Transcript DSM-5 Understanding and Interpreting

DSM-5 Overview
Understanding the Fifth Edition Changes
LAURA HANKINS
MISSISSIPPI STATE UNIVERSITY
SEPTEMBER 17, 2013
What is the DSM?
 Diagnostic and Statistical Manual of Mental Disorders – Fifth
Edition
 Produced by the American Psychiatric Association
 Used by clinicians, students, practitioners, and researchers from
a wide range of professional fields associated with mental health.
 Created to serve a variety of functions:
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A tool for clinicians.
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Provides an organized way for professionals to gather and categorize
information to accurately diagnose and treat mental disorders.
An essential educational resource for students and practitioners.
A reference for researchers in the field.
School Counselors need this book thing, too??
 Diagnosing is not the first role of the majority of school counselors, but
shouldn’t be overlooked.
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Although diagnosis isn’t a daily part of all school counseling roles, being
familiar with the language of the DSM and current trends in diagnosis can
only provide benefits for both counselor and students.
 Often, school counselors do not like to diagnose, but it is important that
they consider the reason diagnoses are given.
 The purpose of a diagnosis:
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Provide a common language.
Prognosis and Course Information
Inform Treatment Planning
Definition of a Mental Disorder
 Inclusion Criteria:
 A syndrome characterized by a disturbance in cognition,
emotion regulation, or behavior.
 Reflects dysfunction of psychological, biological, or
developmental aspects of mental functioning.
 Associated with clinically significant distress or disability.
 Exclusion Criteria:
 Not simply an expected or culturally sanctioned behavior or
response to a stressful event.
 Not simply socially deviant behavior.
Major Innovations of DSM-5
THESE FIVE MAJOR CHANGES PROVIDED
THE BASIS FOR THE REVISED
ORGANIZATIONAL STRUCTURE OF THE DSM-5
Greater ICD/DSM Harmony
 It was the goal of both ICD and DSM revision groups to
create as much harmony and overreach between the two
classifications systems as possible because:
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Two major classifications of mental disorders existing at the
same time can cause problems for many aspects of research.
 Overall, there is just a clear need for a uniform
classification system to reduce confusion and
misinterpretation of mental disorders.
 ICD-11 codes will eventually be placed into the DSM
following the current sequential format, but currently the
ICD-9-CM and ICD-10-CM have been indicated for each
disorder in the DSM-5.
Discontinuation of the Multiaxial System
 Previously, diagnosis was done using a five axis system, but now the
DSM uses a more dimensional approach to diagnosis.
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Basically, DSM-5 has employed a non-axial documentation of diagnosis
(formerly Axes I, II, and III), with separate notations for important
psychosocial and contextual factors (formerly Axis IV) and disability (formerly
Axis V).
The revision is consistent with the text in the DSM-IV which states, “The
multiaxial distinction among Axis I, Axis II, and Axis III disorders doesn’t
imply that there are fundamental differences in thir conceptualization, that
mental disorders are unrelated to physical or biological factors or processes, or
hat general medical conditions are unreltated to behavioral or psychosocial
factors or processes.”
 DSM-5 uses a single axis system that combines the former Axis I-III
codes:
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Mental Disorders
Medical Disorders
Reasons for Visit that are not mental disorders (V-codes)
Sample Diagnoses
 DSM-IV-TR Diagnosis:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
296.22 Major Depressive Episode, Single Episode, Moderate
V71.09 No Diagnosis
None
Recent Academic Problems, Few Peer Relationships
GAF=35 (Current)
 DSM-5 Diagnosis:
296.42
Bipolar I Disorder, current episode manic, moderate
severity, with anxious distress
301.83
Borderline Personality Disorder
Spectrum Disorders and Dimensional Ratings
 Comorbidity and the need for NOS diagnoses being a substantial
part of some disorders lead to the change in rating.
 Previous DSM viewed each diagnosis to be categorically different
than any other health issue as well as any other diagnosis.
 Basically, the majority of disorders have been placed on a
spectrum providing a wider range of possibility to fall within the
diagnosis criteria.
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This lowered diagnostic pathology has allowed the diagnosing
of individuals to increase and as a result the validity is much
greater.
Greater Recognition of the Influence of
Age, Gender, and Culture
 Age is now considered as an important component of understanding
and diagnosing mental disorders.
