DSM 5: TOP 10 Changes Justin K. Hughes, MA, LPC, NCC

DSM 5:
TOP 10 Changes
Justin K. Hughes, MA, LPC, NCC
Contact
Justin K. Hughes, MA, LPC, NCC
www.JustinKHughes.com
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I. Brief History of DSM
1
• American Psychiatric Association (APA) began in 1844
–
–
Part of its focus was to gather stats on how prevalent mental illness
was
“Idiocy” and “Insanity” as key terms
• In 1917, the first uniform statistical reporting system was
developed, and titled the Statistical Manual for the Use of
Hospitals for Mental Diseases.
–
This was used throughout mental hospitals in the U.S.
• It was later expanded in 1952 into the Diagnostic and
Statistical Manual (the first DSM), later revised in 1968
(DSM-II).
–
These were both heavily impacted by psychoanalytic theories.
• Continued major changes were the publishing of the DSM-III
in 1980, the DSM-IV in 1994, and the newly released DSM-5
• Comparatively speaking, the World Health Organization’s
(WHO) International Classification of Diseases (ICD) is in
the prep stage for their 11th edition, due in 2015.
–
–
–
This manual is used for all medical diagnoses
Began circulation in late 1800’s
Consistently being updated and revised
• As research and science advances in the realm of both
medicine and mental health, having diagnostic manuals that
unify such information is crucial.
• Dr. Dilip Jeste, current President of the APA, notes
challenges inherent in developing such a manual for
psychiatric diagnosis:
–
“The primary criterion for any diagnostic revisions should be strictly scientific
evidence. However, there are sometimes differences of opinion among scientific
experts. At present, most psychiatric disorders lack validated diagnostic
biomarkers, and although considerable advances are being made in the arena of
neurobiology, psychiatric diagnoses are still mostly based on clinical
assessment” (Jeste, 2012)
II. The Basics of the DSM-5
•
The Diagnostic and Statistical Manual of
Mental Disorders, 5th Edition (DSM-5),
released on May 18th at the APA World
Conference
•
14 year process (first discussions began in
1999)
•
Classification of Disorders aligned to the ICD,
improving communication between mental
health and medical providers
•
Change made from Roman numeral (i.e., V)
to Arabic (5) in order to help with searchability
in a more technological age, allowing for
updated editions to be numbered as 5.1, 5.2,
etc. This manual is seen as a “‘living
document,’ adaptable to future discoveries in
neurobiology, genetics, and epidemiology”
(APA, 2013b, p. 13)
2
III. Structure and Organization
• Disorders are organized based on apparent
relatedness to each other
• “Lifespan” or “developmental” approach,
attempted to arrange disorders more likely to
begin in childhood first and so forth
• Sections
•
•
•
•
•
Contents
Section I: Introduction and Use of the Manual
Section II: Diagnostic Criteria and Codes
Section III: Emerging Measures and Models
Appendix
• Extended Cultural information in Section III
• Gender-specific symptoms & information added
• NOS (Not otherwise specified) designation
replaced with two options:
• Other specified disorder (specific reason given)
– Aka, if someone comes into an emergency room with
psychotic features, the reason for this may not be clear
(drugs, schizophrenia, etc.)
– Allows greatest specificity without needing a full
diagnosis
• Unspecified disorder (categorized, but no specific reason)
– Gives clinician flexibility based on their judgment
– Like NOS before
• Online
– Find out about continued updates at:
www.dsm5.org
or
www.psychiatry.org/dsm5
– Online assessments available at:
http://www.psychiatry.org/practice/dsm/dsm5/onlineassessment-measures
– Online subscription has modules and assessment tools
BIG Change #1:
Dimensional Assessments
• Shift in focus from a categorical, yes/no
model in two significant ways:
1) Spectrum of severity considered for some
disorders
2) Chapter structure based on apparent
relatedness and development by age
1) Indicators of Severity were minimal with
former DSM’s
– Some specifiers with MDD (mild, moderate,
severe w/ and w/o psychosis), for example, but
few other disorders
• Little specificity of improvement, either
– Now, numerous severity levels and added
specifiers:
•
•
•
•
•
•
Autism Spectrum
Psychotic Disorders
Anorexia and Bulimia
Insomnia Disorder
Substance Use Disorder
And more
2) Structural problems in basic design
created too narrow diagnostic categories
– Seen in practice and research
• Need for substantial number of NOS diagnoses
– Found to be the majority of diagnoses with eating,
personality, and autism spectrum disorders
• Studies on comorbidity, genes, and environmental
risk factor studies
Rationale
Former manuals were categorically narrow
– Apparent from widespread NOS usage
– Disorders commonly share symptoms and risk factors
“…Like most common human ills, mental disorders are
heterogeneous at many levels, ranging from genetic risk
factors to symptoms” (APA, 2013b, p. 12) .
