insane"1840StatisticalManual for theUse ofInstitutions forthe Insane ispublished bypredecessor tothe APAU.S. Census includesSchedule for Insane1880FlorenceNightingaleproposes useof morbiditystatisticsKraepelin'sCompendium derPsychiatrie18831860Kingdom ofEvils – PsychCases text19225th edition ofICD includessection onpsychiatricconditions1938Medical 203Classificationdeveloped byU.S. Army194319176th edition of ICDshares focus betweenmorbidity and mortality;significant expansion ofpsych sectionBertillon’sClassification ofCauses of 01994DSM-IV Text Revision19742000DSM-III1952198019661930DSM-II 520131987199420012008Today3

8/25/14Summary of Gross # Changes in DSM EditionsDSM-5May 201313 new disorders, 2 eliminated disorders, and 22 “combined” disorders; 947 pagesDSM IV-TR2000943 Pages365 DiagnosesDSM IV1994886 Pages297 Diagnoses494 PagesDSM III1980265 DiagnosesDSM II1968134 PagesDSM I1952130 Pages182 Diagnoses106 DiagnosesAttempts to Classify Mental Illness:A HistoryDSM-I (1952) Similar to ICD-6 with glossary of clinicaldescriptionsHeavily influenced by Freudian terms (e.g.reactions) and conceptsThree diagnostic categories: organicpsychoses, psychogenic neuroses, andcharacter disorders4

8/25/14DSM-1 (1952) Addiction Definitions Categorized under Sociopathic Personality Disturbance along with Antisocial / Dyssocial [Psychopath] & Sexual Deviation [homosexuality, transvestism, pedophelicfethisism, sadism] Alcoholism: Included in this category will be cases in whichthere is well established addiction to alcohol withoutrecognizable underlying disorder. Simple drunkenness andacute poisoning due to alcohol are not included in thiscategory. Drug Addiction: Drug addiction is usually symptomatic of apersonality disorder, and will be classified here while theindividual is actually addicted; the proper personalityclassification is to be made as an additional diagnosis. Drugaddictions symptomatic of organic brain disorders, psychoticdisorder, psychophysiologic disorders, and psychoneuroticdisorders are classified here as a secondary diagnosis.Attempts to Classify Mental Illness:DSM-II (1968)A History Developed to coincide with ICD-8 (2010)“Reactions” term removedContinued gap between neurosis and psychosis1974 revision, diagnosis of homosexualityreplaced with ego-dystonic homosexualityAttempts to Classify Mental Illness:DSM-III (1980)A History Attempted to base diagnoses on criteria fromresearch and empirical evidenceMental health viewed on a continuum with healthand illness as endpointsAlignment with ICD-9 for clinical utility and billingutilityIntroduced the multi-axial diagnostic system: Axis I-V Alcohol Dependence Syndrome introduced in DSM-III-R(1986) Differentiated between the physiological dependence process and social,legal & other consequences of heavy drinking biaxial concept Removed ego-dystonic homosexuality and added sexualdisorders not otherwise specified (NOS)5

8/25/14Attempts to Classify Mental Illness:DSM-IV (1994)/DSM-IV-TR (2000)A History Development influenced by otherdisciplinesContinued attempt to align with ICDAdded NOS and comorbidities to manydisordersRequirement of distress or disability inassociation with psychological orbehavioral syndromesDSM-IV-PC: primary care version withdiagnostic algorithms was developedNIMH vs. APA (DSM)?Dr. Thomas Insel, director of the NIMH,wrote, “NIMH will be re-orienting itsresearch away from DSM categories.” RDoC NIMH has launched the Research DomainCriteria project to transform diagnosis byincorporating genetics, imaging, cognitivescience, and other levels of information to laythe foundation for a new classification system.Psychiatric Interviewing & Useof DSM-5 for Diagnostics6

8/25/14Question?Categories of hizophrenia SpectrumBipolar and RelatedDepressiveAnxietyObsessive-CompulsiveTrauma and StressorDissociativeSomatic SymptomFeeding and WakeSexual DysfunctionsGender DysphoriaDisruptive, ImpulseControl, and ConductSubstance Related stering of ChaptersNeurodevelopmental DisordersEmotional (Internalizing) Disorders Somatic Disorders Externalizing Disorders Neurocognitive Disorders Personality Disorders 7

