Jim Messina, Ph.D., CCMHC, NCC Assistant Professor Troy University, Tampa Bay Site Objectives DSM-5 Workshop Update status of new DSM-5 Identify categories & changes in DSM-5 Suggest impact of DSM-5 for Professional Counselors
Using DSM-5 for Improved Clinical Assessment, Diagnosis and Treatment Planning Websites on DSM-5 Official APA DSM-5 site: www.dsm5.org DSM-5 on: www.coping.us Timeline of DSM-5
1999-2001 Development of Research Agenda 2002-2007 APA/WHO/NIMH DSM-5/ICD-11 Research Planning conferences 2006 Appointment of DSM-5 Taskforce 2007 Appointment of Workgroups 2007-2011 Literature Review and Data Re-analysis
2010-2011 1st phase Field Trials ended July 2011 2011-2012 2nd phase Field Trials began Fall 2011 July 2012 Final Draft of DSM-5 for APA review May 2013 Publication Date of DSM-5 Revision Guidelines for DSM-5
Recommendations to be grounded in empirical evidence Any changes to the DSM-5 in the future must be made in light of maintaining continuity with previous editions for this reason the DSM-5 is not using Roman numeral V but rather 5 since later editions or revision would be DSM-5.1, DSM-5.2 etc. There are no preset limitations on the number of changes that may occur over time with the new DSM-5 The DSM-5 will continue to exist as a living, evolving document that can be updated and reinterpreted over time Focus of DSM-5 Changes
DSM-5 is striving to be more etiological-however disorders are caused by a complex interaction of multiple factors and various etiological factors can present with the same symptom pattern The diagnostic groups have been reshuffled There is a dimensional component to the categories to be further researched and covered in Section III of the DSM-5 Emphasis was on developmental adjustment criteria New disorders were considered and older disorders were to be deleted
Special emphasis was made for Substance/Medication Induced Disorders and specific classifications for them are listed for Schizophrenia; Bipolar; Depressive, Anxiety, Obsessive Compulsive; Sleep-Wake; Sexual Dysfunctions; and Neurocognitive Disorders. Definition of Mental Disorder A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as
death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition DSM-5. Arlington VA: Author, p. 20.) Why identify a mental disorder diagnosis? The diagnosis of a mental disorder should have clinical utility: Helps to determine prognosis Helps in development of treatment plans Helps to give an indication of potential treatment outcomes A diagnosis of a mental disorder is not equivalent to a need for treatment.
Need for treatment is a complex clinical decision that takes into consideration: Symptom severity Symptom salience (presence of relevant symptom e.g., presence of suicidal ideation) The client's distress (mental pain) associated with the symptom(s) Disability related to the client's symptoms, risks, and benefits of available treatment Other factors such as mental symptoms complicating other illness DSM-5 Diagnostic Categories 1. 2. 3.
19. 20. Neurodevelopmental disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorder Elimination Disorders Sleep-Wake Disorders
Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse-Control, and Conduct Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Mental Disorders Obvious Changes in DSM-5 (1)
The DSM-5 will discontinue the Multiaxial Diagnosis, No more Axis I,II, III, IV & V-which means that Personality Disorders will now appear as diagnostic categories and there will be no more GAF score or listing of psychosocial stressor or contributing medical conditions The Multi-axial model will be replaced by Dimensional component to diagnostic categories Obvious Changes in DSM-5 (2)
Developmental adjustments will be added to criteria The goal has been to have the categories more sensitive to gender and cultural differences Diagnostic codes will change from numeric to alphanumeric e.g., Obsessive Compulsive Disorder will change from 300.3 to F42 Diagnostic codes will change from numeric ICD-9-CM codes on September 30, 2014 to alphanumeric ICD-10-CM codes on October 1, 2014 e.g., Obsessive Compulsive Disorder will change from 300.3 to F42
They have done away with the NOS labeling and replaced it with Other Specified... or Unspecified What Replaces NOS? NOS is replace by either: Other specified disorder or Unspecified disorder type are to be used if the diagnosis of a client is too uncertain because of: 1. Behaviors which are associated with a classification are seen but there is uncertainty regarding the diagnostic category due to the fact that The client presents some symptoms of the category but a complete clinical impression is not clear The client responds to external stimuli with symptoms of psychosis, schizophrenia etc. but does not present with a full range of the symptoms need for a complete diagnosis