– Beginning attempt based on some research to order
chapters with connection to another
• Bridge to research further (aka, what connection does OCD have
with anxiety disorders, but how is it different?)
• Not enough scientific evidence for alternate definitions now
• DSM 5 notes that the grouping of disorders “is intended to enable
future research to enhance understanding of disease origins and
pathophysiological commonalities between disorders.” (APA,
2013b, p. 12-13)
Rationale
• Interconnectedness
– Connection between various mental health
issues, medical, psychosocial issues, etc., is
made throughout the manual (Dropping the
use of Axes I-V is part of this)
Rationale
• Clinical benefits
– Narrow categories constricted range of
information and could affect treatment planning
and outcomes
• I.e., Is someone improving from severe to moderate?
• I.e., Clarity on level of disruption.
– Getting more specific
• Dropping NOS in hopes to decrease “catch-all”
diagnoses
– Major categories are still kept, minimizing
disruption in clinical practice (APA, 2013c;
APA, 2013b, pp.12-13)
BIG Change #2:
Removal of Axes
• The multiaxial system will no longer
be used (Axes I-V)
• Axes I – III combined (diagnoses and
physical conditions)
– Medical conditions are to still be listed when it
is important to the understanding and
management of mental disorder(s)
• Axes IV and V covered by separate
notations (noting situational context and
disability)
– Psychosocial and environmental problems will
be noted using a selected set of codes from the
ICD (V codes- and new Z codes in 10th edition)
– As noted, severity level will be noted with many
disorders
– GAF will not be used
Rationale
• Not required to make a mental disorder
diagnosis
• All relevant information is still to be noted,
but not separated from each other
• Seeks to encourage the interrelation
between mental disorders, medical
conditions, and various psychosocial,
contextual, and behavioral factors
Rationale
• GAF
– “conceptual lack of clarity” and “questionable
psychometrics in routine practice” (APA,
2013b, p. 16)
– The WHO Disability Assessment Schedule
(WHODAS) now included in Section III
• Encouraged to be used to measure disability level
• Encouraged to be researched further
Billing, insurance, and charting
implications to be covered later
IV. Clinical Changes
Section II Chapters
Neurodevelopmental
Disorders
Schizophrenia Spectrum
and Other Psychotic
Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and
Related Disorders
Trauma- and StressorRelated Disorders
Dissociative Disorders
Somatic Symptom and Related
Disorders
Feeding and Eating
Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse-Control,
and Conduct Disorders
Substance-Related and
Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Mental Disorders
Medication-Induced Movement
Disorders and Other Adverse
Effects of Medication
Other Conditions That
May Be a Focus of
Clinical Attention
BIG Change #3:
Autism Spectrum Disorder
• Autism Spectrum Disorder
– Asperger’s is OUT!
– Criteria now encompasses 5 diagnoses:
•
•
•
•
•
Autism
Asperger’s
Childhood Disintegrative Disorder
Pervasive Developmental Disorder NOS
Rett’s Disorder
• 2 Components Required:
• 1) Deficits in social communication and
interaction
• 2) Restricted repetitive behaviors, interests,
and activities (RBBs)
[Social Communication D/O is diagnosed if #2 is not present]
Rationale
• Scientific consensus on varying levels of
symptom severity, but the same condition
• Various PDD related diagnoses not
consistently applied across practices and
treatment centers
– Often due to common characteristics. (APA,
2013a; APA, 2013c)
Rationale
– Allows clinicians to acknowledge
variations in ASD from person to person
– Symptoms must now be evidenced in
early childhood
• Attempts to encourage earlier recognition
(within 1-2 years if possible)
• If ASD is not realized until beyond
childhood, it can still be diagnosed, but only
if there is prior criteria
Rationale
– “Anyone diagnosed with one of the four
pervasive developmental disorders
(PDD) from DSM-IV should still meet the
criteria for ASD in DSM-5 or another,
more accurate DSM-5 diagnosis.” (APA,
2013a)
– DSM-5 criteria was tested in real-life
clinical settings (field trials)
• No significant changes on prevalence of the
disorder were found. (APA, 2013a)
BIG Change #4:
Depressive Disorders
• Two additional diagnoses:
– Disruptive Mood Dysregulation Disorder
(DMDD)
• Children up to 18 years with persistent irritability and
frequent extreme behavioral outbursts.
