DSM-5 OVERHAULWHAT’S IN, OUT, AND RELEVANT IN THE GP’S WORLD

Presented by Jaana Kastikainen, MD, FRCPCSMH General Practitioner RoundsMarch 31, 2015

DISCLOSURES

No affiliations, sponsorship, or financial reimbursements to disclose

OBJECTIVES

Briefly review the history of the DSM

Briefly review the changes made (what’s in, what’s out, what didn’t make it) in the newest version of the DSM

Review the changes most relevant to our population of medically ill patients and the implications of these changes

OBJECTIVES

Briefly review the history of the DSM

Briefly review the changes made (what’s in, what’s out, what didn’t make it) in the newest version of the DSM

Review the changes most relevant to our population of medically ill patients and the implications of these changes

WHY THE NEED FOR A DIAGNOSTIC MANUAL?

DSM IN THE MAKING...

1840 Government wanted to collect data on mental illness “idiocy” and “insanity” was terminology used in census

1880 Census expanded to feature seven categories

1917 Census committee embraced Statistical Manual for the Use

of Institutions for the Insane Mental illness separated into 22 groups 10 editions over next 25 years

DSM HISTORY DSM

Published in 1952 106 disorders, “reactions” Mental disorders were reactions of personality to bio/psycho/social

factors on continuum from normalcy psychosis

DSM-II Published in 1968 Glossary of definitions

DSM-III Published in 1980 Reconceptualized with research-based criteria, 5 axes Criteria broadened further with DSM-III-R (1987)

DSM-IV Published in 1994 Diagnosis required clinically significant distress/functional impairment

LOFTY GOALS OF THE DSM-5

Eliminate “not otherwise specified” (NOS) diagnoses within categories

Remove functional impairments as necessary components of diagnostic criteria

Use scientific evidence to justify classifications and criteria

THE CURRENT DSM-5

Released at APA annual meeting in May 2013

Represents decade of revision in criteria

Standard classification of mental disorders, applicable in wide array of contexts to clinicians and researchers

Tool for collecting and communicating accurate public health stats

Three major components: classification, criteria sets, and descriptive text

Diagnostic guide – not treatment guide

MAKING THE TRANSITION...DSM-IV-TR DSM-5

WHAT DEFINES “MENTAL DISORDER”? DSM-IV-TR

A clinically significant behavioural or psychological syndrome that is associated with present distress, disability, or significantly increased risk of suffering death, pain, disability, loss of freedom

DSM-5 A syndrome characterized by significant disturbance

in cognition, emotion regulation, or behaviour that reflects dysfunction in bio/psycho/developmental processes and are usually associated with significant distress

HIGHLIGHTS OF CHANGES FROM IV TO 5 Terminology – “general medical condition” replaced with “another medical condition”

Neurodevelopmental disorders Intellectual Disability Communication Disorders Autism Spectrum Disorders ADHD Specific Learning Disorder Motor Disorders

Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia/Subtypes Schizoaffective Disorder Delusional Disorder Catatonia

Bipolar and Related Disorders Bipolar Disorder Anxious Distress Other Specified Bipolar and Related Disorder

Depressive Disorders Disruptive Mood Dysregulation Disorder PMDD Persistent Depressive Disorder Bereavement exclusion

HIGHLIGHTS OF CHANGES FROM IV TO 5 Anxiety Disorders

Exclusion of OCD, PTSD, acute stress disorder Agoraphobia, Specific Phobia, SAD Panic Attack Panic Disorder and Agoraphobia Separation Anxiety Disorder Selective Mutism

Obsessive-Compulsive and Related Disorders Insight specifiers Body Dysmorphic Disorder Hoarding Disorder/Trichotillomania/Excoriation Disorder

Trauma- and Stressor-Related Disorders Acute Stress Disorder Adjustment Disorder PTSD Reactive Attachment Disorder

Dissociative Disorders Depersonalization/derealization disorder Exclusion of dissociative fugue DID

HIGHLIGHTS OF CHANGES FROM IV TO 5 Somatic Symptom and Related Disorders

Exclusion of Somatization Disorder, Hypochondriasis, Pain Disorder Somatic Symptom Disorder Illness Anxiety Disorder Conversion Disorder

Feeding and Eating Disorders Pica and Rumination Disorder Avoidant/Restrictive Food Intake Disorder Anorexia Nervosa Bulimia Nervosa Binge-Eating Disorder Elimination Disorders

Sleep-Wake Disorders Insomnia Disorder Narcolepsy Breathing-Related Sleep Disorders REM Sleep Behaviour Disorder Restless Legs Syndrome