8/25/14Question?DSM-5 Arabic numbers used to facilitateupdates Removed the multi-axial system More evidence-basedrecommendationsDevelopmental approachorganization (DSM-5, DSM-5.1, DSM-5.2, etc.) Now what? Overlapping categoriesInstead of the Axes Axes I, II & III collapsed Axis IV All Diagnoses entered together (ICD) Coding those Diagnoses related toservices being billed How might this affect Stigma? “Other Conditions that may be a Focus ofClinical Attention” - Axis V WHODAS 2.0 - 8

8/25/14Other Conditions that may be aFocus of Clinical Attention [Replace Axis IV Psychosocial Stressors] V-codes in DSM-5 to match ICD-9, p. xxxiv Z-codes also listed (to match ICD-10 anticipation) More specific to Psychosocial Conditions Relational problemsAbuse/NeglectEducational/Occupational problemsSocial EnvironmentCrime/Legal SystemPersonal HistoryWHODAS 2.0[Replaces Axis V GAF] why? DSM-5: Section III, p. 745 Focuses on 6 domains, 180 total points Overall scoring 0 No Disability - 100 Full DisabilityUnderstanding &communicating (30)Getting along withpeople (25)Getting around (25)Life activities[Household (20) School/Work (20)]Self-care (20)Social participation (40)Assessment Measures Level 1 Cross-Cutting Symptom Measures DSM-5: Section III, p. 735 Threshold to guide further assessment - Level 2 Cross-Cutting Symptom Measures Dimensional – each symptom with its severity AnxietySomatic SymptomsSuicidal IdeationPsychosisSleep ProblemsMemoryRepetitive Thoughts & BehaviorsDissociationPersonality FunctioningSubstance UseInattention (Child)Irritability (Child)9

8/25/14Additional Measures Early Development and HomeBackground (EDHB) Cultural Formulation Interview (CFI) Pediatric development & experiences 16 questions Impact of culture on aspects of clinical presentationand treatment planning Supplementary Cultural Modules Include Spiritual AssessmentOVERVIEW OF CHANGESBY DIAGNOSTICCATEGORY GROUPINGDSM-5 Child and AdolescentChronological arrangement within eachcategory Addition of new diagnoses Revised criteria for some existing diagnoses 10

8/25/14Neurodevelopmental DisordersNeurodevelopmental DisordersFormerly known as Disorders Usually First Evident in Infancy,Childhood, and Adolescence Intellectual Developmental Disorder Communication Disorders Social (pragmatic) communication disorder -newAutism Spectrum Disorder - changesAttention Deficit/Hyperactivity Disorder - changesLearning DisordersMotor DisordersSocial (Pragmatic) CommunicationDisorderPersistent difficulty with verbal andnonverbal communication that cannot beexplained by low cognitive ability Cannot be diagnosedin presence of restrictiveor repetitive patterns ofbehavior. 11

8/25/14Autism Spectrum DisordersAutistic Disorder, Asperger’s Disorder,Childhood Disintegrative Disorder, and PervasiveDevelopmental Disorder NOS – all nowcombined under one heading but on a severitycontinuum.ConcernsHigher functioning people will “lose” theirdiagnosis – unlikely, although new generationsmay find it more difficult due to tighter criteria.People with Asperger’s Syndrome may bestigmatized with an Autism diagnosisAttention Deficit/HyperactivityDisorderDSM-5:Symptoms must be present age 12(DSM-IV: age of onset 7 years old)“Why open the floodgates to even more over-diagnosis andover-medication of attention deficit disorder” (by raising theallowed age of onset to 12)? –Allen Frances, Professor Emeritus, Duke University, chair of DSM-IV TaskForceSchizophrenia Spectrum Disorder Schizotypal PersonalityDisorderDelusional DisorderBrief Psychotic DisorderSchizophreniform DisorderSchizophrenia (no subtypes)Schizoaffective DisorderSubstance-MedicationInduced Psychotic DisorderPsychotic Disorder Due toAnother Medical Condition Catatonia Associated WithAnother Mental Disorder(specifier)Catatonic Disorder Due toAnother Medical ConditionUnspecified Catatonia12

8/25/14Schizophrenia Subtypes Removed Specifier for Catatonia (not exclusive toschizophrenia spectrum disorders)At least 1 of the 2 symptoms required tomeet Criterion A must be delusions,hallucinations, or disorganized speech Elimination of special treatment of bizarredelusions and "special" hallucinations inCriterion A (characteristic symptoms) Schizophrenia Spectrum AttenuatedPsychosis Syndrome ControversyPro: People with early psychotic-like symptoms areoften diagnosed as depressed or anxious. Earlydetection of symptoms and treatment can reduceseverity and disabilityVSCon: Ambiguous diagnosis results in unnecessary alarmand stigmatization; early antipsychotic treatment nothelpful in the long-term and exposes people tounnecessary antipsychotic therapy“MOOD DISORDERS”13