2. The client has been unwilling to provide information due to an unwillingness to be with the clinician or angry about being brought in to be seen or the there is too brief a period of time in which the client has been seen or the clinician is untrained in the classification Rules for use of Other Specific or Unspecified This designation can last only six months and after that a specific diagnostic category has to be determined for the diagnosis of the client. Principle Diagnosis Principle Diagnosis is to be used when more than one diagnosis for an individual is given in most cases as the main focus of attention or treatment: In an inpatient setting, the principle diagnosis is the condition established to be chiefly responsible for the admission of the individual In an outpatient setting, the principle diagnosis is the condition established as reason for visit responsible for care to be received
The principle diagnosis is often harder to identify when a substance/medication related disorder is accompanied by a non-substancerelated diagnosis such as major depression since both may have contributed equally to the need for admission or treatment. Principle diagnosis is listed first and the term "principle diagnosis" follows the diagnosis name Remaining disorders are listed in order of focus of attention and treatment Provisional Diagnosis Specifier "provisional" can be used when there is strong presumption that the full criteria will be met for a disorder but not enough information is available for a firm diagnosis. It must be recorded "provisional" following the diagnosis given
Respect for Age, Gender & Culture in DSM-5 Each diagnostic definition, where appropriate will incorporate: 1. Developmental symptom manifestation regarding the age of client 2. Gender specific disorders 3. Cultural sensitivity in regards to certain behaviors Specific Changes Per Diagnostic Category in DSM-5 Neurodevelopmental Disorders
1. Intellectual Disability (Intellectual Developmental Disorder) no longer relies on IQ used as specifier because it is the adaptive functioning that determines levels of support required. IQ measures are less valid in the lower end of the IQ range Still accepted that people with intellectual disability have scores two standard deviations or more below the population mean, including a margin for error which is generally +5 points. Thus on tests with standard deviations of 15 and mean of 100 the score for mild would involve 65-75 (70+5). 2. Asperger's Syndrome is lumped into Autism Spectrum since it is at the milder end of the Spectrum 3. Childhood disintegrative disorder, Rett's disorder and Pervasive developmental disorder not otherwise specified are also now incorporated into the Autism Spectrum Disorder 4. Autism Spectrum Disorder is now characterized by deficits in two
domains: Deficits in social communication and social interaction Restricted repetitive patterns of verbal and nonverbal communication. Schizophrenia and Other Psychotic Disorders 1.Changes for Criteria A for Schizophrenia were made: 1) elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (two or more voices conversing), leading to the requirement of at least two Criterion A symptoms for any diagnosis of schizophrenia 2) the addition of the requirement that at least one of the Criterion A symptoms must be delusions, hallucinations, or disorganized speech. 2. DSM-IV-TR subtypes of schizophrenia were eliminated
3. Schizoaffective disorder is reconceptualized as a longitudinal rather than a cross sectional diagnosis and requires that a major mood episode be present for a majority of the total disorder's duration after Criterion A has been met 4. Schizotypal Personality Disorder is now listed in this category Bipolar and related disorders 1. Bipolar is now a free standing category 2. Bipolar was taken out of the mood disorder category 3. Diagnostic criteria now include both changes in mood and changes in activity or energy
Depressive Disorders 1. Dysthymia is now called Persistent Depressive Disorder 2. Disruptive Mood Dysregulation Disorder has been added for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behaviors 3. Premenstrual Dysphoric Disorder has been added Anxiety Disorders 1. No longer has PTSD in this category 2. No longer has OCD in this category 3. Social Phobia is now called Social Anxiety
Disorder 4. Panic Disorder and Agoraphobia are unlinked and each now have their own separate criteria 5. Separation anxiety disorder and selective mutism are now classified as anxiety disorders Obsessive-Compulsive and Related Disorders 1. OCD is now a stand alone category 2. Body Dysmorphic Disorder is now listed under OCD 3. Hoarding has been added under the category of OCD 3. Trichotillomania (Hair-Pulling Disorder) is listed
under OCD 4. Excoriation (Skin Picking Disorder) is listed under OCD Trauma and Stressor Related Disorders 1 Trauma related disorders are now a stand alone category 2. Reactive Attachment Disorder is now listed here 3. Disinhibited Social Engagement Disorder has been added 4. PTSD is listed here 5. PSTD in Preschool Children has been added 6. Acute Stress Disorder is listed here and requires qualifying traumatic events as explicit as to whether they were experienced directly, witnessed or experienced indirectly 7. Adjustment Disorders are now listed here and
conceptualize as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event. Dissociative Disorders 1. Dissociative Fugue has been removed from this category and is now a specifier of dissociative amnesia 2. Derealization is included in the name and symptom structure of the former depersonalization disorder to become: Depersonalization/Derealization disorder. Somatic Symptom Disorder