Sexual Dysfunctions Gender-specific sexual dysfunctions Genito-Pelvic Pain/Penetration Disorder

HIGHLIGHTS OF CHANGES FROM IV TO 5 Gender Dysphoria

New diagnostic category

Disruptive, Impulse-Control, and Conduct Disorders ODD CD IED

Substance-Related and Addictive Disorders Substance Use Disorder (exclusion of abuse/dependence) Gambling Disorder

Neurocognitive Disorders Mild and Major Neurocognitive Disorder Etiological subtypes

Paraphilic Disorders Specifiers “in remission,” “in controlled environment” Addition of “disorder” to diagnostic names

OBJECTIVES

Briefly review the history of the DSM

Briefly review the changes made (what’s in, what’s out, what didn’t make it) in the newest version of the DSM

Review the changes most relevant to our population of medically ill patients and the implications of these changes

WHAT’S OUT Multiaxial Diagnosis

I, II, III dropped IV replaced with “with significant psychosocial and contextual

features” V dropped, WHODAS recommended

Not Otherwise Specified diagnoses Other specified... Unspecified...

Disorders usually first diagnosed in infancy, childhood, or adolescence

Pervasive Developmental Disorders Autism/Asperger’s/PDD/Rett’s Autism Spectrum Disorder

WHAT’S OUT

Mood Disorders MDE distinction Distinction between dysthymia and chronic MDD Bereavement exclusion

Substance Disorders Distinction between abuse and dependence

Psychotic Disorders Bizarre specifier for A criteria in Schizophrenia Subtypes of Schizophrenia

WHAT’S IN

Dimensions Categorical diagnoses stand Indicators of severity throughout Course (partial/full remission, recurrent) Descriptive (with insight, in structured environment)

Biomarkers Polysomnography Hypocretin

New Terminology “Other specified/Unspecified...” Secondary to “another medical condition” Neurodevelopmental disorders Persistent Depressive Disorder Peripartum Onset Neurocognitive Disorder

NEW DIAGNOSES

Disruptive Mood Dysregulation Syndrome Premenstrual Dysphoric Disorder Hoarding Disorder Trichotillomania Excoriation Disorder Disinhibited Social Engagement Disorder Illness Anxiety Disorder Binge Eating Disorder Central Sleep Apnea Neurocognitive Disorder

WHAT DIDN’T MAKE THE CUT Personality disorders revision

Major changes proposed Spectrums of personality, trait-focused

Attenuated Psychosis Syndrome

Mixed Anxiety Depression

Posttraumatic Stress Injury

Other Substance Use Disorders (additional addictions)

New diagnoses Body Integrity Disorder Male-to-Eunuch Disorder Hypersexual Disorder Persistent Complicated Bereavement Olfactory Reference Syndrome

OBJECTIVES

Briefly review the history of the DSM

Briefly review the changes made (what’s in, what’s out, what didn’t make it) in the newest version of the DSM

Review the changes most relevant to our population of medically ill patients and the implications of these changes

A LOT OF CHANGES...

BUT WHAT IS ACTUALLY RELEVANT TO YOU AS A FAMILY

PHYSICIAN?

... ALL OF IT!!

RELEVANT CHANGES WE’LL COVER...

Neurodevelopmental Disorders Schizophrenia Spectrum Disorders Bipolar Disorders Depressive Disorders Anxiety Disorders Somatic Symptom Disorders Sleep-Wake Disorders Substance-Related Disorders Neurocognitive Disorders

NEURODEVELOPMENTAL DISORDERS

Intellectual Disability Emphasizes assessment of both cognitive capacity (IQ) and

adaptive functioning Severity is determined by adaptive functioning rather than IQ Term “mental retardation” eliminated

Communication Disorders Language Disorder (DSM-IV’s expressive + mixed receptive-

expressive language disorders) Speech Sound Disorder (=phonological disorder) Childhood-onset Fluency Disorder (=stuttering) Social (Pragmatic) Communication Disorder (new diagnosis

for persistent difficulties in social uses of communication)

NEURODEVELOPMENTAL DISORDERS Autism Spectrum Disorder

Encompasses Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder, PDD NOS

Previously separate disorders actually a single condition w/ different levels of symptom severity

2 core domains Deficits in social communication and interaction Restricted, repetitive behaviours, interests, activities

ADHD Neurodevelopmental disorder to reflect developmental correlates Onset criterion changed to <12 yrs (vs onset before age 7) Comorbid ASD diagnosis allowed Change to symptom threshold for diagnosis in adults (5 symptoms vs 6)

Specific Learning Disorder Combines Reading Disorder, Mathematics Disorder, Disorder of Written