• Without changes in mood
• Additional information to differentiate from
Oppositional Defiant Disorder
– Premenstrual Dysphoric Disorder (PMDD)
• Previously in the appendix of DSM-IV
• Mood lability, anxiety, irritability, and dysphoria that
occurs consistently; more extreme than premenstrual
syndrome (PMS)
• Elimination of “bereavement exclusion”
– Previously, after the death of a loved one,
clinicians were encouraged to refrain from
diagnosing MDD within the first two months
• Added specifiers (working on a spectrum)
– “With anxious distress”
– Notes presence of significant anxiety that affects the
chronic nature of the diagnosis
– “With mixed features”
– Symptoms of mania in depressed patients (or
symptoms of depression in Bipolar patients)
– Insufficient for criteria of a manic or depressed
episode
Rationale
• “Bereavement exclusion”
– Grief does not protect someone from Major
Depression
– A detailed note is given, calling for clinical
judgment to distinguish normal grief/loss and
an actual mental disorder
• Based on individual history and cultural norms
– Prevents overlooking MDD
• Offers the opportunity for treatment when needed,
even if someone is grieving
• The death of a loved one can precipitate Major
Depression, as can other stressors (APA, 2013d;
APA, 2013b, p. 161)
Rationale
• DMDD
– Seeks to address over-diagnosis and
treatment of Bipolar in children
– Brain imaging reveals differences
between Bipolar and DMDD (Moran,
2013a)
• PMDD
– “Strong scientific evidence” leads to its
full inclusion (APA, 2013c)
BIG Change #5:
OCD and Company
• Obsessive Compulsive and Related
Disorders
– OCD gets its own chapter
• No longer under Anxiety disorders
– NEW: Hoarding is considered a
diagnosis in its own right.
– NEW: Excoriation (Skin-picking)
Disorder
– Other NEW:
– Substance/medication-induced obsessivecompulsive and related disorder
– Obsessive-compulsive and related disorder due
to another medical condition
– Trichotillomania (hair-pulling disorder)
• No longer under impulse-control disorders
– Body dysmorphic disorder
• No longer listed as somatoform
– Refining of insight specifiers for all
conditions
– Formerly only “with poor insight”
• Now includes 3 distinctions:
– “With good or fair insight”
– “With poor insight”
– “With absent insight/delusional beliefs”
Rationale
– Grouping of disorders based on
increasing evidence of the relatedness
of these disorders
• Diagnostic validators
• Similar clinical features
– Obsessive preoccupation & repetitive behaviors
• Often runs in families; some are comorbid
– Hoarding gets separate D/O as research
shows it functioning distinctively and
needing distinct treatments from OCD
(APA, 2013b, pp. 811-812; Moran, 2013a;
APA, 2013e)
BIG Change #6:
Personality Disorders
• Personality Disorders
– The Big Change is that the Categories
and Criteria didn’t change
– However, expect changes in the future
• Section III has an “Alternative DSM-5 Model
for Personality Disorders”
• Meant to encourage further study in
diagnosing personality disorders in clinical
practice
• “Dimensional model” suggested
• Needs further research
• Attempting to avoid great overlap of
symptoms and overuse of NOS
• Consider seeing these problems on a
continuous spectrum
– E.g., Blood pressure and hypertension
• Scale used to measure level of impairment
– Also, removal of Axis II takes away
arbitrary boundaries between mental
and personality disorders
Rationale
– Attempt to reflect the patient versus
apparent preconceived categories
– During field trials, the new model was
“well received”
– Attempts to be a simpler approach
(Moran, 2013b; APA, 2013b pp. 816; 761-781)
Rationale
– Current model can be “concise” and “too
rigid to fit patients’ symptoms” (APA, 2013f)
• Original work of DSM-5 workgroups ended
up with too complex of a model.
• Now suggested is a hybrid approach
evaluating impairments in:
– Personality functioning (how a person
experiences self and others)
– Five broad pathological personality traits
» Negative Affectivity, Detachment,
Antagonism, Disinhibition, and Psychoticism.
