Post on 15-Dec-2015
2013 FAADA Conference2013 FAADA Conference
“Introduction to the New Diagnostic and Statistical
Manual For Mental Disorders, 5th
Edition, DSM-5 and the New ASAM
Criteria”
8/7/13
Orlando, FL
© 2013, Shulman & Associates, Training & Consulting in Behavioral Health
CAUTIONS
• The rates of psychiatric disorders have skyrocketed alongside the expanded DSM increasing the list of what constitutes a mental disorder
• Most of the psychiatrist authors of the DSM-5 have ties to the pharmaceutical industry
• There was a significantly sized group of psychiatrists who actually tried to block the release of the DSM-5
The DSM and Democracy
• Winston Churchill said: No one pretends that democracy is perfect or all-wise. Indeed, it has been said that democracy is the worst form of government except all those other forms that have been tried from time to time.
• Sounds like the DSM!
General Changes
Publication 5/22/13 Two year phase-in Movement from categories to continuums Severity scales Simplification (but not simple!) Discontinuation of 5 Axis system for
purposes of diagnosis Replacement of NOS (Not Otherwise
Specified) with NEC (Not Otherwise Categorized)
Coding will change to be consistent with the ICD-10
Dimensional Assessment
In DSM-IV, a categorical approach was used:
An individual either had a symptom of the disorder or they didn’t
They either met criteria (e.g., 4 of 7 symptoms) or they didn’t
An individual either had a disorder or they didn’t
Cross Cutting Symptom Assessment
Assessment across areas that are relevant (and “cut across”) but are not a specific diagnostic criterion depressed mood anxiety substance use sleep problems anger
0-4 scale encouraged with 0 being absence of difficulty
Five Axis Diagnostic Structure
Goes away for purposes of diagnosis
Replaced with list of diagnoses I strongly recommend,
”Continue using Axes 4, 5 and 6 for purposes of informing the assessment, even if not used for purposes of diagnosis”
DSM IV Criteria for Substance DependenceDSM IV Criteria for Substance Dependence A Maladaptive pattern of substance use, leading to
clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
(1) tolerance (2) withdrawal (3) the substance taken in larger amounts or over
a longer period of time than was intended(4) there is a persistent desire or unsuccessful
attempts to cut down or control substance use(5) a great deal of time spent is in activities
necessary to obtain the substance, use the substance, or recover from its effects
(6) important social, occupational or recreational activities are given up or reduced because of substance use
(7) substance use is continued despite knowledge of having persistent or recurring physical or psychological problems that are likely to have been caused or exacerbated by the substance
DSM IV Criteria for Substance AbuseDSM IV Criteria for Substance Abuse
A Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a 12-month period:
(1) Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home
(2) Recurrent substance use in situations in which it is physically hazardous
(3) Recurrent substance-related legal problems(4) Continuing substance use despite having persistent or
recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
B The symptoms have never met the criteria for Substance Dependence for this class of substance
The DSM-5 (May, 2013)
Changes from DSM-IV Use of the term “addiction” No longer diagnoses of “abuse” or
“dependence” “Substance Use Disorders” (DSM-IV) >
“Substance Use and Addictive Disorders” (DSM-5)
The seven criteria from the DSM-IV for dependence and the four for abuse are collapsed into 11 criteria
Substance-related legal problems (from abuse criteria) has been removed???
A new criteria of craving, strong desire or urge to use a substance has been added
12
Removal of “Legal Problems”Pro:
• Discrimination based on race and socioeconomic status
• Misuse of a DUI as equivalent to old “abuse”
• Geographic inequalities (crossing Colorado state line)
Con:
• For some, serves an SBIRT function, as early intervention
• May function as the impetus for treatment
• 54% of DUI offenders who received an abuse diagnosis under the DSM-IV will receive no diagnosis under the DSM-5 – what will this mean in terms of reoffending?
