The DSM-5

Report
The DSM-5:
New
Directions for
Mental
Disorders
Todd Finnerty, Psy.D.
September, 2012
NADE
Introductions…
• President of
PsychContinuingEd.com, LLC
• APA Public Education
Coordinator for the state of
Ohio
ApA Permissions Policy
•
The DSM-5, published by the American Psychiatric Association (APA), is in development
and scheduled for publication in May 2013. It currently is undergoing review and
revision and being prepared for eventual approval by the APA leadership. During the
development process, the diagnostic criteria have been posted online at
www.dsm5.org, periodically opened for public comment, and updated in response to
comments and reviews.
•
DSM-5 is a registered trademark, and all content, whether in final or proposed form, is
protected by copyright held by the APA. All rights are reserved, and written permission
is required from the APA for use in any way, commercial or noncommercial. If
permission is granted, it will be for one-time usage on the conditions that the content is
not modified or adapted in any way and credit to the APA is indicated.
•
During the development process, permission will not be granted for use of the
diagnostic criteria. The criteria are subject to change, and it would be a disservice to the
community to allow various preliminary versions to remain in circulation. For this
reason, after the end of the current comment period, the content of DSM-5 will be
under strict embargo until publication. This policy applies to all uses and parties,
including for those who wish to produce DSM-5 educational materials, diagnostic
instruments, or computer-assisted applications of these materials. The APA owns all
products generated by the Work Groups developing DSM-5, but requests will be
considered for permission to describe the criteria and development process in narrative
form. However, APA will not grant permission to reproduce the diagnostic criteria while
they are under development.
Fair Use Resources: http://fairuse.stanford.edu
Obligatory Opening Quote
“Facts” in science do not speak for
themselves but assume their meaning
based on theoretical and ideological
commitments. The practice and the
beliefs of scientists are embedded in a
greater social context.
–Frank J. Sulloway
May 5-9, 2012
DSM5.org
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Important dates:
• ICD-10 codesOctober, 2014
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DSM-5 May, 2013
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ICD-11 2015???
• DSM-V is now
DSM-5 (DSM-5.0)
• Goodbye multiaxial
system- ICD
?
• Hello more decimal
places in your
diagnostic codes
296.32 ?
F 33.1xx ?
We’re moving from 3-5 “digits” to 5-7
(4 potential decimal places instead of 2)
“The Blue Book” :
The ICD-10 Classification
of Mental and
Behavioural Disorders
The ICD-11 Alpha draft’s
“recurrent depressive disorder”
doesn’t have specific codes
listed yet
What is a mental disorder? dsm5.org
• A Mental Disorder is a health condition characterized by
significant dysfunction in an individual’s cognitions,
emotions, or behaviors that reflects a disturbance in the
psychological, biological, or developmental processes
underlying mental functioning. Some disorders may not be
diagnosable until they have caused clinically significant
distress or impairment of performance.
• A mental disorder is not merely an expectable or culturally
sanctioned response to a specific event such as the death
of a loved one. Neither culturally deviant behavior (e.g.,
political, religious, or sexual) nor a conflict that is primarily
between the individual and society is a mental disorder
unless the deviance or conflict results from a dysfunction
in the individual, as described above.
Goodbye
GAF?
Mild
Moderate
Severe
Extreme
WHODAS 2.0:
disability assessment schedule
Cognition – understanding &
communicating
Mobility– moving & getting around
Self-care– hygiene, dressing, eating
& staying alone
Getting along– interacting with
other people
Life activities– domestic
responsibilities, leisure, work &
school
Participation– joining in community
activities
Different Forms- ex: 12 and 36 items
• In the past 30 days how much difficulty have
you had in…
• In the past 30 days, how many days were you
totally unable to carry out your usual activities
or work because of any health condition?
• …how many days did you cut-back or reduce
your usual activities or work because of any
health condition?