• Would retain only 6 types of PDs (plus an
unspecified diagnosis)
Rationale
– Support diagnosis and care of patients
– Greater understanding of personality
disorder causes and treatments (APA,
2013f)
BIG Change #7:
Trauma & Stressor Related
• Trauma and Stressor-Related
Disorders
– Further expansion of addressing
trauma’s impact by giving it its own
chapter; separate from anxiety disorders
– Developmental sensitivity to recognize
that such disorders can be developed
earlier than previously considered
• PTSD will expand from three diagnostic
categories to four:
–
–
–
–
Re-experiencing
Avoidance
Negative Cognitions and Mood
Arousal
• Specifiers of dissociative symptoms added
• Diagnosis can be made for children 6 and
younger
• Differentiation between Acute and Chronic PTSD
eliminated
• Reactive Attachment Disorder now included in
this chapter
• Adjustment Disorders
– Requires exposure to a distressing event, not just a
category of diagnosis when there is no other fit
Rationale
– Tighter line drawn in defining a traumatic event
and the requirement that the disorder may be
diagnosed when following such an event
– Rationale provided was minimal (APA, 2013h)
BIG Change #8:
Substance Use Disorder
• Substance Abuse and Dependence
will be combined under one name
– Under DSM-IV, one symptom was
needed to diagnose substance abuse.
– Now, two symptoms are required to
diagnose the most mild form
–
–
–
–
0-1
2-3
4-5
6+
No Diagnosis
Mild
Moderate
Severe
– Same symptom criteria used except:
• Legal problems dropped
• Craving added
Rationale
– Diagnosis of “dependence” created much
confusion
• “Addiction” was seen as one-and-the-same with
dependence by many people.
• Dependence can be a normal bodily response to a
substance
Rationale
– Research reviewed indicated substance
problems fit better on a continuum of severity
• “Eliminating the category of dependence will better
differentiate between the compulsive drug-seeking
behavior of addiction and normal responses of
tolerance and withdrawal that some patients
experience when using prescribed medications that
affect the central nervous system” (APA, 2013g)
– According to APA, the diagnosis is also
“strengthened.”
• Clinically, those who fell in the abuse category could
be severe, even though it was formerly seen as a
milder phase (APA, 2013g)
The Real Meth Makeover
BIG Change #9:
Gambling Disorder
– Significant Shift in focus on
behavioral addiction
• “Sole condition in a new category on
behavioral addictions.” (APA, 2013g)
Rationale
– Substance and addictive disorders
reveal strong similarities:
• Shared behavior, neurocircuitry, clinical
expression, comorbidity, physiology, and
treatment
Rationale
– “The idea of a non-substance-related addiction may be
new to some people, but those of us who are studying
the mechanisms of addiction find strong evidence from
animal and human research that addiction is a disorder
of the brain reward system, and it doesn’t matter whether
the system is repeatedly activated by gambling or
alcohol or another substance,” said Charles O’Brien,
M.D., chair of the DSM-5 Work Group on SubstanceRelated and Addictive Disorders, Moran, 2013c)
– Assist in helping secure treatment and services
needed
– Help others understand challenges inherent
with treating behavioral addiction
– Internet Gaming Disorder is in Section III
Additional Noteworthy Changes
(Organized by Chapter Order )
• Term mental retardation changed to intellectual disability
• ADHD sees several changes
– Added examples, age of onset moved from 7 to 12 y/o, subtype
specificity added, comorbid diagnosis with ASD now allowed,
and only 5 criteria required for adult diagnosis
• Specific Learning Disorder
– Combines Former Diagnoses into 3 subtypes (dropping NOS)
• Reading disorder
• Mathematics disorder
• Disorder of the written expression
• Learning disorder NOS
• Schizophrenia conceptualized on a spectrum
– Changes to Criterion A
• 1) Elimination of 1-symptom requirement when delusions were bizarre or
auditory hallucinations had two or more voices
• 2) Requires 2 out of 5 symptoms, with 1 out of 3 “positive” sx (hallucinations,
delusions, or disorganized speech
– Subtypes eliminated
• Paranoid, disorganized, etc.
• Dimensional approach taken in Section III under Assessments
• Delusional Disorder
– No longer requires nonbizarre delusions to be diagnosed
• Catatonia
–
–
Can be a specifier (i.e., with depression, bipolar, etc.)
