DSM-5: Introduction to Classification, Criteria and, Use Qualis Behavioral Health Conference

April 23, 2014

Wandal W. Winn, M.D.Regional Medical DirectorQualis Health

4/21/2014, W. W. Winn, M.D.

IntroductionThis presentation is:

Introductory in nature;

Not a basic course on DSM-5;

Assumes some familiarity with psychiatric diagnostics;

For both clinical and administrative staff; and

For both mental health and non-mental health staff.

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High rates of comorbidity

High use of NOS category

Treatment non-specificity

Inadequate laboratory markers / tests

Hindrance of research progress

Inconsistencies with ICD classification (ICD-9 -> ICD-10)

Desire for improved validity

Desire for etiology rather and descriptive drive schema

New data and new developments

Growing Problems with DSM-IV

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New Data / Developments

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Are there data in these areas that can be helpful in developing/changing/refining diagnoses?

Cognitive or behavioral science

Family studies and molecular genetics

Neuroscience—NIMH RDoC Program

Functional and structural imaging

International participation in criteria development

APA/WHO/NIH Diagnosis Research Planning Conferences: Participant Distribution

U.S.A., 194

Latin America, 16

Western Pacific, 32

Canada, 12

Africa, 9

South-East Asia, 10

Europe, 119

Eastern Mediterranean, 5

AfricaKenya, 2Nigeria, 3South Africa, 4

Latin AmericaArgentina, 2Brazil, 4Chile, 3Mexico, 5Puerto Rico, 2

Eastern MediterraneanBahrain, 1Israel, 3Lebanon, 1

EuropeBelarus, 1Belgium, 2Denmark, 4Estonia, 1France, 3Germany, 11

Europe (Cont)Greece, 1Hungary, 1Italy, 5Luxembourg, 1Netherlands, 12Norw ay, 2Russia, 4Spain, 5Sw eden, 4Sw itzerland, 21UK, 41

South-East AsiaIndia, 5Pakistan, 2Sri Lanka, 1Thailand, 2

Western PacificAustralia, 9China, 9Japan, 8Korea, 3New Zealand, 3

- 397 Participants- 39 Countries- 16 Developing Nations- 51% Non-US Participants- 10% Developing Nation Paticipants

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The “Bible”

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. . . and its children

Case formulation

Definition of a mental disorder

Clinical significance criteria

Structure of disorder chapters

ICD-9-CM and ICD-10-CM coding

Making a diagnosis

Uses of DSM-5

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DSM-5 Structure

Section I: DSM-5 Basics

Section II: Essential Elements: Diagnostic Criteria and Codes

Section III: Emerging Measures and Models

Appendix

Index

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Section I

Brief DSM-5 developmental history

Guidance on use of the manual

Definition of a mental disorder

Cautionary forensic statement

Brief DSM-5 classification summary

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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 the 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.

Definition of a Mental Disorder

Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association.

Until incontrovertible etiological or pathophysiological mechanisms are identified to fully validate specific disorders or disorder spectra, the most important standard for the DSM-5 disorder criteria will be their clinical utility.

The diagnosis of a mental disorder should have clinical utility: it should help clinicians to determine prognosis, treatment plans, and potential treatment outcomes for their patients. However, the diagnosis of a mental disorder is not equivalent to a need for treatment.

Definition of a Mental Disorder

.Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association.

The validation of diagnostic criteria for discrete categorical mental disorders in DSM-5 included the following types of evidence:

Antecedent validators (similar genetic markers, family traits, temperament, and environmental exposure);

Concurrent validators (similar neural substrates, biomarkers, emotional and cognitive processing, and symptom similarity); and

Predictive validators (similar clinical course and treatment response).

Definition of a Mental Disorder

.Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association.

Sequence of Quality Care

Data

Dx

Rx

Response

Criteria

Subtypes and/or specifiers

Severity

Codes and recording procedures

Explanatory text: diagnostic and associated features; prevalence; development and course; risk and prognosis; culture- and gender-related factors; diagnostic markers; functional consequences; differential diagnosis; comorbidity

Structure of Section II

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Administer cross-cutting assessments (suggested);

Administer WHODAS 2.0 (suggested) = Semi-replacement for Axis V;

Conduct clinical interview;

Determine whether or not diagnostic threshold is met;

Consider subtypes and/or specifiers.

Making a Diagnosis

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Consider contextual information, disorder text (e.g., course, differential), distress, clinician judgment;

Diagnoses given as a list; no Axis I-V!

Administer severity assessments (suggested);

Apply codes and follow instructions as per coding and recording procedures;

Develop treatment plan and outcome monitoring approach.