Expression, LD NOS

SCHIZOPHRENIA-SPECTRUM DISORDERS Schizophrenia

Elimination of attribution of bizarre delusions (poor reliability) and Schneiderian first-rank AH (non-specificity)

1 of 3 core positive symptoms must be present: hallucinations, delusions, disorganization

Elimination of subtypes (paranoid, disorganized, catatonic, undifferentiated, residual)due to limited stability, reliability, validity

Dimensional approach to rating severity instead

SCHIZOPHRENIA-SPECTRUM DISORDERS Schizoaffective Disorder

Major mood episode must be present for majority of disorders’ total duration after Criterion A met

Longitudinal versus cross-sectional (DSM-IV-TR) diagnosis, comparable to other SPMIs

Delusional Disorder No longer requirement that delusions must be non-bizarre (specifier

exists) New exclusion from OCD, BDD with absent insight/delusional beliefs No longer separated from shared delusional disorder

Catatonia Same criteria regardless of context

(psychotic/bipolar/depressive/AMC) All require 3 of 12 characteristic symptoms May be diagnosed as separate diagnosis (AMC) or as specifier

BIPOLAR DISORDERS Criteria A for manic/hypomanic episodes now include changes in

activity/energy as well as mood

Addition of “with mixed features” specifier to manic/hypomanic episodes with depressive features, and vice versa

Elimination of need to meet full criteria for manic/hypomanic/depressive episodes simultaneously

Other specified bipolar and related disorder Individuals with hx of MDD with all but time criteria for hypomanic

episode, or time criteria but too few symptoms for bipolar II diagnosis

Anxious distress specifier Identifies patients with anxiety symptoms not part of bipolar disorder

criteria Also included as new specifier in depressive disorders

DEPRESSIVE DISORDERS Several new disorders

Disruptive Mood Dysregulation Disorder Addresses concerns of overdiagnosis/overtx of bipolar disorders

in children < age 18 with persistent irritability and frequent episodes of

extreme behaviour dyscontrol

Premenstrual Dysphoric Disorder Moved from DSM-IV-TR “criteria sets for further study” to main

body

Persistent Depressive Disorder Includes both chronic MDD and dysthymia No scientifically meaningful differences

DEPRESSIVE DISORDERS

MDE no longer separate diagnostic criteria set (captured within MDD)

Bereavement exclusion Recall DSM-IV – MDE could not be diagnosed if symptoms fell within

two months of death of loved one Bereavement typically lasts 1-2 years Bereavement is severe psychosocial stressor that can precipitate MDE Bereavement-related MDD more likely to occur in those with

personal/family hx of MDD Treatment approach and response is same

Addition of “with mixed features” specifier

Change in specifier from “w/ postpartum onset” to “w/ peripartum onset”

ANXIETY DISORDERS No longer encapsulates OCT, PTSD, Acute Stress Disorder

Agoraphobia, Specific Phobia, Social Anxiety Disorder Deletion of requirement that >18 yrs must recognize excessive nature

of fear 6 month duration (previously only for <18 yrs) now extended to all

ages

Panic Attack Complicated subtypes (DSM-IV) replaced with “expected” or

“unexpected” Can now be listed as specifier for all DSM diagnoses

Panic Disorder and Agoraphobia Now two separate diagnoses with own criteria At least two agoraphobic situations, at least 6 months duration

required for agoraphobia

ANXIETY DISORDERS Social Anxiety Disorder

“Generalized” specifier removed “Performance only” specifier added

Separation Anxiety Disorder Reclassified as anxiety disorder Wording of criteria modified to include adults

Attachment figures can include children of adults affected Avoidance behaviours can occur in the workplace No longer specify age of onset must be <18 yrs Duration of at least 6 months

Selective Mutism Reclassified as anxiety disorder

SOMATIC SYMPTOM DISORDERS

Recall DSM-IV-TR – significant overlap and lack of clarity across somatoform disorders nonpsychiatric MDs found them problematic to use

Removal of somatization disorder, pain disorder, hypochondriasis

Somatic Symptom Disorder Somatic symptoms with abnormal thoughts, behaviours,

feelings may or may not have a diagnosed medical condition Arbitrarily high symptom count (SD) did not accommodate

spectrum of relationship btw somatic sx and psychopathology SSD has no specific number of sx required Medically unexplained symptoms not overemphasized

SOMATIC SYMPTOM DISORDERS

Illness Anxiety Disorder Hypochondriasis eliminated – pejorative, not conducive to

effective therapeutic relationship Most “hypochondriacs” now fit into Somatic Symptom