8/25/14Bipolar and Related DisordersFormerlylisted underMoodDisordersIncreasedenergy/activityhas beenadded as acore symptomof manic andhypomanicepisodes Bipolar I DisorderBipolar II DisorderCyclothymicDisorderSubstance InducedBipolar DisorderBipolar DisorderAssociated withAnother MedicalConditionAddition of ‘Activity or Energy’ toCriterion A for Mania/HypomaniaDistinct period of abnormally andpersistently elevated, expansive, orirritable mood and abnormally andpersistently increased activity or energy Increased clarity and specification ofincreased activity or energy as a coresymptom of mania and hypomania Remaining symptom list (Criterion B)essentially unchanged Bipolar and Related DisordersMixed EpisodesDSM-IVBipolar I MixedEpisodeSimultaneous presenceof:1. fully manic syndrome2. fully depressivesyndrome for atleast 4 daysDSM-5Mixed specifier for majordepression, hypomania, ormaniaSimultaneous presence of:1.2.2 to 3 manic or hypomanicsymptomsfully depressive syndrome for atleast 2-3 daysThe criteria (except for duration)are met for both a manic episodeand a major depressive episodenearly every day during at least a 1week period14

8/25/14DepressiveDisordersPreviously in the MoodDisorder Chapter withBipolar Disorders Disruptive MoodDysregulation Disorder(old childhood bipolar,onset before age 10)Major DepressiveDisorder (single andrecurrent)Dysthymic Disorder PDD Premenstrual DysphoricDisorder (new) Substance InducedDepressive DisorderDisruptive Mood DysregulationDisorder (DMDD)Essential feature: severe recurrent temperoutbursts in response to common stressors;outbursts can be verbal and/or behavioral,are out of proportion to the provocation,and are inconsistent with the child'sdevelopmental level Frequency: on average 3 times per week Mood between temper outbursts:persistently angry, irritable, and/or sad; observable byothers Rationale for DMDDEffort to define a condition that mayshare some characteristics with pediatricbipolar disorder but on prospectivefollow-up, does not evolve into bipolardisorder Children meeting these criteria typicallydevelop unipolar depression and/oranxiety disorders in adolescence oradulthood 15

8/25/14Persistent Depressive Disorder (PDD) Essentially combines what was formerly chronicdepression and dysthymia– Depressed mood for 2 years (in children andadolescents, mood can be irritable, and durationneed only be 1 year)– Presence of 2 or more additional depressivesymptoms: poor appetite or overeating, insomniaor hypersomnia, low energy or fatigue, low selfesteem, poor concentration or difficulty makingdecisions, feelings of hopelessness– No more than 2 months without symptoms-May meet criteria for MDD for 2 yearsPre-Menstrual Dysphoric Disorder(PMDD) Now moved to the main body of the manualCriteria essentially unchanged from those that appeared inDSM-IVIn the majority of menstrual cycles, 5 symptoms must bepresent in the week before onset of menses, start to improvewithin a few days after onset of menses, and become minimalor absent in the week post-mensesOne or more of the following symptoms must be present ata marked level:1. Affective lability Irritability, anger, or increased interpersonal conflicts Depressed mood, hopelessness, or self-deprecating thoughts 4. Anxiety, tension, feeling 'keyed up' or ’on edge'Bereavement Exclusion removedfrom diagnostic criteriaFor Losing a loved one is similarto other losses/stressors inlifeTreatment delay for severegrief increases the risk ofsuffering and impairmentCriteria for grief could betightened to reduce falsepositives AgainstLosing a loved one is differentthan other stressorsA diagnosis impairs thenormal, dignified process ofgrief and the usual reliance oncultural ritualsA variation of normal griefwould result in a mentaldisorder label andunnecessary treatment16