“Cross-cutting” Assessments
• Symptoms experienced are not always
communicated by a diagnosis (ex: suicidality)
• Many are still in development (ex: a possible
new “PID-5” for personality disorders)
• The use of the PHQ-9 for depression and similar
screeners will likely be endorsed
• Potential severity rankings which are
qualitative/subjective
• Some may be used to track progress/outcomes
Organizational Structure
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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 Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse Control, and Conduct Disorders
Substance Use and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Disorders
Developmental
Lifespan/
related areas
Neurodevelopmental
Disorders
• Goodbye “mental retardation” Hello
“Intellectual Developmental Disorder”
– Not Intellectual Disability? (see also Rosa’s Law)
• IQ scores may be removed from the criteria but
kept in the text narrative. IQ-based severity cutoffs (ex: moderate, profound) will likely be
eliminated in favor of severity being more
associated with adaptive behaviors
• Adaptive behaviors may receive more emphasis
Will we use adaptive behavior
measures more?
• “Adaptive functioning refers to how well a
person meets the standards of personal
independence and social responsibility in one
or more aspects of daily life activities, such as
communication, social participation,
functioning at school or at work, or personal
independence at home or in community
settings. The limitations result in the need for
ongoing support at school, work, or
independent life.”
Neurodevelopmental
Disorders
• Autism Spectrum Disorder
– Fixated interests and repetitive behaviors
– Social/communication deficits
Aspergers and other Pervasive
Developmental Disorders will be included
together under one diagnosis that has
multiple specifiers to communicate
severity and associated features.
• A more purely inattentive type of ADHD (ex:
Sluggish Cognitive Tempo) compared to
individuals with a mixture of hyperactive and
inattentive symptoms?
• ADHD: Higher onset cut off than age 7 (ex: 12)
• ADHD: Fewer symptoms in an adult to make
the diagnosis?
• Specific Learning Disorder: History or current
presentation of persistent difficulties in the
acquisition of reading, writing, arithmetic, or
mathematical reasoning skills during the formal
years of schooling (i.e., during the
developmental period).
• Reading, written expression, mathematics
specifiers
• Proposal changed from: dyslexia, dyscalculia,
etc.
Schizophrenia Spectrum and Other
Psychotic Disorders
• the classic Schizophrenia subtypes will likely
be deleted; “these subtypes provide a poor
description of the enormous heterogeneity of
this condition, have low diagnostic stability,
and only the paranoid and undifferentiated
subtypes are utilized with any frequency.”
• Attenuated Psychosis Syndrome (Proposed for
Section III of the DSM-5)
Bipolar and Related Disorders
• A need to improve diagnostic precision
– Many with bipolar disorder do not receive a “correct”
diagnosis of bipolar until later
• increased energy/activity has been added as a
core symptom of manic/hypomanic episodes
• “caution is indicated so that one or two symptoms
(particularly increased irritability, edginess or
agitation following antidepressant use) are not
taken as sufficient for diagnosis of a Hypomanic
Episode, nor necessarily indicative of a bipolar
diathesis.”
Depressive Disorders
• Disruptive Mood Dysregulation Disorder????? (previously
known as “Temper Dysregulation Disorder with Dysphoria)
• Ellen Leibenluft, MD: Severe Mood Dysregulation:
– “severe, nonepisodic irritability and the hyperarousal symptoms
characteristic of mania but who lack the well-demarcated
periods of elevated or irritable mood characteristic of bipolar
disorder. Levels of impairment are comparable between youths
with bipolar disorder and those with severe mood
dysregulation”
– nonepisodic irritability in youths: associated with an elevated
risk for anxiety and unipolar depression, but not bipolar
disorder, in adulthood.
– lower familial rates of bipolar disorder than those with bipolar
disorder
Disruptive Mood Dysregulation
Disorder
Will it reduce pediatric bipolar diagnoses in
children without an episodic presentation?
Alternatives could also potentially be
considered (ex: highlight the mood
components of ODD & ADHD).
• In your practice you may treat irritability and
anger like the non-specific symptoms that
they are.
Depressive Disorders
• Premenstrual Dysphoric Disorder: In the
majority of menstrual cycles, symptoms must
be present in the final week before the onset of
menses, start to improve within a few days
after the onset of menses, and
become minimal or absent in the week postmenses
– Likely brought in from the appendix
Anxiety Disorders
• Panic Disorder and Agoraphobia will likely be
split in to two separate diagnoses
• Hoarding disorder and Skin-picking disorder
may be added (separately from OCD)
ObsessiveCompulsive a
Related
Disorders
Trauma and
Stressor
Related
Disorders
Some Additional Changes:
• Somatic Symptom Disorders may include
“Illness Anxiety Disorder” (as opposed to
hypochondriasis)
• Binge Eating Disorder will likely be brought in
from the DSM-IV appendix
• Substance Use and Addictive Disorders:
“Internet Use Disorder” for further research
(heavily focused on “internet gaming”)
• The term “Dementia” is likely out; and the term
“Neurocognitive Disorder” is likely in
“Guide to Implementation” from DSM5.org
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A standard approach to the assessment of personality pathology using the DSM-5 model could be the
following:
1. Is impairment in personality functioning (self and interpersonal) present or not?
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We evaluate the presence of impairment first and then “severity” of impairment second
2. If so, rate the level of impairment in self (identity or self-direction) and interpersonal (empathy or
intimacy) functioning on the Levels of Personality Functioning Scale.
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Ranges from Healthy Functioning to Extreme Impairment
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3. Is one of the 6 defined types present?
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4. If so, record the type and the severity of impairment.
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5. If not, is PD-Trait Specified present?
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6. If so, record PDTS, identify and list the trait domain(s) that are applicable, and record the severity of
impairment.
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7. If a PD is present and a detailed personality profile is desired and would be helpful in the case
conceptualization, evaluate the trait facets.
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8. If neither a specific PD type nor PDTS is present, evaluate the trait domains and/or the trait facets, if
these are relevant and helpful in the case conceptualization.
The 6 Types (at first 5)
• DSM-IV has 10 Personality Disorders not
counting PD NOS and the ones in the
appendix.
• The DSM-5 proposal deletes the names of all
but 6 of them and re-conceptualizes them as
personality “types.”
Disorders we “lost”
• Goodbye Paranoid (they were out to get you)
• Goodbye Schizoid (though you don’t seem to
care)
• Goodbye Histrionic (yes, I’m sorry that no one is
paying attention to you)
• Goodbye Dependent (at this point I’m not sure if
we can help you any more)
• Hey, close call Narcissistic-- it was all about you for
a while wasn’t it?
– These “disorders” can still theoretically be addressed
to some extent as personality traits & facets
The DSM-5 Personality “Types”
(the names are what have remained the
same– not the “criteria”)
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Borderline Personality Disorder
Obsessive-Compulsive Personality Disorder
Avoidant Personality Disorder
Schizotypal Personality Disorder
Antisocial (Dyssocial) Personality Disorder
Narcissistic Personality Disorder
Personality Disorder Trait Specified
• Originally some proposed to have only one
personality disorder at all that included a
description of traits and their facets (and possibly
type specifiers as well). This proposal did not
survive.
• PDTS replaces Personality Disorder NOS and is a
“make-your-own-ice-cream-sundae” personality
disorder with the trait and facet options provided
on the “sundae bar.”
Personality Disorder Trait Specified
(cont.)
• A. Significant impairments in self (identity or self-direction)
and interpersonal (empathy or intimacy) functioning.
• B. One or more pathological personality trait domains OR
specific trait facets within domains, considering ALL of the
following domains:
1. Negative Affectivity
2. Detachment
3. Antagonism
4. Disinhibition (vs. Compulsivity)
5. Psychoticism
(see DSM5.org)
DSM-5 CLINICIANS’ PERSONALITY
TRAIT RATING FORM
Negative Affectivity
Detachment
Antagonism
Disinhibition
Psychoticism
Very little or not at all
descriptive
Mildly descriptive
Moderately descriptive
Extremely descriptive
Currently available at www.dsm5.org
The FFM
(“the big five”)
• Neuroticism
• Extraversion
• Openness to
Experience*
• Agreeableness
• Conscientiousness
PSY-5
• Negative Emotionality
• Psychoticism*
• Introversion
• Disconstraint
• Aggressiveness
“higher order” traits with each having a number of facets/subtraits
Personality Assessment Options Under
DSM-5 include…
• Five-Factor Model NEO inventories (ex: NEOPI-3, NEO-FFI-3)
• MMPI-2 PSY-5 Scale: (Negative Emotionality,
Psychoticism, Introversion, Disconstraint and
Aggressiveness)
• SNAP-2; DAPP-BQ (these and the PAI were
authored by PD Work Group Members)
• New Scales involved in research? ex: The
Personality Inventory for DSM-5 (PID-5)
Thank you!
Questions? Contact:
Todd Finnerty, Psy.D.
www.toddfinnerty.com
[email protected]
twitter.com/DrFinnerty
(330)495-8809

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