Making a Diagnosis

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Cautionary Note – Clinical Use

Diagnostic criteria are offered as guidelines for

making diagnoses, and their use should be

informed by clinical judgment. On the basis of

the clinical interview, text descriptions, criteria,

and clinician judgment, a final diagnosis is made.

Cautionary Note - Forensic Use“However, the use of DSM-5 should be informed by an awareness of

the risks and limitations of its use in forensic settings. In most

situations, the clinical diagnosis of a DSM-5 mental disorder . . . does

not imply that an individual with such a condition meets legal criteria

for the presence of a mental disorder or a specified legal standard

(e.g., for competence, criminal responsibility, or disability). For the

latter, additional information is usually required beyond that contained

in the DSM-5 diagnosis.”

Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association.

Section II: Disorder Chapters

A. Neurodevelopmental DisordersB. Schizophrenia Spectrum and Other Psychotic

DisordersC. Bipolar and Related DisordersD. Depressive DisordersE. Anxiety DisordersF. Obsessive-Compulsive and Related DisordersG. Trauma and Stressor Related Disorders

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Section II: Disorder Chapters

H. Dissociative DisordersJ. Somatic Symptom and Related DisordersK. Feeding and Eating DisordersL. Elimination DisordersM. Sleep-Wake DisordersN. Sexual DysfunctionsP. Gender Dysphoria

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Section II: Disorder Chapters

Q. Disruptive, Impulse-Control and Conduct Disorders

R. Substance-Related and Addictive DisordersS. Neurocognitive DisordersT. Personality DisordersU. Paraphilic DisordersV. Other Disorders:

Medication-Induced Movement Disorders and Other Adverse Effects of Medication

Other Conditions That May Be a Focus of Clinical Attention

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Section III: Purpose

For items that appear to have initial support in terms of clinical use but require further research before being officially recommended as part of the main body of the manual

Separate from diagnostic criteria, text, and clinical codes

(This separation clearly conveys that the content may be clinically useful and warrants review, but is not a part of an official diagnosis of a mental disorder and cannot be used as such.)

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Section III: Emerging Measures and Models

Assessment Measures

Cultural Formulation

Alternative DSM-5 Model for Personality Disorders

Conditions for Further Study

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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 Alcohol Exposure

Suicidal Behavior Disorder

Non-suicidal Self-Injury

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New & Eliminated DisordersNew Disorders:1.

Social (Pragmatic) Communication Disorder2.

Disruptive Mood Dysregulation

Disorder3.

Premenstrual Dysphoric Disorder (DSM�IV appendix)4.

Hoarding Disorder5.

Excoriation (Skin�Picking) Disorder6.

Disinhibited Social Engagement Disorder (split from Reactive Attachment Disorder)7.

Binge Eating Disorder (DSM�IV appendix)8.

Central Sleep Apnea (split from Breathing�Related Sleep Disorder)9.

Sleep‐Related Hypoventilation (split from Breathing�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 Body Disease (Dementia Due to Other Medical 

Conditions)

15.

Mild Neurocognitive Disorder (DSM�IV Appendix) 

Eliminated Disorders:1.

Sexual Aversion Disorder2.

Polysubstance�Related Disorder

Net Difference = +13

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Changes in Specific DSM Disorder Numbers; Combination of New, Eliminated, and Combined

Disorders

DSM-IV DSM-5

Specific Mental Disorders* 172 157

*NOS (DSM-IV) and Other Specified/Unspecified (DSM-5) conditions are counted separately.

(net difference = -15)

Examples of Specific Disorders

Revisions and Rationales

Specific subtypes have been eliminated;

Catatonia is now a specifier for multiple disorders; and

At least one of two required symptoms must be delusions, hallucinations, or disorganized speech

Schizophrenia

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Largely unchanged

Same subtypes

Axis II is eliminated

“Alternative model" is presented in section III

Personality Disorders

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Elimination of the "bereavement exclusion" for major depression;

Dysthymic Disorder subsumed under the diagnosis of "Persistent Depressive Disorder”;

PMDD has been added to the "Depressive Disorders" chapter; and

Disruptive Mood Dysregulation Disorder (DMDD) added.

Depressive Disorders

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Consolidation of Autism, Asperger’s, and Pervasive Developmental Disorder into "Autism Spectrum Disorder”;

ADHD added to the chapter;

Age of onset raised from 7 to 12; and

Threshold for diagnosis in adults reduced from 6 to 5 symptoms.

Neurodevelopmental Disorders

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"Neurocognitive Disorders" replaces delirium, dementia, amnestic, and geriatric cognitive disorders;

Elevation of 10 etiological subtypes (e.g., fronto- temporal dementia, dementia with Lewy Bodies, etc.) to separate, independent disorders;

Addition of "Mild Neurocognitive Disorder” to this chapter and differentiated from Major by:

1) Single cognitive domain impairment and

2) Preservation of independence.

