Psychiatry Update: The DSM-5 and More David J. Kupfer, M.D. Professor of Psychiatry, University of Pittsburgh Chair, DSM-5 Task Force American College of Physicians Virginia Chapter Richmond, VA March 2, 2013 DSM-5 Review of Process Revisions – Rationales Table of Contents Development of Primary Care Version DSM-5 Work Groups and Chairs ADHD & Disruptive Behavior Disorders (David Shaffer, M.D.) Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders (Katharine Phillips, M.D.) Disorders in Childhood and Adolescence (Daniel Pine, M.D.) Eating Disorders (Timothy Walsh, M.D.) Mood Disorders (Jan Fawcett, M.D.) Neurocognitive Disorders (Dilip Jeste, M.D., Dan Blazer, M.D., Ron Peterson, M.D.) Neurodevelopmental Disorders (Susan Swedo, M.D.) DSM-5 Work Groups and Chairs (Cont’d) Personality and Personality Disorders (Andrew Skodol, M.D.) Psychotic Disorders (William Carpenter, M.D.) Sexual and Gender-Identity Disorders (Kenneth Zucker, Ph.D.) Sleep-Wake Disorders (Charles Reynolds, M.D.) Somatic Distress Disorders (Joel Dimsdale, M.D.) Substance-Related Disorders (Charles O’Brien, M.D., Ph.D.) Cross-Cutting Study Groups Diagnostic Spectra Life Span Developmental Approach Study Group Gender and Cross-Cultural Study Group Psychiatric/General Medical Interface Study Group Impairment Assessment and Instruments Diagnostic Assessment Instruments DSM-5 Revisions: Rationales DSM-5 Revisions: Rationales DSM-IV’s organizational structure failed to reflect shared features or symptoms of related disorders and diagnostic groups (like psychotic disorders with bipolar disorders, or internalizing (depressive, anxiety, somatic) and externalizing (impulse control, conduct, substance use) disorders. DSM-5 restructuring better reflects these interrelationships, within and across diagnostic chapters DSM-5 Revisions: Rationales The strict categorical approach of DSM-IV failed to capture variations of disorders (e.g., atypical, subthreshold, & common comorbidities). A strict application of diagnostic criteria did not fit patient presentations resulting in overuse of the NOS designation. DSM-5 integrates cross-cutting symptomatic descriptions that better reflect the true presentation of disorders and may reduce reliance on OS diagnoses. DSM-5 Revisions: Rationales DSM-IV did not adequately address the lifespan perspective, including variations of symptom presentations across the developmental trajectory, or cultural perspectives DSM-5’s chapter structure, criteria revisions, and text outline actively address age and development as part of diagnosis and classification Culture is similarly discussed more explicitly to bring greater attention to cultural variations in symptom presentations DSM-5 Revisions: Rationales DSM-5 represents an opportunity to better integrate neuroscience and the wealth of findings from neuroimaging, genetics, cognitive research, and the like, that have emerged over the past several decades – all of which are vital to diagnosis and treatment development DSM-5 will be more amenable to updates in psychiatry and neuroscience, making it a “living document,” less susceptible to becoming outdated than its predecessors DSM-5 Revisions: Rationales The multiaxial system in DSM-IV is not required to make a mental disorder diagnosis and has not been universally used DSM-5 has moved to a nonaxial 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) This approach is consistent with established WHO and ICD guidance to consider the individual’s functional status separately from his or her diagnoses or symptom status DSM-5 - Section II Revised DSM-5 Chapter Structure Clustering of Chapters Neurodevelopmental Disorders Emotional (Internalizing) Disorders Somatic Disorders Externalizing Disorders Neurocognitive Disorders Personality Disorders Strategy to Improve DSM-5: Revised Chapter Organization (1) 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 Strategy to Improve DSM-5: Revised Chapter Organization (2) Somatic Symptom and Related Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Strategy to Improve DSM-5: Revised Chapter Organization (3) Disruptive, Impulse Control, and Conduct Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Mental Disorders Living Document – What does that mean? Not waiting 20 years for revision Allows advances to be incorporated into DSM-5.1, etc. Deals with unanticipated “events” • Prevalence changes • Unclear criteria Development of electronic-online enhancements to accommodate advances Next Step Primary care version – how to further integrate psychiatry with general medicine To provide