Disorder, unless no somatic sx present

Conversion Disorder Emphasize essential importance of neuro exam Recognizes potential absence of psychological factors at

time of diagnosis

Psychological Factors Affecting Other Medical Conditions

SLEEP-WAKE DISORDERS

Reconceptualized to emphasize sleep disorders as their own entity requiring independent clinical attention

Elimination of sleep disorders related to another mental disorder/GMC

Primary Insomnia renamed Insomnia Disorder

Narcolepsy distinguished because of hypocretin deficiency (part of criteria)

REM Sleep Behaviour Disorder and RLS added as own diagnoses

SUBSTANCE-RELATED DISORDERS Substance Use Disorder

No distinction between substance abuse and dependence combined into one symptom list requiring at least 2 criteria

Recurrent legal problems criterion deleted Craving or strong desire/urge to use added Severity specifiers (2-3 = mild; 4-5 = mod; 6+ = severe)

New: Tobacco Use Disorder, Cannabis Withdrawal, Caffeine Withdrawal

Gambling Disorder

On premise that behaviour activates same reward centres in brain

NEUROCOGNITIVE DISORDERS

APA president, at time of DSM-5’s release, called for a movement among psychiatrists to retire the term “dementia” for stigmatic reasons, as the literal Latin translation is “without mind”

Old habits die hard

NEUROCOGNITIVE DISORDERS Mild and Major Neurocognitive Disorder

DSM-IV-TR diagnoses of dementia and amnestic disorder subsumed under newly named major NCD

Evidence of significant decline from previous level of performance in one or more domains based on concern and substantial impairment in performance

Interference with independence in everyday activities

Mild NCD is new disorder of less disabling syndrome Evidence of modest decline from previous level of

performance in one or more domains based on concern and modest impairment in performance

Do not interfere with independence in everyday activities

NEUROCOGNITIVE DISORDERS

Etiological Subtypes Major/mild vascular NCD criteria retained Major/mild NCD due to Alzheimer’s disease

retained New separate criteria for major or mild

NCD due to frontotemporal NCD, Lewy Bodies, TBI, Parkinson’s disease, HIV, Huntington’s disease, prion disease, AMC

WHAT WE DIDN’T COVER...

Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Dissociative Disorders Feeding and Eating Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse-Control, and Conduct

Disorders Paraphilic Disorders

A NOTE ON PERSONALITY DISORDERS Criteria have not changed in DSM-5 but...

PDs have: Poor inter-rater reliability (except BPD) Poor stability over time Poor discriminate validity Poor clinical utility

Extensive work done on alternative approach Maintain 6/10 PDs (BPD, OCPD, APD, NPD, ASPD, SPD) Move from categorical to trait-based, dimensional classification system Captures nuances of human personality by measuring traits on

continuum

++ labour-intensive approach in the end with ++ pushback from psychiatric community ultimately voted down!

Available in Section 3 of DSM-5

DSM-5 TOP TEN1. DSM-5 is reorganized into a new series of chapters that either

reflect common clinical features or seem to fall in the same spectrum.

2. The multiaxial system has been eliminated. There is now no such thing as Axis II – personality disorders are considered in the same way as other categories.

3. With the elimination of Axis V, levels of functioning can be rated using scores of severity or disability.

4. The criteria for several categories have been expanded, which will probably lead to more frequent diagnosis.

5. The grief exclusion for diagnosis of major depression has been eliminated.

DSM-5 TOP TEN

6. Substance use disorders no longer distinguish between abuse and dependence.

7. Overly aggressive children can now be diagnosed with disruptive mood dysregulation disorder.

8. Autism spectrum disorder now captures both classical autism and Asperger’s disorder.

9. Dementias are now classified as neurocognitive disorders, rated by severity.

10.Somatic symptom disorders replace somatoform disorders and are classified differently.

CLOSING REMARKS

Have there been sufficient advances in the pathophysiologic, phenomenologic, and therapeutic understanding of mental illness to warrant a revised DSM?

Ultimate aim (in all of medicine) is to base diagnoses mostly on objective and, ideally, biologically measurable criteria psychiatry is still far from this goal

CHANGE WE CAN BELIEVE IN...

THANK YOU!

REFERENCES

American Psychiatric Association. Desk reference to the diagnostic criteria from DSM-5. American Psychiatric Publishing. 2013.

American Psychiatric Association. Highlights of changes from DSM-IV-TR to DSM-5. May 2013. http://www.dsm5.org/Documents/changesfromdsm-iv-trtodsm-5.pdf

Paris, J. The intelligent clinician’s guide to the DSM-5. Oxford University Press. March 2013.