DSM-5 Changes

Naval Center for Combat

& Operational Stress Control

July 10th, 2013

Presentation Aims

-- New organizational structure

-- Trauma- and Stressor-Related Disorders

-- Depressive Disorders/Anxiety Disorders/ADHD

-- Substance-Related and Addictive Disorders

DSM-5 Organizational Structure

Chapter organization now represents a

developmental/lifespan approach

In the DSM-5 both ICD-9 and ICD-10 codes are attached to the relevant disorders

DSM-5 Organizational Structure

Non-Axial Documentation of Diagnosis

-- Axis I, II, and III no longer have axial designations; they have been combined

-- Axis IV removed; the DSM-5 recommends the use of V codes and new Z codes contained in the ICD

-- Axis V GAF has also been dropped

Trauma- and Stressor-Related Disorders

Conditions in which symptoms occur after a

distressing or traumatic event

-- Acute Stress Disorder

-- Posttraumatic Stress Disorder

-- Adjustment Disorder

-- Reactive Attachment Disorder

Acute Stress Disorder Criterion A

DSM-IV Criteria -- Groups together whether the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

DSM-5 Criteria -- Requires being explicit about how the event was experienced: directly, witnessed or indirectly* *Does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related

Acute Stress Disorder Criterion A

DSM-IV Criteria

-- The person’s response involved intense fear,

helplessness, or horror

DSM-5 Criteria

-- Subjective reaction has been eliminated

Acute Stress Disorder Criterion B

DSM-IV Criteria

-- Must meet at least 3 (out of 5) dissociative symptoms

DSM-5 Criteria

-- Must meet at least 9 listed symptoms in the following categories: intrusion, negative mood, dissociation, avoidance and arousal

Posttraumatic Stress Disorder Criterion A

DSM-IV Criteria -- Groups together whether the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

DSM-5 Criteria -- Requires being explicit about how the event was experience: directly, witnessed or indirectly*

*Does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related

Posttraumatic Stress Disorder Criterion A

DSM-IV Criteria

-- The person’s response involved intense fear, helplessness, or horror

DSM-5 Criteria

-- Subjective reaction has been eliminated

Posttraumatic Stress Disorder Criterion B – E

DSM-IV Criteria

-- Three symptom clusters: reexperiencing (B), avoidance (C) and arousal (D)

DSM-5 Criteria

-- Four symptom clusters: reexperiencing (B), avoidance (C), negative alterations in cognitions and mood (D) and arousal (E)

Posttraumatic Stress Disorder Criterion B – E

DSM-5 includes new symptoms:

-- Persistent and exaggerated beliefs or expectations about oneself, others or the world (D)

-- Persistent, distorted cognitions about the cause or consequences of the traumatic events that lead the individual to blame himself/herself or others (D)

-- Reckless or self-destructive behavior (E)

Posttraumatic Stress Disorder Criterion E/F

DSM-IV Criteria -- Duration of the disturbance (Criteria B, C and D) is more than 1 month Specify if: Acute: Duration of symptoms is less than 3 months Chronic: Duration of symptoms is 3 months or more Delayed onset: Onset of symptoms is at least 6 months after the stressor

DSM-5 Criteria -- Duration of the disturbance (Criteria B, C, D and E) is more than 1 month Specify if: Delayed expression: Full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate)

Posttraumatic Stress Disorder

DSM-5 Criteria Specify whether:

With dissociative symptoms: The individual experiences persistent or recurrent symptoms of either:

Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body

Derealization: Persistent or recurrent experiences of unreality of surroundings

Adjustment Disorders

DSM-IV

-- Residual category for those exhibiting clinically significant distress without meeting criteria for other disorders

DSM-5

-- Now falls under the category of stress-response syndromes that occur after exposure to a distressing event

Adjustment Disorders

DSM-IV and DSM-5:

-- Symptoms are essentially unchanged

-- Same subtypes: Depressed mood, anxious symptoms, mix of depression and anxiety, disturbances in conduct, mixed disturbance of emotions and conduct and unspecified

DSM-5

-- Does not specify if acute (less than 6 months) or chronic (longer than 6 months)

Depressive Disorders

DSM-5 -- Separated from Bipolar and Related Disorders

-- Contains new diagnoses such as Disruptive Mood Dysregulation Disorder (children up to age 18) and Premenstrual Dysphoric Disorder (women)