easier strategies for assessment of the most common disorders with the greatest public health impact Primary Care Version: Key Questions How to determine which disorders Should there be two versions – pediatric and adult? Printed vs. online version Levels of assessment Advice needed DSM-5 PC Content Options Brief (10 disorder groups), low specificity Moderate (33 specific disorders) Complex (entire DSM-5: approximately 160 disorders) Brief List: 10 Disorder Groups Neurodevelopmental Disorders Psychotic Disorders Bipolar Disorders Depressive Disorders Anxiety Disorders Trauma and Stress-related Disorders Somatic Symptom and Related Disorders Eating Disorders Sleep Disorders Substance Use Disorders Moderate Complexity: 33 Specific Disorders Within Disorder Groups (1) Neurodevelopmental Disorders • Intellectual Developmental Disorder (Intellectual Disability) • Autism Spectrum Disorder • Specific Learning Disorder • Attention Deficit/Hyperactivity Disorder Psychotic Disorders • • • Brief Psychotic Disorder Schizophrenia Psychotic Disorders NOS Moderate Complexity: 33 Specific Disorders Within Disorder Groups (2) Bipolar Disorders • Depressive Disorders • • Bipolar I/II Disorder Major Depressive Disorder Depression due to another medical condition Anxiety Disorders • • • Generalized Anxiety Disorder Panic Disorder Anxiety due to another medical condition Moderate Complexity: 33 Specific Disorders Within Disorder Groups (3) Obsessive-Compulsive and Related Disorders • Trauma and Stress-related Disorders • • • Unspecified Obsessive-Compulsive and Related Disorder Adjustment Disorder Acute Stress Disorder Posttraumatic Stress Disorder Somatic Symptom and Related Disorders • • Somatic Symptom Disorder Illness Anxiety Disorder Moderate Complexity: 33 Specific Disorders Within Disorder Groups (4) Eating Disorders • • Sleep Disorders • Binge Eating Disorder Anorexia and Bulimia Insomnia Disorder Sexual Dysfunctions • • • • Erectile Disorder Female Orgasmic Disorder Substance/Medication-Induced Sexual Dysfunction Unspecified Sexual Dysfunction Moderate Complexity: 33 Specific Disorders Within Disorder Groups (5) Disruptive, Impulse-Control, and Conduct Disorders • Conduct Disorder Substance Use Disorders • • • Alcohol Use Disorder Substance Use Disorder Tobacco Use Disorder Moderate Complexity: 33 Specific Disorders Within Disorder Groups (6) Neurocognitive Disorders • • Delirium Major and Mild Neurocognitive Disorder Personality Disorders • Personality Disorders, general Primary Care Version: Key Questions How to determine which disorders Should there be two versions – pediatric and adult? Printed vs. online version Levels of assessment Advice Needed A Potential Strategy for DSM-5 PC (1) DSM-5 PC provides a guide for primary care clinicians to facilitate the assessment of mental disorders. This guide recognizes that primary care clinicians will vary in their choice of the level of specificity of a mental disorder diagnosis required for optimal care, depending on the clinician’s expertise, available treatment resources, and patient preferences. A Potential Strategy for DSM-5 PC (2) With this guide the clinician can proceed as needed from the least to the most specific level of assessment for mental disorders in primary care. Stepped Care Overview ( Initial Clinical Assessment (1) Key tasks at this stage include: Attaining a targeted history and physical exam Ordering targeted laboratory and imaging studies if indicated Performing targeted Screening Measures Assessing/ensuring safety Assessing environmental stressors including exposure to trauma and loss Initial Clinical Assessment (2) Assessing current functioning including capacity for relationship Assessing medical and iatrogenic comorbidities Assigning either a symptom based, Level I or Level II (Specific ) DSM-5 PC diagnosis More Advanced Assessments Key tasks at this stage include: Additional history Review laboratory and imaging studies if obtained Continuing psychological assessment Severity Measures (to support diagnosis and/or monitoring) Assigning a Level I DSM-5 PC diagnosis Primary Care Version: Key Questions How to determine which disorders Should there be two versions – pediatric and adult? Printed vs. online version Levels of assessment Advice Needed What do you Need? Pre-visit screening tools? On-line diagnostic algorithms? Brief assessment measures for monitoring change: • • clinician administered? self-report? Other needs? Printed vs. Electronic Materials Which are you most likely to use? Do you want/need both? What have I forgotten to ask?