The DSM–5 (May, 2013)
Changes in the DSM-5 from Categories to Continuums
Meeting 0-1 of the 11 criteria results in No Diagnosis
Meeting 2-3 criteria qualifies as Mild (akin to old “abuse”)
Meeting 4-5 criteria qualifies as Moderate (akin to old “abuse” or “dependence”)
Meeting 6 or more qualifies as Severe (akin to old “dependence”) 14
Cannabis WithdrawalPeak symptoms 1 – 21 days post cessation of
heavy cannabis use, markedly reduced or absent by 4 weeks. Psychological symptoms may persist for up to a year
Anger Decreased appetite Irritability Anxiety Restlessness Sleep difficulties Dream rebound Physical symptoms (frequent but mild) Depressed mood
Other Changes in Substance Use and Addictive Disorders
Addition of: “Alcohol-Related Disorders” changed
to “Alcohol Use Disorders” Gambling Disorder (from a type of
OCD disorder to its own disorder) Tobacco-Related Disorders Caffeine withdrawal
Course Specifiers Early full remission
From 1 month but less than 12 months in DSM-IV to 3 month but less than 12 months in DSM-5, no criteria met
Early partial remission Sustained full remission Sustained partial remission Sustained remission
No symptoms for 12 months except craving
Sustained partial remission On agonist maintenance therapy In a controlled environment With physiological dependence Without physiological dependence
The Conundrum Alcoholism/addiction is a chronic,
relapsing brain disease Alcoholism is an insidious,
progressive, incurable and fatal disease and if the person doesn’t stop drinking/using, they will end up either dead or institutionalized
Yet some alcoholics are able to go back to “social” (non-problem) drinking???
RETHINKING THE CONTINUUM OF SUBSTANCE USE
AFOUR PHASE
RISK MODEL
A New Way of Conceptualizing Substance
Use
Phases of Substance Use
Phase Character-istics
Outcomes Response
Phase 1
DSM-5 Severity Level 0-1“Orphan”(no dx.)
Low Risk Choices
• No significant increase in tolerance• Do not use illegal drugs• Use medications only as prescribed• Use results in no problems
Continue to make low risk choices
Phases of Substance Use
Phase Character-istics
Outcomes Response
Phase 2
DSM-5 Severity Level 2-3 – Mild –old “abuse”
• Makes high risk choices• Drinks high risks amounts
• May develop social dependence• State dependent learning begins• Abstract thinking skills may become impaired, e.g., illicit drug use
Return to Phase 1 to make low risk choices
Phases of Substance Use
Phase Character-istics Outcomes Response
Phase 3
DSM-5 Severity Level 4-5 Moderate – old “abuse” or“depend-ence”
• Development of psychological dependence• Substance use more integrated into life•State dependent learning• High risk choices become more important than relationships•Defense of choices
• Substance-related health or impairment problems• Blackouts• Drinking to cure hangovers• Continued use likely to lead to Phase 4
• Return to low-risk drinking choices may still be possible• May require outside help to change choices• 50% are able to return to low-risk choices
Phases of Substance Use
Phase Character-istics
Outcomes Response
Phase 4
DSM-5 Severity Level 6+ Severe – old“depend-ence”
• Physical addiction• Withdrawal• Loss of control• Tolerance continues to increase
• More negative, more severe outcomes than in Phase 3• Possible imprisonmentor death
• Return to low-risk choices no longer possible• Requires abstinence• Usually requires outside help
Anorexia Nervosa
Anorexia Nervosa is the most lethal of all psychiatric disorders with 5% dying per decade after diagnosis either from medical complications or suicide
Before 40 day fast
After 40 day fast
Bulimia Nervosa
People with bulimia: Binge on a regular basis. They eat large
amounts of food in a short period of time, often over a couple of hours or less. During a binge they feel out of control and feel unable to stop eating
They purge to get rid of food and avoid weight gain. The may makes themselves vomit, exercise very hard or for a long time, or misuse laxatives, enemas, diuretics or other medications
All of this is based on how they feel about themselves, on how much they weigh and how they look
Prognosis more positive than with anorexia
Binge Eating Disorder The difference from Bulimia in the course is that
no compensatory behavior (e.g., purging) takes place
Binge will be differentiated from garden variety overeating in that the binger will have several of these features: Eating more rapidly than normal Feeling uncomfortably full Feeling embarrassed or ashamed of eating behavior Hiding eating Eating when not hungry
Frequency will likely be the same as for Bulimia (averaging once/week for 3 months)
Prognosis more optimistic that Anorexia or Bulimia
Personality Disorders The essential element of personality disorder is
that it is not an episodic condition in an otherwise well-functioning individual
It is a chronic dysfunction that begins early in life and is slow to change
The DSM-IV system for categorizing personality disorders is unchanged in the DSM-5
Patients with these disorders are often not likeable, may be seen as difficult rather than sick and may be rejected by clinicians and payers (treatment refractory)
With Substance Use Disorders, Antisocial Personality Disorder is often associated with the use of illicit substances
Axis II has been eliminated
Personality Disorders Most Likely to Co-occur
with Substance Use Disorders
Antisocial Personality Disorder
& Borderline Personality
Disorder
Non-Suicidal Self Injury Disorder (Condition for Further Study)
At present, surface self-mutilation behavior is reflected only as a symptom of Borderline Personality Disorder (BPD). In reality the behavior occurs with a variety of psychiatric disorders and not all cutters have BPD.