-- Contains Persistent Depressive Disorder (Dysthymia), a consolidation of DSM-IV chronic Major Depressive Disorder and Dysthymic Disorder

Persistent Depressive Disorder (Dysthymia)

All symptoms remain essentially unchanged

from DSM-IV to DSM-5 except Criteria D

-- Depressed mood for most of the day, for more days than not…for at least 2 years (A) -- Presence of two or more of the following: poor appetite or overeating, insomnia or hypersomnia, low energy/fatigue, low self-esteem, poor concentration/difficulty making decisions, feelings of hopelessness (B)

Persistent Depressive Disorder (Dysthymia)

-- During the 2-year period of the disturbance, the person has never been without the symptoms in Criteria A or B for more than 2 months at a time (C) -- DSM-IV: No Major Depressive Disorder has been present during the course (D) -- DSM-5: Criteria for Major Depressive Disorder may be present (D)

Major Depressive Episode

DSM-IV Criteria -- The symptoms are not better accounted for by Bereavement (i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation) (E)

DSM-5 Criteria

-- Omitted the bereavement exclusion

Anxiety Disorders

DSM-5 chapter no longer includes: -- Obsessive-compulsive disorder (which is included with the obsessive-compulsive and related disorders) -- Posttraumatic stress disorder and acute stress disorder (which are included with the trauma- and stressor-related disorders)

Attention-Deficit/Hyperactivity Disorder

DSM-IV and DSM-5

-- The same 18 symptoms are used and continue to be divided into two symptom domains (inattention and hyperactivity/impulsivity)

DSM-5

-- The cross-situational requirement has been strengthened from “some” to “several” symptoms in each setting

-- Onset criteria: Symptoms need to be present prior to age 12 (used to be age 7)

Attention-Deficit/Hyperactivity Disorder

DSM-5: -- Comorbid diagnosis with Autism Spectrum Disorder is now allowed -- Only 5 symptoms required for adults compared to 6 for children

Attention-Deficit/Hyperactivity Disorder

DSM-IV and DSM-5 both specify:

-- Combined presentation -- Predominately inattentive presentation -- Predominately hyperactive/impulsive presentation

Substance-Related and Addictive Disorders

DSM-IV -- 11 classes of substances

DSM-5 -- Includes a new diagnosis: Gambling disorder

-- 10 classes of substances

Amphetamines and cocaine combined into single “stimulants” class

PCP placed as its own category in “hallucinogen” class

Addition of “other/unknown substance” class

Substance-Related and Addictive Disorders

DSM-IV -- Included diagnostic criteria for substance dependence and substance abuse

DSM-5 -- Does not differentiate between substance dependence and substance abuse

-- Polysubstance dependence diagnosis eliminated

-- Physiological subtype specifier eliminated

Substance Use Disorders

DSM-IV and DSM-5 criteria are almost identical with some exceptions: -- Recurrent legal problems criterion has been deleted from DSM-5 -- Craving or strong desire/urge to use substance has been added to DSM-5

Substance Use Disorders

DSM-IV and DSM-5 criteria are almost identical with some exceptions (cont): -- DSM-IV Criteria: Must meet at least one criteria for substance abuse and at least three criteria for substance dependence -- DSM-5 Criteria: Must meet at least two criteria

Substance-Related and Addictive Disorders

Other changes to DSM-5:

-- Cannabis and caffeine withdrawal added

-- Tobacco use disorder added

-- Severity of disorders added

Mild: 2-3 criteria met

Moderate: 4-5 criteria met

Severe: 6+ criteria met

Substance-Related and Addictive Disorders

Other changes to DSM-5 (cont):

-- Specifiers

Eliminated “full” and “partial” specifiers

Use “In early remission” if no criteria for substance use disorder (except “craving”) have been met for at least 3 months, but less than 12 months

Use “In sustained remission” if no criteria for substance use disorder have been met for 12 months or longer

Substance-Related and Addictive Disorders

Other changes to DSM-5 (cont):

-- Specifiers

DSM-IV: “On agonist therapy”

DSM-5: “On maintenance therapy”

Substance-Related and Addictive Disorders

Potential implications for clinical practice?

-- SUD screening processes

-- Psychoeducation content/materials

-- “Designer drug SUDs” (e.g., spice, bath salts)

Thank you!

Questions?