1. Replaced Somatiform Disorders category with this category 2. Somatization Disorder; Pain Disorder; Hypochondriasis and undifferentiated somatoform disorder were eliminated 3. Complex Somatic Symptom Disorder was added 4. Simple Somatic Symptom Disorder was added 5. Illness Anxiety Disorder was added and replaces Hypochondriasis 6. Conversion Disorders (Functional Neurological Disorder) have modified criteria to emphasize essential importance of neurological examination, in recognition that relevant psychological factors may not be demonstrable at time of diagnosis 7. Psychological factors affecting other medical conditions has been added to this category and along with Factitious disorder both have been placed among the somatic symptom and related disorders because somatic symptoms are predominant in both disorders
Feeding and Eating Disorders 1. Pica was moved to this category 2. Rumination Disorder was moved to this category 3. The "feeding disorder of infancy or early childhood has been renamed: Avoidant/Restrictive Food Intake Disorder 4. Binge Eating Disorder was added Elimination Disorders 1. This category was created as freestanding category 2. Enuresis was moved to this category 3. Encopresis was move to this category
Sleep-Wake Disorders 1. Primary Insomnia renamed Insomnia Disorder 2. Primary Hypersomnia joined with Narcolepsy without Cataplexy 3. Cheyne-Stokes Breathing added 4. Obstructive Sleep Apnea Hypopnea added 5. Idiopathic Central Sleep Apnea added 6. Congenital Central Alveolar Hypoventilation added 7. Rapid Eye Movement Behavior Disorder added 8. Restless Leg Syndrome added Sexual Dysfunctions 1. Male orgasmic disorder renamed Delayed Ejaculation 2. Premature (Early) Ejaculation renamed
3. Dyspareunia and Vaginismus were combined into Genito-Pelvic Pain/Penetration Disorder 4. Sexual Aversion Disorder combined in other categories 5. For females-sexual desire and arousal disorders have been combined into one disorder: Female sexual interest/arousal disorder Gender Dysphoria 1 This is a new diagnostic class 2. It emphasizes the phenomenon of "gender incongruence" rather than cross-gender identification per se. 3. Posttransition specifier has been added to identify individuals who have undergone at
least one medical procedure or treatment to support new gender assignment Disruptive, Impulse Control, and Conduct Disorders 1. This is a new diagnostic class and combines "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" and the "Impulsecontrol Disorders Not Elsewhere Classified" 2. Oppositional Defiant Disorder was added here 3. Trichotillomania removed from this category 4. Conduct Disorder now in this freestanding category 5. Antisocial Personality Disorder added to this category as well as in Personality Disorders Category
Substance Abuse and Addictive Disorders Only 3 qualifiers are used in the category: 1.Use - replaces both abuse and dependence 2.Intoxication and Withdrawal remain the same 2. Nicotine Related renamed Tobacco Use Disorder 3. Caffeine Withdrawal added 4. Cannabis Withdrawal added 5. Polysubstance Abuse categories discontinued 6. Gambling added to this category Neurocognitive Disorders 1. Category replaces Delirium, Dementia, and Amnestic and Other Cognitive Disorders Category
2. Now distinguishes between Minor and Major Disorders 3. Replace wording of Dementia "due to" with Neurocognitive Disorder "Associated with" for all the conditions listed 4. Added new Neurocognitive Disorders: 1.Fronto-Temporal Lobar Degeneration 2.Traumatic Brain Injury 3.Lewy Body Disease 5. Renamed Head Trauma to Traumatic Brain Injury 6. Renamed Creutzfeldt-Jakob Disease to Prion Disease Personality Disorders Cluster A Personality Disorders 301.0 (F60.0) Paranoid Personality Disorder 301.20 (F60.1) Schizoid Personality Disorder 301.22 (F21) Schizotypal Personality Disorder
Cluster B Personality Disorders 301.7 (F60.2) Antisocial Personality Disorder 301.83 (F60.3) Borderline Personality Disorder 301.50 (F60.4) Histrionic Personality Disorder 301.81 (F60.81) Narcissistic Personality Disorder Cluster C Personality Disorders 301.82 (F60.6) Avoidant Personality Disorder 301.6 (F60.7) Dependent Personality Disorder 301.4 (F60.5) Obsessive-Compulsive Personality Disorder Other Personality Disorders 310.1 (F07.0) Personality Change Due to Another Medical Condition Specify whether Labile type; Disinhibited Type; Aggressive Type; Apathetic Type; Paranoid Type; Other Type; Combined Type; Unspecified Type 301.89 (F60.89) Other Specified Personality Disorder 301.9 (F60.9) Unspecified Personality Disorder
Paraphilic Disorders 1. They all carried over to DSM-5 2. New names for them all but the category remains the same 3. Overarching change is the addition of course specifiers in a controlled environment in remission 4. Distinction between paraphilias and paraphilic disorder was made: Paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to
others. Paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not automatically justify or require clinical intervention Conditions Designated for Further Study in DSM-5 in Section III