Can be used on its own in an Other Specified Diagnosis
• Bipolar disorders add criteria:
–
Changes in activity or energy, not just mood
• Persistent Depressive Disorder (name change from
Dysthymia)
–
To be coded alongside MDD when both are present
• Panic Attack Specifier added
– This can be used to supplement any diagnoses
• E.g., “Posttraumatic Stress Disorder with Panic Attacks
• Panic Disorder and Agoraphobia are un-linked
– Two separate diagnoses with separate criteria
• Separation Anxiety Disorder & Selective Mutism
– Now considered anxiety disorders
• Dissociative Disorders
–
A few technical changes
• Somatoform Disorders now Somatic Symptoms and Related
Disorders
– Reduction in number of disorders and subcategoriesattempting to reduce overlap
• Chapter on Somatic Symptoms takes away key focus of
unexplained medical symptoms as a requirement
• Somatic Symptom Disorder
– Replaces Somatization Disorder, noting there are maladaptive
behaviors and thoughts defining the disorder
– Undifferentiated Somatoform Disorder merged under this
• Former Hypochondriasis as Illness Anxiety Disorder:
– When they have anxiety over their health without somatic
symptoms
– Unless better explained by another primary anxiety disorder
• Conversion Disorder (Functional Neurological Symptom
Disorder)
– Focuses on essentiality of a neurological examination and that
psychological factors at the time of diagnosis may not be
demonstrable
• Feeding and Eating Disorders
–
Includes several formerly seen in disorders of “Infancy and Early
Childhood”
•
–
I.e., Pica and Rumination Disorder
Feeding Disorder now Avoidant/Restrictive Food Intake Disorder;
criteria sees additional factors
• Anorexia Nervosa
–
Relatively unchanged; requirement is eliminated for amenorrhea
• Bulimia Nervosa
–
One change: Binge eating’s minimum average frequency along with
compensatory behavior- now once weekly (formerly twice weekly)
• Binge Eating Disorder- NEW
– No longer under further consideration
• Primary Insomnia renamed to Insomnia Disorder and other
various changes in Sleep-Wake Disorders chapter
• Sexual Dysfunctions sees a combination of some disorders,
some change in duration and severity
• Sexual Aversion Disorder removed
• Gender Dysphoria
– Formerly “Gender Identity Disorder”
• Reflects distress over incongruence between assigned and
expressed/experienced gender 4
• Posttransition specifier added
• New chapter of Disruptive, Impulse-Control, and Conduct
Disorders
• Three types grouped for Oppositional Defiant Disorder:
• Angry/irritable mood
• Argumentative/defiant behavior
• Vindictiveness
• Intermittent Explosive Disorder now allows verbal
aggression and non-destructive physical aggression
• Cannabis Withdrawal and Caffeine Withdrawal- NEW
• Caffeine Use Disorder is not included and was placed in
Section III
• Major Neurocognitive Disorder (NCD) now includes
dementia and amnestic disorder
– Mild NCD is a NEW disorder, acknowledging a lower threshold
with concerns of cognitive impairment
– NCD’s include etiological subtypes
• Distinguishing b/t Paraphilias (aka, atypical, but not
disordered behavior) and a Paraphilic Disorder
– Two keys: 1) must be distressing or impair functioning OR 2)
involves non-consenting individuals
– Added specifiers of “in a controlled environment” and “in
remission”
• Disorders Not Accepted
– Didn’t make the “cut”; not accepted in
Sections 2 or 3
• Anxious Depression
• Hypersexual Disorder (aka, Sexual
Addiction)
• Parental Alienation Syndrome
• Sensory Processing Disorder
• Conditions for Further Study (Section III)
• Attenuated Psychosis Syndrome
• Depressive Episodes w/ Short-Duration
Hypomania
• Persistent Complex Bereavement D/O
• Caffeine Use Disorder
• Internet Gaming Disorder
• Neurobehavioral Disorder Associated w/
Prenatal Alcohol Exposure
• Suicidal Behavior Disorder
• Nonsuicidal Self-Injury
Disclaimer on Changes
• There are MANY small changes and
nuances
–
–
–
–
–
Name changes
Specifier changes
Age cutoffs
Textual changes
More
• Be careful to check out the new
manual to verify diagnoses you use!