The behavior is often labeled or interpreted as suicidal when there is no suicidal intent
Cutters are generally different and healthier than suicide attempters in significant ways; better self-esteem, better mood, better parental relationships
Cutting is a rare suicide method (.5%). However, many will make an actual suicide attempt. Risk increase with the number of incidents and number of modalities
Attention-Deficit/Hyperactivity Disorder
Changes in DSM-5: Onset prior to 12 years old rather than 7
years old Have 3 rather than 6 of the
characteristic symptoms during childhood
From 2 or more settings to “several”
Will make it easier to diagnose adults with ADHD
ATTENTION DEFICIT/HYPERACTIVITY DISORDER
(ADHD)
ATTENTION DEFICIT/HYPERACTIVITY DISORDER
(ADHD)• Incidence in the General Population is: 2.3%
• Incidence in a cocaine using population
is: 32-34%
•Up to 15% of adults with ADHD will still meet full criteria by age 25
•Up to 65% of adults with ADHD will still meet in “partial remission” criteria by age 30
•Rate of ADHD are higher among people with SUDs
Note on Medications for ADHD
Medication works better for hyperactive than inattentive symptoms
Different disorders?
Anxiety Disorders
The DSM-IV described five forms of anxiety disorder
1. Panic Disorder2. Generalized Anxiety Disorder (GAD)3. Phobias4. Post Traumatic Stress Disorder (PTSD)5. Obsessive Compulsive Disorder (OCD)
Anxiety Disorders
There is symptomatic overlap between among the spectrum of anxiety disorders but they have different clinical presentations and are in different chapters of the DSM-5
Generalized Anxiety Disorder is kept in the DSM-5 but renamed Generalized Anxiety and Worry Disorder
Post Traumatic Stress Disorder (PTSD) Obsessive Compulsive Disorder (OCD) Phobias
Obsessive-Compulsive & Related Disorders
Obsessive-Compulsive disorder (OCD) Body Dysmorphic Disorder Hoarding Disorder* Trichotillomania (hair pulling) Excoriation Disorder (skin picking
disorder)* Substance-Induced Obsessive-
Compulsive or Related Disorder (“coke bugs”)
Obsessive-Compulsive or Related Disorder Attributable to Another Medical Condition
*New
Symptoms of OCDObsessions: Unwanted thoughts, ides and urges that
occur repeatedly and won’t go away They get in the way of normal thoughts
and cause anxiety and fear The thoughts may be violent or sexual
or worry about illness or infection Example include:
Fear of harm to self or loved ones A need to do things perfectly Fear of getting dirty or infected
Symptoms of OCDCompulsions: Repeated behaviors to try to control the
obsessions Some have behaviors that are rigid and structured
while others have complex behaviors that change Examples include:
Washing (e.g., hands) Checking (e.g., doors & windows to see if locked) Counting, often while doing another compulsive action Repeating things or always moving items to keep them
in perfect order Hoarding Praying incessantly
Substance-Induced Anxiety Disorder
Prominent anxiety symptoms that are due to the direct physiological effects of a substance
Symptoms may occur during intoxication or withdrawal
The disturbance may not be better accounted for by a mental disorder
The diagnosis is not made if the anxiety symptoms occur only during the course of delirium
The context may be specified as: Onset during intoxication Onset during withdrawal
Panic Attack – 4 or > Symptoms Sudden high anxiety- with or without cause
Heart palpitations Sweating Shaking A smothering sensation or shortness of breath A feeling of choking Chest pain or discomfort Nausea Dizziness or faintness A sense of unreality A fear of going crazy or losing control A fear of dying Numbness or tingling Chills or hot flashes
Panic Disorder
Panic disorder describes the negative impact on an individual’s life from recurrent, unexpected Panic Attacks, taking the form of the restriction of daily or self-care activities to avoid further attacks or marked fear or distress while engaged in activities for fear of further Panic Attacks
Phobias The classic picture of a specific phobia need
not lead to serious dysfunction and clinicians rarely see these cases (arachnophobia)