8/25/14Specifier for Anxiety in MoodDisorders “With Anxious Distress” Presence of 2 of thefollowing symptoms in thecontext of mania,hypomania, or depression:– Feeling 'keyed up' ortense– Feeling unusually restless– Difficulty concentratingbecause of worry– Fear that something awfulmay happen– Feeling that the individualmight lose control– Indecisiveness Specify current severityof anxious distress Mild:2symptoms- Moderate: 3 symptoms- Moderate–severe: 4 or5 symptoms- Severe: 4 or 5symptoms with motoragitationSpecifier for 'With Hypomanic Features’If predominantly depressed, full criteria aremet for a major depressive episode, and atleast 3 of the following symptoms arepresent nearly every day during the episode: - Elevated mood - Inflated self-esteem - More talkative/pressured speech - Flight of ideas/racing thoughts - Increased energy/visible hyperactivity - Increased risk-taking - Decreased need for sleep Other Disorders Non-Suicidal SelfInjury Disorder – 5x inone year intentional selfinflicted damage to thesurface of the body (new)Suicidal BehaviorDisorder – within thelast two years initiated abehavior in theexpectation that it wouldlead to the individual’sown death (new)17

8/25/14Suicidal BehaviorDisorder & NSSIFor the diagnosisCreates a way to tracksuicide risk Distinguishes a disorderfrom a “symptom” Distinguishes betweenself-injury and suicidalactions Against the diagnosis We don’t need it. Gives another stigma tolabel a patient with Are people suicidalwithout othersymptoms?-ANXIETY DISORDERS &EXPANDED CATEGORIES-OTHER DIAGNOSTICCATEGORIESAnxiety DisordersChanges: Agoraphobia unlinked from Panic Disorder Obsessive-Compulsive Disorder moved into its ownchapter (next) Posttraumatic Stress Disorder added to Trauma andStressor Related Disorders0 Separation Anxiety Disorder(not just for kids anymore!)0 Panic0 Specifier “with PanicAttacks” for any mentaldisorder0 Agoraphobia0 Specific Phobia0 Generalized Anxiety Disorder(physical sx lowered from 6-2)0 Social Anxiety Disorder0 Selective Mutism (move from C/A)18

8/25/14Obsessive CompulsiveDisorders Obsessive-Compulsive Disorder Body Dysmorphic Disorder Formerly listed with anxietydisorders Insight specifier (good, fair, poor,absent/delusional) Formerly listed with somatoformdisorders Insight specifier Hoarding Disorder (new)Trichotillomania (Hair pulling)Excoriation Disorder (Skinpicking) (new)Trauma and Stressor-Related Disorders[new]Trauma and Stressor-Related Disorders (new) Reactive Attachment Disorder(RAD) Internalized failure to attach Fearful, irritable, poor social &emotional reciprocity Disinhibited Social EngagementDisorder (DSED) (new) Subtype (split from ReactiveAttachment Disorder) Disinhibited regarding strangers,boundaries Acute Stress Disorder Adjustment Disorder (may berelated to bereavement)19

8/25/14Post Traumatic Stress Disorder (PTSD) Age 6 Increased to 4 symptom clusters Subtypes for age 6, “with dissociative sx” Avoidance Numbing separated Intrusion Negative alterations in cognition & mood New sx (persistent & distorted blame of self or others) New sx (persistent negative emotional state) Alterations in arousal & activity New sx (reckless or destructive behavior) Removed Sx (fear, helpless or horror)Dissociative DisordersDepersonalization-DerealizationDisorder DissociativeAmnesia DissociativeIdentity Disorder Somatic Symptom DisordersFormerly knownas SomatoformDisorders – alldisorders in thisgroup have physicalsymptoms and/orconcern aboutmedical illness Somatic SymptomDisorder - replacesSomatization Disorder,Undifferentiated SomatoformDisorder, and Pain DisorderIllness Anxiety Disorder(worry without somaticsymptoms)Functional NeurologicalSymptom Disorder(Conversion Disorder)Psychological FactorsAffecting Medical ConditionFactitious Disorder20

8/25/14Feeding and EatingDisorders Pica (moved from C/A)Rumination Disorder(moved from C/A)Avoidant/RestrictiveFood Intake Disorder(formerly feedingdisorder of infancy orearly childhood)Anorexia Nervosa0 Bulimia Nervosa0 Binge Eating Disorder (new –moved from appendix) – onebinge eating episode per weekfor three months Removed amenorrhearequirementElimination Disorders No major changes EnuresisEncopresisSleep-Wake Disorders(formerly Sleep Disorders) Insomnia Disorder(Primary insomnia)HypersomnolenceDisorder yCircadian RhythmSleep Wake Disorder Non-Rapid Eye MovementSleep Arousal Disorders –Sleep Terror and SleepwalkingNightmare DisorderRapid Eye Movement SleepBehavior Disorder (new)Restless Legs Syndrome (new)Substance Induced SleepDisorder21