– (APA, 2013b)
V. Concerns
What’s At Stake: Overview
• Practically, everyone who has a connection to the
DSM is at least a little upset
– Arguments are being given on every side
– Treatment areas most of us are dedicated to working in
have either seen change or lack of inclusion
• Technical impact
–
–
–
–
–
Institutions will have to change approaches
Insurance may no longer cover certain diagnoses (or now cover ones
formerly not included)
Time spent developing change
Possible increased social stigma and/or discrimination for some
populations
Obtaining health insurance
• Clinical and research purposes heavily rely upon
the DSM
– Many journals require studies to be based on DSM
classifications
• Greatly influences:
– Insurance companies in disorders that are covered
– How clinical trials will be designed by pharmaceutical
companies
– Which research ultimately is funded
– Huge influence on the $113 Billion a year the US spends
on mental health treatment
• Conversations held between ICD and DSM imply
the monumental importance that the DSM 5 will
have in the upcoming ICD-11- slated for a 2015
release. (Mestel, 2012)
– Impacting the medical world and vice versa
What’s being said: You Decide
• Dr. Frank Farley of Temple University
• DSM “overmedicalizes human
distress” (Temple University, 2012)
• Geraldine Dawson from Autism Speaks
•
Expressed unease that with the changes to Autism and Aspergers,
“We want to make sure that no one is excluded from obtaining a
diagnosis and accessing services who needs them” (Sederer, 2012)
•
However, she generally expressed “cautious optimism.”
• A basic web search reveals extensive
commentary and lots of concern.
– With the availability of sharing opinions so broadly
with the Internet and social media, “everyone’s an
expert.”
– LA Times notes, “The DSM-5 panel has been
accused of overdoing it and underdoing it, and you
can get more of a sense of that by scrolling around
on the DSM-5 website” (Mestel, 2012).
• Allen Frances, M.D.
– Possibly the most outspoken critic
– Chair of the DSM-IV task force, Professor
Emeritus at Duke University, Psychiatrist,
Author
• “This is the saddest moment in my 45 year
career….” The DSM-5 is “deeply flawed”
with “many changes that seem clearly
unsafe and scientifically unsound.”
• “My best advice to clinicians, to the press,
and to the general public– be skeptical and
don’t follow DSM-5 blindly down a road
likely to lead to massive over-diagnosis and
harmful over-medication” (Frances, 2012)
– Challenges unrealistic goals and excessive
ambition
– Notes > 50 mental health associations petitioned
an outside review for independent judgment
– Believes massive misdiagnosis will result
– Argues that the task force has fallen into conflicts of
interest intellectually (not financially)
– States that DSM-5 was rushed to the press to avoid
pushing back deadlines further and for the sake of
meeting budgetary goals
10 “Worst Changes”:
(According to Frances)
1) DMDD will mean temper tantrums = mental disorder
– Work of one research group
– Notes the risk of psychiatric fads; within the past 20 years
seeing 3x ADD, 20x increase in Autism, and 40x more children
with Bipolar
• Believes this is a poor track record
– Exhorts education for clinicians and the public about difficulties
inherent in diagnosing children and risks of over-medication
2) Normal grief will = MDD
– Worries that pills will be used instead of deep connections
3) Forgetfulness of old age to be seen as Minor Neurocognitive
Disorder
– Creating false positives (aka, crying wolf)
– No effective treatment, thus no benefit
4) Fad likely for Adult ADD
– Misuse of stimulants to result
5) Excessive Eating = Binge Eating Disorder
6) ASD definition will result in lowered rates and disruption of
services
– Argues 10-50 percent may lose diagnosis
– Notes it is not a bad decision, other than being misleading
7) All substance abusers will be in the same category as
addicts
– Stigma
8) Behavioral addictions is seen as a slippery slope to see as a
mental disorder what people like to do frequently
– Cautions careless overdiagnosis and development of lucrative
treatment programs
9) Minor changes to definition of GAD could create “millions” of
newly ill people with mis-prescribing of meds
10) Offers more opportunity in forensic settings for
misdiagnosis of PTSD (Frances, 2012)
Example of one challenge
• Disruptive Mood Dysregulation Disorder begins to
“medicalize” temper tantrums
– A study from NIH stated diagnostic usefulness was
questionable (Axelson, et. al, 2012)
– DSM-5 notes its benefit
– Allen Frances argues strongly against it
– Other critics will find it as a help to decrease
overtreatment of Bipolar in children
Middle Child Syndrome
• “The moment he
realized he was
now the middle
child.”