One change in the DSM-5 is removal of the requirement that phobias be recognized by patients who suffer from them as irrational
Social Anxiety Disorder (previously social phobia) , because of the high prevalence of social anxiety and shyness in community populations may be too broadly defined (e.g., anxiety about speaking in public)
Social Phobia
Social phobia renamed Social Anxiety Disorder has significant implications for treatment for when it co-occurs with substance use disorders:
For treatment For self-help recovery groups
Generalized Anxiety and Worry Disorder
Characterized by excessive, exaggerated anxiety and worry about everyday life for no obvious reasons
Patients tend to expect disaster and can’t stop worrying about health, money, family, work or school
The worry is often unrealistic or out of proportion for the situation
Post Traumatic Stress Disorder Such disorders reflect a biological
predisposition or vulnerability Most people who are exposed to
trauma do not develop PTSD The DSM-5 combines a recognized
cause (a traumatic event) with a set of characteristic symptoms
The traumatic event is either life threatening, could lead to serious injury or rape
Broadening the Diagnosis of PTSD
The DSM-5 diagnosis has been broadened to incidents that consist only of hearing about the trauma
Specifically, the DSM-5 : Allows being a witness to a
disaster Reactions to learning about
disasters
Depressive Disorders Disruptive Mood Dysregulation Disorder
(previously combined with Attention Deficit, now a Depressive Disorder)
Major Depressive Disorder, Single Episode Major Depressive Disorder, Recurrent Dysthymic Disorder (renamed “Persistent
Depressive Disorder” but criteria the same)
Substance-Induced Depressive Disorder Depressive Disorder Associated with
Another Medical Condition Premenstrual Dysphoric Disorder
Major Depressive Disorder (MDD) As many as 40% of those diagnosed
with MDD actually have Bipolar Disorders
If misdiagnosed as MDD and prescribed anti-depressive drugs instead of a mood stabilizer, the anti-depressive medication may precipitate mania or hypomania
When do you medicate for an anxiety, depressive or bipolar disorder? When the risk of not
medicating exceeds the risk of medicating!
Time for Medications to Work
6 to 8 weeks minimum To find the correct drug in the correct dose
may take up to 6 months Complicated by who prescribes (PCPs) Antidepresssant drugs now the most
commonly prescribed class of drug in the U.S. (1 in 10 people)
Work best for very severe cases of depression and have little or no benefit over placebo (inactive pills) in less serious cases.
Depression - Bereavement Many symptoms are characteristic of a major
depressive episode Feelings of sadness Insomnia Loss of appetite Weight loss
In the DSM-IV a diagnosis of MDD was made for a death unless symptoms persist for over 2 months but not other losses
In the DSM-5, don’t diagnose MDD if bereavement symptoms best account for the depressive symptoms
“Persistent Complex Bereavement Disorder”**Proposed for further study
Bipolar Disorder
Unipolar disorders present with only depression
Bipolar Disorder presents with both depression and mania and is divided into two types:
Bipolar I: with full mania (not changed in the DSM-5)
Bipolar II: with hypomaniaBipolar Disorder is one of the most
misdiagnosed, over-diagnosed psychiatric disorder
Bipolar Disorder Misdiagnosis* Total misdiagnosis
69% Times individual misdiagnosed
3.5 Physicians consulted before correct
diagnosis 4
Misdiagnosed as: Unipolar Depression
60% Anxiety Disorder (especially PTSD)
26% Schizophrenia
18% Borderline or Antisocial Personality
Disorder 17%
* Hirschfield, RM et al. J Clin Psychiatry. 2003, 64(2):161-174
Autism Spectrum Disorder
Now encompasses range from Asperger’s to Autism
Concern: Many higher functioning Asperger’s or those with Pervasive Developmental Disorder may not be diagnosed with ASD
If so, may lose services available through Medicaid waivers available in a number of states through the Social Security Act. Under a waiver program, states can choose to waive income when determining Medicaid eligibility.