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The entire DSM-5 is built from a developmental standpoint.
 Gender can influence illness in a variety of ways, such as:
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determining if a person is at all at risk for a certain disease based on
their gender,
susceptibility to certain disorders is higher for one gender than another,
and the symptoms of certain disorders being more readily endorsed by
one gender, therefore increasing the extent to which the disorder
appears.
 Culture provides the framework by which we interpret mental disorders
because it shapes the expression and experience of that person affecting
how the signs, symptoms, and behaviors appear to meet criteria for
diagnosis.
New Organization of Chapters
 DSM-5 is organized on developmental and lifespan
considerations.
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It begins with diagnoses thought to reflect developmental
processes that manifest early in life, followed by diagnoses
more common to manifest in adolescence and young
adulthood, and ends with diagnoses relevant to adulthood and
later life.
 This approach has been taken on in a similar fashion
when possible within each chapter.
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The organizational structure facilitates the comprehensive use
of lifespan information as a way to assist in diagnostic decision
making.
Additional Changes to DSM-5
THESE CHANGES INCLUDES THE
CONSOLIDATION, ADDITION, EXTENSION,
AND RELOCATION OF DISORDERS
THROUGHOUT THE DSM-5
Additional Changes
 Consolidation into Autism Spectrum Disorder
 Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental
Disorder were consolidated into one group known as Autism Spectrum
Disorder.
 Symptoms of these disorders represent a single continuum of mild to severe
impairments in the two domains of social communication and restrictive
repetitive behaviors/interests rather than being distinct disorders.
 Streamlined Classification of Bipolar and Depressive Disorders
 These are the most commonly diagnosed conditions, so it was important to
streamline the presentation of these disorders to enhance both clinical and
educational use.
 Now, they are separated into two different chapters but each have their own
criteria definitions of manic, hypomanic, and major depressive episodes
within these separate chapters.
Additional Changes
 Enhanced Specificity for Major and Mild Neurocognitive
Disorders
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Developments in neuroscience and neurology throughout the past
decade have results in our recognition of specific brain disorders that
were previously unable to be identified.
These disorders, such as Alzheimer’s disease and Huntington’s
disease, have been separated into specific subtypes.
 Restructuring of Substance Use Disorders for
Consistency and Clarity
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The categories of substance abuse and substance dependence have
been eliminated and replaced with an overarching new category of
substance use disorders – with specific substance used defining the
specific disorders.
Additional Changes
 Transition in Conceptualizing Personality Disorders
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In DSM-5, the categorical personality disorders are virtually
unchanged from the previous editions. However, an alternative
model has been proposed in Section III to guide future research.
A more dimensional profile of personality trait expression is also
proposed for a trait-specified approach.
 Section III: New Disorders & Features
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This new section has been added to highlight disorder that require
further study but are not sufficiently well established to be a part of
the official classification of mental disorders for routine clinical use.
A Brief Look into the DSM-5
THIS SECTION PROVIDES AN OVERVIEW OF
HOW THE DSM-5 IS COMPILED, BRIEFLY
TOUCHING ON A FEW CHAPTERS RELEVANT
TO OUR FIELD OF SCHOOL COUNSELING .
Neurodevelopmental Disorders
 Highlights of this Chapter:
 New Chapter in DSM.
 Intellectual Disability replaces Mental Retardation.
 Revised Communication Disorders
 Introduction of Autism Spectrum Disorder
 ADHD Criteria Changes
 Organization of Chapter:
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Intellectual Disability (Intellectual Developmental Disorder)
Communication Disorders
Autism Spectrum Disorder
ADHD
Specific Learning Disorders
Motor Disorders
Other Neurodevelopmental Disorders
Bipolar and Related Disorders
 Highlights of this Chapter:
 Bipolar Disorders and Depressive Disorders are separate chapters.
 Mixed Episode removed.
 Increased activity/energy added as core feature of mania.
 New specifiers:
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With mixed features
With anxious distress
With peripartum onset
Depressive Disorders
 Highlights of this Chapter:
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Chronic depressive spectrum introduced.
Changes to Major Depression
 Elimination of bereavement exclusion
 New specifiers
New disorders added
Disruptive Mood Dysregulation Disorder is new within this category.
Dysthymia is know referred to as Persistent Depressive Disorder as
part of this chapter.