8/25/14Sexual Dysfunction Erectile DisorderDelayed EjaculationEarly EjaculationMale Hypoactive SexualDesire DisorderGenito-Pelvic Pain/Penetration Disorder Female Orgasmic DisorderFemale Sexual Interest/Arousal Disorder,Female Orgasmic DisorderGender Dysphoria (not ‘Disorder’)Emphasizing “gender incongruence” rather than “cross-gender identification”Gender Dysphoria in ChildrenGender Dysphoria in Adolescents and Older Adults Disruptive, ImpulseControl, and ConductDisorders Formerly listedin DisordersUsually FirstDiagnosed inInfancy,Childhood, orAdolescence andImpulse ControlDisorders NotElsewhereClassified. Oppositional DefiantDisorderIntermittent ExplosiveDisorder (18 years )Conduct Disorder Callous and UnemotionalSpecifier Antisocial ive Disorders DeliriumMild Neurocognitive Disorders – Modest cognitive decline,functions with effortMajor Neurocognitive Disorders – Substantial cognitivedecline, independence not possibleMild and Major matic Brain Injury,Lewy Body, Parkinson’s,HIV, Substance Induced,Huntington’s, Prion22

8/25/14Paraphilic DisordersPreviously in the Sexualand Gender IdentitychapterDistress or NonconsentAdds risk-assessingspecifiers: In a ControlledEnvironment In Remission (nodistress, impairment,or recurring behaviorfor five years in anuncontrolledenvironment)Exhibitionistic DisorderFetishistic Disorder Pedophilic Disorder(formerly pedophilia Sexual MasochismDisorder Sexual Sadism Disorder Transvestic Disorder Voyeuristic Disorder Personality DisordersDSM-IV-TR Pervasive pattern ofthinking/emotionality/behaving Ten personality types:antisocial, avoidant,borderline, obsessivecompulsive, schizotypalparanoid, schizoid,narcissistic, histrionic,dependent, and a nototherwise specifiedcategoryDSM-5 Impaired sense of selfidentity or failure todevelop effectiveinterpersonalfunctioning Six personality types:antisocial/psychopathic,avoidant, borderline,narcissistic, obsessivecompulsive, andschizotypal typesSUBSTANCE USE &ADDICTIVE DISORDERS23

8/25/14New DSM-5 Category:Substance Related & Addictive Disorders Substance Use Disorders Substance Induced Disorders 10 classes of Drugs Medical/Psychiatric Disorder E.g., Alcohol-Induced Major Neurocognitive Disorder Intoxication or Withdrawal Non-Substance Related (Addictive) Disorder10 classes of Drugs Diagnosis of a Substance Use Disordercan be applied to all 10 classes of drugs however for certain classes some symptomsare less salient Was Tobacco Abuse a DSM-IV dx? Caffeine withdrawal? Cannabis withdrawal? Can a person have Poly-Substance I/WI/WI/WI/W/PII/WII/WIXXXXX (new)IXXX lDysfunctionsCannabisSubstance useDisordersSleep DisordersI/WCaffeineObsessiveCompulsive andRelated DisordersI/WAnxiety DisordersBipolar DisordersAlcoholDepressiveDisordersDSM-5 p. 482PsychoticDisordersTable 1 Diagnoses associated with substance IXXXX (new)XXXXInhalantsIOpioidsSedatives,Hypnotics, baccoOther ote. X The category is recognized in DSM-5.I The specifier "with onset during intoxication" may be noted for the category.W The specifier "with onset during withdrawal" may be noted for the category.I/W Either "with onset during intoxication" may be noted for the category.P The disorder is persisting.* Also hallucinogen persisting perception disorder (flashbacks).** Includes amphetamine-type substances, cocaine, and other or unspecified stimulants.24

8/25/14So Nobody has Abuse orDependence Anymore?. Substance Use Disorder Severity Mild: presence of 2-3 symptoms DSM-IV Abuse: 1 and Dependence 3 Moderate: presence of 4-5 symptoms Severe: presence of 6 Specifiers Early Remission: 3-12 monthsSustained Remission: 12 monthsIn controlled environmentOn maintenance therapyDiagnostic Criterion A DomainsImpaired ControlSocial Impairment Risky Use Pharmacological Impaired Control: Criteria 1-4 Criterion 1: individual may take the substance in largeramounts over a longer period than was originally intendedCriterion 2: individual may express a persistent desire tocut down or regulate substance used and may reportmultiple unsuccessful efforts to decrease or discontinue useCriterion 3: individual may spend a great deal of timeobtaining the substance, using the substance or recoveringfrom the substance*Criterion 4: cravings: individual has an intense desire orurge for the drug that may occur at any time but is morelikely when in an environment where the drug previously wasobtained or used. *Craving a new diagnostic criterion1.Why?25