Neurocognitive Disorders

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Separation of Anxiety Disorders into four distinct chapters:1) fear-based anxiety disorders (e.g., phobias);

2) disorders of obsessions or compulsions (e.g., OCD);

3) trauma-related anxiety disorders (e.g., PTSD);

4) dissociative disorders (e.g., Fugue, DID, etc.)

Panic now a specifier for any mental disorder

Panic and Agoraphobia now separate disorders

Social Phobia is now Social Anxiety Disorder

Anxiety Disorders

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Mental Retardation renamed Intellectual Disability (Intellectual Developmental Disorder)

Greater emphasis on adaptive functioning deficits rather than IQ scores alone

Intellectual Disability

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New Chapter

PTSD moved from Anxiety Disorders chapter to Trauma and Stressor Related Disorders

Adjustment Disorders now included in Trauma and Stressor Related Disorders

Trauma & Stressor Related Disorders

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Moved to new TSRD chapter;

Stressor criteria (Criterion A) are more explicit (e.g., elimination of “non-violent death of a loved one” as a trigger) and subjective reaction (Criterion A2) is eliminated;

Expansion to four symptom clusters (intrusion symptoms; avoidance symptoms; negative alterations in mood and cognition; alterations in arousal and reactivity), with the avoidance/numbing cluster divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood;

Separate criteria are now available for PTSD occurring in preschool-age children (i.e., 6 years and younger).

Posttraumatic Stress Disorder

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Consolidation of Substance Abuse with Substance Dependence into a single disorder called Substance Use Disorder;

Removal of one DSM-IV abuse criterion (legal consequences) and addition of a new criterion for SUD diagnosis (craving or strong desire or urge to use the substance).

Substance Use Disorder

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Section III: Optional Measures Recommended for Further Study and Evaluation

Level 1 Cross-Cutting Symptom Measures

Referred to as “cross-cutting” because it calls attention to symptoms relevant to most, if not all, psychiatric disorders (e.g., mood, anxiety, sleep disturbance, substance use, suicide)

Self-administered by patient

13 symptom domains for adults

12 symptoms domains for children 11+, parents of children 6+

Brief—1-3 questions per symptom domain

Screen for important symptoms, not for specific diagnoses (i.e., “cross-cutting”)

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Level 2 Cross-Cutting Measure

Completed when the corresponding Level 1 item is endorsed at the level of “mild” or greater (for most but not all items, i.e., psychosis and inattention)

Gives a more detailed assessment of the symptom domain

Largely based on pre-existing, well-validated measures, including the SNAP-IV (inattention); NIDA-modified ASSIST (substance use); and PROMIS ® forms (anger, sleep disturbance, emotional distress)

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Example of a Level 2 Cross-cutting Assessment: SleepPlease respond to each item by choosing one option per question.

In the past SEVEN (7) DAYS....Not at all A little

bitSomewhat Quite a

bitVery much

My sleep was restless.

1

2

3

4

5

I was satisfied with my sleep.

5

4

3

2

1

My sleep was refreshing.

5

4

3

2

1

I had difficulty falling asleep.

1

2

3

4

5

In the past SEVEN (7) DAYS.... Never Rarely Sometime s

Often Always

I had trouble staying asleep.

1

2

3

4

5

I had trouble sleeping.

1

2

3

4

5

I got enough sleep.

5

4

3

2

1

In the past SEVEN (7) DAYS… Very Poor Poor Fair Good Very goodMy sleep quality was...

5

4

3

2

1

World Health Organization Disability Assessment Schedule (WHODAS 2.0)

Recommended (but not required) assessment for disability

Corresponds to disability domains of ICF;

For use in all clinical and general population groups;

Tested world-wide and in DSM-5 Field Trials;

36 questions, self-administered with clinician review;

For Adult Patients (child version developed by DSM-5, not yet approved by WHO).

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WHODAS Domains

Understanding and communicating;

Getting around;

Self Care;

Getting along with people;

Life activities (household, work, & school);

Participation in society.

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Coding Aspects of DSM-5

For more information about CMS acceptance of DSM-5 and ICD-9-CM and ICD-10-CM codes, visit their online FAQ at: https://questions.cms.gov/faq.php?id=5005&faqId=1817

For more information about DSM-5 implementation, a detailed Frequently Asked Questions document can be found at www.DSM-5.org

Questions not addressed by the online FAQs can be submitted to the APA through the Website.

Coding Questions?

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DSM-5Questions

&Answers