-Reddit
VI. How Do I Implement?
BIG Change #10:
Billing, Insurance, and Coding
• When does the DSM transition
happen?
– Immediately!
• DSM 5 is completely compatible with the
ICD-9-CM coding system now in use
• Note: due to change from multi-axial
system, there may be a delay while
insurance updates claim and reporting
procedures
• DSM-5 acknowledges it will take
some time to transition
– If your agency requires the use of the
multiaxial system or anything DSM-IVTR related, you may default to this
– Any data that is the focus of treatment
may be coded (Disorders, relevant
medical concerns, V codes, and levels
of severity), and they may be entered
into the client’s record
Dates!
• October 1, 2014
– U.S. adopts ICD-10-CM
• These codes are in parentheses (and grey
vs. black ink) in the manual
• December 31st, 2013
– Full transition expected with the DSM-5
– APA is working with insurance industry
• TBD
–
–
–
–
Insurance claim forms
Reporting procedures
Insurance determinations
Variation in agencies
• Follow your agency’s requirements (APA,
2013i)
• Some Disorders and Subtypes share
the same diagnostic code
– What the heck?
• Since the codes in the DSM right now are
limited to the ICD, this is for recording and
billing purposes, though APA will seek
separate codes
– Always record the name in the medical
record to avoid confusion
• E.g., Hoarding and OCD, 300.3
• E.g., DMDD uses the code 296.99 (formerly
• Time for a first step check-in!!
– “We admitted we were powerless
over DSM-5, that our lives had
become unmanageable.”
Suggestions For Keeping Your Edge
• Sit Down With The New Manual
 Identify diagnoses / categories you regularly utilize
Note Changes and have readily available as a reference
 Ask yourself, “What are my responsibilities for the work I
do?”
• Simplify! If there are diagnoses and categories
outside of your work, leave them for the realm of
discussion over coffee
 Use the change as an opportunity to stay fresh
 Use this as an opportunity to re-examine or newly
examine what is really going on for clients- beyond just
fitting them in a comfortable category
• Making Change for today forward
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Remember, clinicians, researchers, and leaders in the medical field
had influence in the development of the DSM 5.
How might you be involved in changing that which needs change?
Even the general public was allowed to offer comments on the DSM 5and they were reviewed and considered.
• Not having a DSM diagnosis has not stopped treating OR
considering “outside issues.”
– I.e.,
• Seasonal Affective Disorder
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•
•
•
•
•
Not a Disorder in its own right- in the eyes of the DSM, but is actually related to a mood
disorder specifier
Sexual Addiction or behavioral addictions
Attachment Disorders
Adoption-related issues
Codependency
Alcoholism
• Work within the parameters you have
– If a person presents with an issue that is not diagnosable,
remember what might apply
• Consider, for instance, when someone comes for help due to relationship
problems. Many times, they may be exhibiting a disorder for anxiety, mood,
substance use, AD/HD, or any other number of issues, not even touching on
whether Adjustment Disorder covers it
– Don’t forget Other Specified Disorder and Unspecified Disorder
• While looking realistically at what you can do (paying
attention to the good, the bad, and the ugly), look at what
the DSM does do:
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Offers a common language
Pursuit of legitimizing care and treatment
Develops set criteria so as to have a common base for research
Lets us have a really, really thick book on our shelves so we look
smart!
• Remember limitations
– Despite brain imaging data and genetic research, there are
major gaps between these and clinical relevance
– There are few biomarkers to lean on in diagnosis
– Classification systems in the DSM are mostly based on criteria
of psychopathology, i.e., collective studies on factors of mental
health (Hebebrand, J. and Buitelaar, J., 2011)
– Researcher Christof Koch notes the brain is “the most complex
object in the known universe.” Understanding it is not simple.
– APA President, Dr. Jeste gives due caution: “It should be
noted, however, that DSM is not a treatment manual and that
diagnosis does not equate to a need for pharmacotherapy”
(Jeste, 2012).
• Reality of Uncertainty
– Despite science, we just don’t know it all!
– We can’t know the effects yet of insurance billing, grants, etc.
• Remember to be proactive- ACTIVE
coping!