8/25/14Social Impairment: Criteria 5-7Criterion 5: recurrent substance use mayresult in a failure to fulfill major roleobligations at work, school or home Criterion 6: individual may continuesubstance use despite having persistent orrecurrent social or interpersonal problemscaused or exacerbated by the effects of thesubstance Criterion 7: important social, occupationalor recreational activities may be given up orreduced Risky Use: Criteria 8-9Criterion 8: recurrent substance use insituations in which it is physicallyhazardous Criterion 9: individual may continuesubstance use despite knowledge ofhaving a persistent or recurrent physicalor psychological problem that is likely tohave caused or exacerbated by thesubstance use Pharmacological: Criteria 10-11 Criterion 10: tolerance: signaled by requiring amarkedly increased dose of the substance toachieve the desired effect or markedly reducedeffect when the usual dose is consumedCriterion 11: withdrawal: syndrome that occurswhen blood or tissue concentration of asubstance decline in an individual who hadmaintained prolonged heavy use of the substance.After developing withdrawal symptoms, theindividual is likely to consume the substance torelieve the symptoms. Withdrawal symptoms varygreatly across the classes of substances.26

8/25/14Which (drug use) criterion wasretired (removed from DSM-5)? Hint removed because of difficulty inconsistent cultural/internationalapplication Not included in WHO’s ICDDiagnosis of Alcohol Use DisordersDawson et al. (2013). Differences in the Profiles of DSM-IV and DSM-5 Alcohol Use Disorders: Implications for clinicians. Alcoholism: Clinical & Experimental Research,37(S1), E305–E313.Alcohol Use Disorder – Severity &Specifiers Current Severity Specifiers Where does Binge Drinking fit in? Mild (2-3 sx) 305.00 Moderate (4-5 sx) 303.90 Severe (6 sx) 303.90 In early remission (3-12 months) In sustained remission (12 months) In a controlled environment Lumped into AUD spectrum (no longer abuse)27

8/25/14Binge-Drinking AlcoholismForAgainst Earlier interventions could 31% of all college students could benip problem in the budlabeled alcoholic Stop physical problems from One study suggests that there willoccurringbe 60% more alcoholic diagnoses Save money in the long-runwith the new criteriaby reducing disabilitySubstance Use DisorderSeverity Scale0-1 criterion: No diagnosis2-3 criteria: Mild4-5 criteria: Moderate6 criteria: Severe Scarce resources could be taxedfurther Stigmatizing Obliterates distinction between“problem drinkers” and alcoholicsBinge DrinkingAlcohol Withdrawal A. Cessation (or reduction in) alcohol use that has beenheavy and prolongedB. 2 of the following, developing within several hours toa few day after cessation Autonomic hyperactivity (sweating, pulse 100)Increased hand tremorInsomniaNausea or vomitingTransient visual, tactile or auditory hallucinations or illusionsPsychomotor agitationAnxietyGeneralized tonic-clonic seizuresSpecifier With or Without perceptual disturbances28

8/25/14Opioid Use Disorder Criterion A same as Alcohol Use D/OEXCEPT Tolerance & Withdrawal Note: this criterion isnot considered to be met for those takingopioids solely under appropriate medicalsupervision Additional Specifier On maintenance therapy Opioid Withdrawal sx criteria differGambling Disorder Formerly Pathological Gambling Formerly categorized with Impulse ControlDisorders NOS Now Addictive Disorder with similardiagnostic criteria to SUDs Additional Specifier Episodic or Persistent Internet Addiction (Gaming Disorder) Section III for further study But 1st inpatient treatment program openedthis month in PA hospitalWho should get treatment?It is the new health care law and notthe revision of the DSM that mayconstitute the biggest expansion in thequality and quantity of treatment. DSM-5 will be in a better position to helpguide treatment than the current artificialdistinction between substance abuse anddependence – which are eligible fortreatment under the better current healthinsurance policies inc

DSM I 1952 DSM II 1968 DSM III 1980 DSM IV 1994 DSM IV-TR 2000 Summary of Gross # Changes in DSM Editions! DSM-5 May 2013 106 Diagnoses 130 Pages 297 Diagnoses 182 Diagnoses 265 Diagnoses 365 Diagnoses 494 Pages 886 Pages 134 Pages 943 Pages 13 new disorders, 2 eli

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