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DSM-5: Implications for Practice

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Chris Cook

on 19 November 2013

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Transcript of DSM-5: Implications for Practice

DSM-5: Implications for Practice
Revision Principles
Neurodevelopmental Disorders
Bipolar Disorders
Eating Disorders
Binge Eating Disorder
Personality Disorders
Survey Says:
No Change!

Chris Cook, MDiv, MACC, LPCA

Louise Suggs, MACC, LPC, AASECT Certified Sex Therapist
Objectives
Highlight the underlying revision principles adopted for development of DSM-5

Review major diagnostic changes to DSM-5

Discuss how those differences affect DSM-5 changes and clinical implications
Optimize Clinical Utility
Research Basis for Diagnostic Categories
- Single Axis
- Field Tests Cut
Emphasis on Dimensionality
Continuity with Previous Editions
No a priori Limits to Change
Emphasize Role of Development
Rearrangement of Diagnostic Categories
Alignment with ICD-11
Increased Cultural Awareness and Consideration
OCPD and work/leisure values

Voodoo and speaking in tongues exempted as criteria for Schizoaffective Disorder
"Living Document"
"Mission Creep"
Diagnostic Changes
Assumes familiarity with DSM-IV-TR
Emphasizes differences in and implications of diagnostic categories and criteria
Schizophrenic Spectrum and Other Psychotic Disorders
Depressive Disorders
Sexual Disorders and Gender Dysphoria
Anxiety Disorders
Addictive Disorders
DSM-5 Assessment Tools
Derived primarily from category "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Includes:
- Intellectual Disabilities
- Communication Disorders
- Autism Spectrum Disorder
- Attention-Deficit/Hyperactivity Disorder
- Specific Learning Disorders
-Motor Disorders
-Other Neurodevelopmental Disorders
Intellectual Developmental Disorder
- Formerly Mental Retardation
- Severity is determined by function rather than IQ score
Autism Spectrum Disorder
Changes
Controversy!
Four Pervasive Development Disorders (Autism, Asperger's Syndrome, Childhood Disintegrative Disorder, PDD NOS) Integrated into
Autism Spectrum Disorder
- Research indicates no significant differences between PDD diagnoses aside from degree of severity

- Effort to improve accuracy in diagnosis
Not focusing on specifics of diagnostic criteria
Severity Scale
Level 1: Requiring Support
Level 2: Requiring Substantial Support
Level 3: Requiring Very Substantial Support
-Deficits in communication and social interaction, taking age, gender and culture into consideration

-Restrictive patterns of behavior, manifested by two (not three) criteria, including sensory criteria
Critique: Autism carries greater stigma than Asperger's Syndrome and less well known diagnoses
Critique: Those who carry a less well known diagnosis will lose treatment options due to placement in Level 1 category of severity
Critique: While severe cases are obvious, spectrum classification creates fuzzy areas between normalcy and mild severity
Critique: This diagnostic arrangement will increase the already skyrocketing levels of overdiagnosis
Real Limitations
There is a lot we still don't know:
- Cause: no biological markers have been discovered
- Whether this diagnosis represents one disease or many with similarities or overlap of symptoms
- The usefulness of changing to a spectrum-based diagnostic category
Attention-Deficit/Hyperactivity Disorder
Primary Change:

Age of onset increased from 7 to 12.
Critique: Later age of onset will significantly expand diagnosis
- High co-morbidity with mood disorders, substance use and personality disorders, all of which can cause attention problems on their own
- Adult ADHD is reported at 4.4% community prevalence
-Over treatment a concern
Changes
Elimination of subtypes - now some subtypes are specifiers (e.g. catatonia)
Increased threshold from one specified symptom to two
Biggest issue remains the same: differentiation between schizophrenia and bipolar

Differential diagnosis makes big difference in treatment approach, especially psycho-pharmacological treatment
Primarily to Schizophrenia Spectrum
Note that Bipolar Disorders and Mood Disorders have been separated in DSM-5
Diagnostic Changes: Minimal
Mixed episode removed: Replaced with "mixed features" as a specifier

"With anxious distress" added as a specifier
Major Change: Coding and Recording
If bipolar I disorder is suspected, determine the following related to the
current or most recent episode
:
1. severity
2. presence/absence of psychotic features
3. remission status
Diagnostic Flow Chart
Find Code
Determine Current/Most Recent Episode
In Remission?
Yes: Partial or Full
NO
With Psychotic Features?
Yes
No
Determine Severity
Major Change Areas
- Bereavement exception removed from MDD
- Addition of Disruptive Mood Dysregulation Disorder (DMDD
- Move Premenstrual Dysphoric Disorder (PMDD) from appendix to Section II
- Chronic depressive spectrum introduced
-Persistent Depressive Disorder (formerly Dysthymia) and Chronic MDD overlap on spectrum of chronic depression
Bereavement Exemption Removed
Grief
Major Depression
- Dominant affect: feelings of grief, loss

- Dysphoria occurs in waves, vacillates with exposure to reminders and decreases with time

- Capacity for positive emotional experiences

- Self-esteem preserved

- Fleeting thoughts of joining deceased
- Dominant affect is depressed mood


- Persistent dysphoria that is accompanied by self-critical preoccupation and negative thoughts about the future