• Model the same resiliency, flexibility,
and serenity with which you might
challenge a client
VII. Q & A
References
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American Psychiatric Association. (2010). APA Announces Draft
Diagnostic Criteria for DSM-5 [Press Release]. Retrieved from
http://www.dsm5.org/newsroom/pages/pressreleases.aspx
American Psychiatric Association (APA). (2013a). Autism Spectrum
Disorder. Retrieved June 3rd, 2013, from
http://www.psychiatry.org/dsm5
American Psychiatric Association (2013b). Diagnostic and Statistical
Manual of Mental Disorders (5th ed). Arlington, VA: American
Psychiatric Association.
American Psychiatric Association (APA). (2013c). Highlights of
Changes from DSM-IV-TR to DSM-5. Retrieved June 3rd, 2013, from
http://www.psychiatry.org/dsm5
American Psychiatric Association (APA). (2013d). Major Depressive
Disorder and the “Bereavement Exclusion.” Retrieved June 3rd, 2013,
from http://www.psychiatry.org/dsm5
American Psychiatric Association (APA). (2013e). Obsessive
Compulsive and Related Disorders. Retrieved June 3rd, 2013, from
http://www.psychiatry.org/dsm5
American Psychiatric Association (APA). (2013f). Personality
Disorders. Retrieved June 3rd, 2013, from
http://www.psychiatry.org/dsm5
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American Psychiatric Association. (2009, June 29). Response to Frances
Commentary on DSM-V [Press Release]. Retrieved from
http://www.dsm5.org/Newsroom/Documents/
American Psychiatric Association (APA). (2013g). Substance-Related and
Addictive Disorders. Retrieved June 3rd, 2013, from
http://www.psychiatry.org/dsm5
American Psychiatric Association (APA). (2013h). Posttraumatic Stress
Disorder. Retrieved June 3rd, 2013, from http://www.psychiatry.org/dsm5
American Psychiatric Association (APA). (2013i). Insurance Implications of
DSM-5. Retrieved June 3rd, 2013, from http://www.psychiatry.org/dsm5
Axelson, D., et. Al. (2012). Examining the proposed disruptive mood
Dysregulation disorder diagnosis in children in the Longitudinal Assessment
of Manic Symptoms study. Journal of Clinical Psychiatry, 73(10), 1342-50.
Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23140653
Frances, Allen. (2012, December 3). DSM-5 Is a Guide, Not a Bible: Simply
Ignore Its 10 Worst Changes. Retrieved from
http://www.huffingtonpost.com/allen-frances/dsm-5_b_2227626.html
Grohol, Psy.D., John M. (2012, December 2). Final DSM 5 Approved by
American Psychiatric Association. Retrieved from http://psychcentral.com
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Hebebrand, J., Buitelaar, J. (2011). On the way to DSM-V, European Child
& Adolescent Psychiatry, 20(2), 57-60. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038228/#CR1
Jayson, Sharon. (2012, December 9). Psychiatrist approve vast changes to
diagnosis manual. Retrieved from
http://www.usatoday.com/story/news/nation/2012/12/01/psychiatristschanges-diagnosis-manual/1739301/
Jeste, M.D., Dilip (2012, December 1). A Message from APA President
Dilip Jeste, M.D., on DSM-5, Psychiatric News, from
http://www.psychiatry.org/dsm5
Kliff, Sarah. (2012, December 17). Seven facts about America’s mental
health-care system. Retrieved from http://www.washingtonpost.com
Mestel, Rosie. (2012, December 9). Changes to the psychiatrists’ bible,
DSM: Some reactions. Retrieved from http://articles.latimes.com/
Moran, Mark (2013, February 15). DSM-5 Updates Depressive, Anxiety,
and OCD Criteria. Psychiatric News, from http://www.psychiatry.org/dsm5
Moran, Mark (2013, February 15). DSM Section Contains Alternative Model
for Evaluation of PD. Psychiatric News, from
http://www.psychiatry.org/dsm5
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Moran, Mark (2013, April 19). Gambling Disorder to Be Included in
Addictions Chapter. Psychiatric News, from http://www.psychiatry.org/dsm5
Sederer, M.D., Lloyd I. (2012, February 6). The DSM-5: Will it Work in
Clinical Practice? Retrieved from http://www.huffingtonpost.com/lloyd-isederer-md/dsm-5_b_1256123.html
Temple University. (2012, December 4). Nation’s psychiatrists rework
diagnostic manual [Press Release]. Retrieved from
http://news.temple.edu/in-the-media/nation%E2%80%99s-psychiatristsrework-diagnostic-manual
Contact
Justin K. Hughes, MA, LPC, NCC
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