Premenstrual Dysphoric Disorder was always added to this chapter.
 Grief can now be looked at as a mild form of depression
instead of requiring the use of bereavement.
Anxiety Disorders
 Highlights of this Chapter:
 New organization of former Anxiety Disorder Chapter
 Panic and Agoraphobia become separate disorders.
 Panic attacks can be applied to any disorder.
 Generalized Anxiety Disorder is unchanged.
 Separation Anxiety Disorder is now for adults instead of only
children.
 Selective Mutism is now apart of this chapter.
 What was previously Social Phobia is now referred to as Social
Anxiety Disorder.
Obsessive-Compulsive and Related Disorders
 OCD is no longer under the category of anxiety, but
instead has a separate individual chapter, including:
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OCD
Body Dysmorphic Disorder
Hoarding Disorder (new disorder)
Trichotillomania (hair-pulling)
Excoriation (skin-picking) disorder
Substance/Medication induced OCD
OCD due to a medical condition
Other specified OCD
Trauma- and Stressor-Related Disorders
 Highlights:
 New chapter for disorders related to exposure to stress
 PTSD has modified criteria and new subtypes
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Now is a PTSD for Children 6 years and younger category
Acute Stress Disorder criteria was modified
Feeding and Eating Disorders
 Highlights:
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New title and organization
Avoidant/Restrictive Food Intake Disorder Added
Modifications to Anorexia and Bulimia
Binge-Eating Disorder added as new disorder.
 Organization of Chapter:
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Pica
Rumination Disorder
Avoidant/Restrictive Food Intake Disorder
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder (new)
Other Specified Feeding or Eating Disorder
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(added so we no longer have to use NOS)
Substance-Related and Addictive Disorders
 Highlights:
 New chapter title.
 Two types of disorders:
Substance USE
 Substance INDUCED
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Dependence and abuse combined into spectrum
Changing face of “dependence”
 Substance Categories in DSM-5:
 Alcohol, Caffeine, Cannabis, Hallucinogen, Inhalants, Opioids,
Sedative/Hypnotics/Anxiolytics, Stimulants, Tobacco-Related,
Other (or unknown) Substance, and Non-Substance-Related
Disorders (Gambling)
Using the DSM-5
THIS SECTION PROVIDES INFORMATION TO
HELP YOU IN YOUR USE OF THE DSM-5.
ADDITIONALLY, THIS SECTION OUTLINES
THE STEPS IN WRITING A DIAGNOSIS ALONG
WITH CASE STUDIES TO DIAGNOSE USING
THE DSM-5.
Tips in Using DSM-5
 The DSM-5 is a GUIDE that requires clinical judgment.
 Use the whole manual.
 Take it one step at a time.
 Exercise diagnostic hygiene.
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Diagnosis is drawn from your case formulation.
Use diagnostic hierarchies for differential diagnosis.
Watch and wait if you are unsure.
Check how your diagnosis stands the test of time.
Steps in Writing a Diagnosis
Locate the disorder that meets criteria.
Write out he name of the disorder:
1.
2.
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Now add any subtype or specifiers that fit presentation:
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Ex: Posttraumatic stress disorder, with dissociative symptoms, with delayed
expression
Add the code number (located either at the top of the criteria set or
among the subtypes or specifiers):
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Ex: Posttraumatic Stress Disorder
All codes are ICD codes. Two code numbers are listed, one in bold (ICD-9)
and one in parentheses (ICD-10), for example, 309.81 (F43.10). Use the
ICD-10 codes starting October 1, 2014.
Order of multiple diagnoses: The focus of treatment or reason for visit
is listed first, followed by the other diagnoses in descending order of
clinical focus.
Now it’s your turn …
 You have two case studies.
 Starting with the first case, Mikayla, take the time to
read through and determine the issues faced by
Mikayla.
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Using the DSM handouts, give Mikayla the diagnosis you think
is appropriate.
 Once Mikayla’s diagnosis is complete, move on to the
next case, Tracey, and provide a diagnosis for her as
well.
Just a
little
funny …
References
 American Psychiatric Association (2000). Diagnostic and statistical
manual of mental disorder-IV Text Revision. Washington, DC: Author.
 American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). Arlington, VA: American
Psychiatric Publishing.
 Hawkins, J. (2013, September 11). Personal interview.