So What Now? Even if you are not permitted under
your scope of practice to do a formal diagnosis, you can always do a “diagnostic impression”
Become familiar enough with the DSM-5 diagnoses to assure that your patients/clients with co-occurring disorders are getting what they need in treatment
As complex as the DSM-5 is, it will get easier over time
ASAM CRITERIA BACKGROUND
Previous Editions PPC ( 1991) PPC-2 (1996) PPC-2R (2001)
Upcoming Edition: “The ASAM Criteria” Release October, 2013
Assessment of Biopsychosocial Severity
and Level of Function
Dimensions are not changed in the new ASAM Criteria
1. Acute Intoxication and/or Withdrawal Potential
2. Biomedical conditions and complications
3. Emotional/Behavioral/Cognitive conditions and complications
4. Readiness to Change
5. Relapse/Continued Use/Continued Problem potential
6. Recovery Environment
Broad Treatment Levels of ServiceDescription of the Continuum of Care
1. Outpatient Treatment2. Intensive Outpatient and Partial Hospitalization3. Residential/Inpatient Treatment4. Medically-Managed Intensive Inpatient TreatmentNo changes except: New edition changes to Arabic numerals from
Roman numerals e.g., Level II.1 becomes Level II.1 The old Level III.3, Clinically Managed Moderate
Intensity Residential Treatment becomes Level 3.3, High-Intensity, Population-Focused Residential Treatment
What’s new in The ASAM Criteria?The Title!
The Title: “The ASAM Criteria” - Treatment Criteria for Substance, Addictive and Co-Occurring Conditions
Shift away from “placement” criteria to “treatment” criteria: it’s more than just “placement”
Diagnostic Admission Criteria terminology changed to be compatible with DSM-5
Section on working with managed care Section on the Affordable Care Act
What’s new in The ASAM Criteria?The Table of Contents!
• Re-ordered to be more user-friendly and follow the flow from Historical Foundations to Guiding Principles to Assessment, Service Planning and Placement decisions
• ADOLESCENT CRITERIA NO LONGER SEPARATE/STAND-ALONE: consolidated Adult and Adolescent content to minimize redundancy while preserving adolescent-specific content
• Appendices include Withdrawal Management instruments, Dimension 5 constructs, and a Glossary
What’s new in The ASAM Criteria?
The wording in the Levels of Care for Withdrawal Management
The overall section that used to be called “detoxification” is now called “Withdrawal Management” and the Levels are now called
1-D is now 1-WM; 2-D is now 2-WM; 3-D is now 3-WM and 4-D is now 4-WM
New approaches described to support increased use of lower levels of care for safe/effective management of withdrawal
What’s new in The ASAM Criteria?
Updated/revised terminology, to be contemporary and strength-based, recovery-oriented:
• “dual diagnosis” becomes “co-occurring disorders”
• “inappropriate use of substances” becomes “high risk use of substances”
• “admitted” becomes “stated”• “compliance” becomes “adherence”
What’s new in The ASAM Criteria?• Specialized services for opioid use disorder re-named:“Opioid Maintenance Therapy”(OMT) becomes “Opioid Treatment Services”(OTS)
Within OTS, mention is made of the use of opioid antagonist medications as well as opioid agonist medications that can be used in OTPs (regulated “Opioid Treatment Programs”) or in office-based opioid treatment (OBOT)
New Content and Sections
Additional text to improve application to address addiction treatment for Special Populations: Older Adults Persons in Safety Sensitive
Occupations Parents with Children and Pregnant
Women Person in the Criminal Justice
System (CJS)
New Content and Sections
Additional text to address treatment of conditions not traditionally included in specialty addiction treatment services: Tobacco Use Disorder Gambling Disorder
New Content and Sections
Revision of the text to address emerging issues:
Health Reform and the integration of addiction treatment into general medical care
The role of physicians in the care team, addiction specialist physicians in particular (addiction medicine physicians, addiction psychiatrists)