Attenuated Psychosis Syndrome Depressive Episodes with Short-Duration Hypomania Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure Suicidal Behavior Disorder Nonsuicidal Self-Injury Possible Disorders Discussed
But Not Included in Section III of DSM-5 Dissociative Trance Disorder Anxious Depression Factitious disorder imposed on another Hypersexual Disorder Olfactory Reference Syndrome Paraphilic Coercive Disorder
Other Conditions That May Be a Focus of Clinical Attention (V CodesProblems and TZ Codes) Relational Problems Related to Family Upbringing Other Problems Related to Primary Support Group Abuse and Neglect Child Maltreatment and Neglect Problems
Child Physical Abuse; Child Sexual Abuse Child Neglect Child Psychological Abuse Adult Maltreatment and Neglect Problems Spouse or Partner Violence, Physical; Spouse or Partner Violence, Sexual; Spouse or Partner Neglect; Spouse or Partner Abuse, Psychological; Adult Abuse by Nonspouse or Nonpartner; Adult Sexual abuse by nonspouse or nonpartner; Adult Psychological abuse by nonspouse or nonpartner
Other Conditions That May Be a Focus of Clinical Attention Continued:
Educational and Occupational Problems Housing and Economic Problems Other Problems Related to Social Environment Problems Related to Crime or Interaction with Legal System Other Health Services Encounters for Counseling and Medical Advice Problems Related to Other Psychosocial, Persons and Environmental Circumstances Other Circumstance of Personal History Problems Related to Access to Medical and Other Health Care Nonadherence to Medical Treatment Steps to formulate an initial tentative diagnosis 1.
2. 3. Do a thorough Psychosocial History Do a Mental Status Examination Develop a Diagnosis using DSM-5 STEP 1: Complete Psychosocial History First: Establish - WHY NOW?
You must be able to describe the presenting problem Listing specific symptoms and complaints which would justify diagnosis You must be able to list the duration of the symptoms or at least estimate the duration Second: Review clients mental health history
Previous treatment for mental health problems? Hospitalization for psychiatric conditions? As child involved in family therapy? Treatment for substance abuse problemsoutpatient or inpatient? Third: Determine if client is on any psychotropic medications
What medications? Level of prescription? Who prescribed medications? For what are the medications prescribed? Fourth: Review clients relevant medical history What is current overall physical health of client? When was last physical?
Is there anything currently or in the past medically accounting for this current mental health complaint? Fifth: Review clients family history Do a genogram of the family Identify psychosocial stressors within the family structure Mental health and/or substance abuse history with in the family and if
successfully treated Sixth: Review clients social history School history: Failed grades? Academic success? Social interaction with peers? Highest academic level attained? Community history: Peer group? Current network of social support? Activities and interests: sports, hobbies, social functioning?
Seventh: Review clients vocational history Level of current employment and commitment to current job? Relevant past employment history: length of tenure on past jobs, job hopping, relationships with work peers? Level of satisfaction with current employment? Eighth: List clients
strengths Identify those strengths which make the client a good candidate for successful therapy to address the here and now mental health problem How motivated for therapy is client? How insightful to symptoms? How psychologically minded is client?
How verbal and intelligent? Ninth: List liabilities client brings to therapy Level of present social support system? Mandated for freely coming to therapy? Perceptual problems which could interfere e.g. hearing, vision, etc. Risk of decompensating (relapsing) if not treated
9. Parental separation or divorce 10. Incarcerated household member Step 2: Mental Status Examination Mental Health Status Exam Mental Health Status Exam Rates Clients:
Appearance Consciousness Orientation to person, place & time Speech Affect Mood
Concentration Activity level Thoughts Memory Judgment Step 3: Formulate Tentative Diagnosis Formulate Tentative Diagnosis You are ready to make a tentative Diagnosis using DSM-5 Including: 1. Principle Diagnoses 2. Any Provisional Diagnosis
3. Any relevant Other Conditions That May Be a Focus of Clinical Attention DSM-5 Single Diagnosis Use DSM-5 Most Appropriate Classification Include relevant rule-out diagnoses Compare clients symptoms lists with those contained in
DSM-5 to get to most appropriate tentative Principle diagnosis Then list any and all secondary diagnosis if the clients symptoms match up for such classifications Also list Provisional diagnoses if the clients presentation allows for these additional diagnoses List all relevant V (T,Z) Code Conditions Each must be listed with number & description just like the principal diagnosis It is important to remember
The Diagnosis given a client is tentative dependent on gathering more data in future anticipated treatment Diagnoses can ALWAYS be changed to address changes with the individuals presentation & functioning
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