- Limited capacity to experience happiness or pleasure

- Worthlessness clouds esteem

- Suicidal ideas about escaping life vs. joining a loved one
Critique: Removal of exemption will pathologize normal grief or expand the diagnosis
- Careful diagnosis necessary
Addition of Disruptive Mood Dysregulation Disorder
Critiques
What is it?
Rationale for addition:
- 40-fold increase in diagnosis of bipolar in children and adolescents
- Mood stabalizers are ineffective for many in this group that never developed adult bipolar disorder
- DMDD is thought to address this discrepancy

Essential Features:
-
Severe
temper outbursts with
underlying persistent
angry or irritable mood
- 3+ times a week for 12+ months occurring in at least 2 settings with onset between ages 6 and 10
- Little research to support this diagnosis

- Based on pragmatic need to fill a gap

- No empirically supported treatments
Applications
- Bipolar medications should be avoided

- CBT treatments used for depression may be helpful

- Curiously placed in with depressive disorders, instead of disruptive behavior disorders
- ODD symptoms are considered to be a feature of DMDD

- Use caution when diagnosing: most severe 15% of ODD clients would meet criteria
- May have been a premature addition

- Keep in mind the subjective nature of the diagnostic criteria, and the rationale for adding this disorder
Premenstrual Dysphoric Disorder
Difference between PMDD and PMS: clinically significant dysfunction and distress
Use caution in diagnoses so as not to pathologize normal symptoms
Clinical Significance:
- increased risk of postpartum depression
- increased risk of suicidal thinking, planning and gestures
- impact on quality of life and social functioning
- treatments:
- diet
- SSRI's
- CBT
Gender Dysphoria
Changed from GID
Terms are defined
Dysphoria versus Identity
Post-transition specifier
Elimination of language
Elimination of sexual orientation specifiers

Sexual Dysfunctions
Separate from paraphilias and gender identity
Combination of diagnoses
Gender specific diagnoses added
Structure simplified
Subtypes
Other Factors Considered
Other Changes
Posttransition Specifier
"A posttransition specifier has been added because many individuals, after transition, no longer meet criteria for gender dysphoria; however, they continue to undergo various treatments to facilitate life in the desired gender."
(Taken from "Highlights of Changes from DSM-IV-TR to DSM-5)
DSM-IV-TR
"a strong and persistent cross-gender identification," and "persistent discomfort with his or her sex or sense of inappopriateness in the gender role of that sex
DSM-5
"a marked incongruence between one's experienced/expressed gender and assigned gender" only if "the condition is associated with clinically significant distress or impairment"
Dr. Elizabeth Boskey stated that...
There seems to be this notion that gender is not determined by external physiological parts, but is more internal.

"Sexuality in the DSM"
Contemporary Sexuality - August 2013 (Volume 47, No. 7)
Dr. Boskey is an AASECT Certified Sexuality Educator & Certified Health Education Specialist
DSM-IV-TR
Hypoactive Sexual Desire Disorder (HSDD) (302.71)
Female Sexual Arousal Disorder (302.72)
DSM-5
Female Sexual Interest/Arousal Disorder (302.72 or F52.22)
DSM-IV-TR
Vaginismus (306.51)
Dyspareunia (302.76)

DSM-5
Genito-Pelvic Pain/Penetration Disorder (302.76 or F52.6)
Gender specific diagnoses
Male Hypoactive Sexual Desire Disorder (302.71/F52.0)
Female Sexual Interest/Arousal Disorder (302.72/F52.22)
Subtypes
generalized v/s situational
acquired v/s lifelong
Removed
psychological factors
combined factors
Other Factors Considered
partner factors
relationship factors
individual vulnerability
cultural religious factors
medical factors
DSM-IV-TR
Male Orgasmic
Disorder
DSM 5
Delayed
Ejaculation
Paraphilias
how and when client is diagnosed
Activities & Targets
New Specifiers:
"in full remission"
"in a controlled environment"
Changes are primarily organizational
Anxiety Related Disorders
Anxiety Disorders
OC, Stereotypic, and Related Disorders
Trauma- and Stressor-Related Disorders
Dissociative Disorders
Social Phobia
Social Anxiety Disorder
Panic Disorder
Agorophobia
Panic attack is now a specifier for a wide array of diagnoses
Selective Mutism
Separation Anxiety Disorder
Age of onset requirement dropped
Anxiety Disorders
Now contains "Performance only" specifier, which is given if anxiety is specific to speaking or performing in public
- Hoarding Disorder

- Excoriation (skin-picking) disorder

- Substance-/medication-induced OC disorder

- OC and related disorder due to another medical condition
RAD Subtypes
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
More closely related to depression
More closely related to ADHD and disruptive behavior
- Minor changes

- Petition to removed Dissociative Identity Disorder from DSM-5 was rejected
Posttraumatic Stress Disorder
Changes
Four symptom clusters instead of three, with avoidance/numbing cluster divided into (1) avoidance and (2) persistent negative alterations in cognitions and mood
Stressor criteria made more explicit
Subjective reaction at time of event criteria eliminated
Discussion
Critique: "Trauma" is itself a subjective construct, especially when people no longer have to feel traumatized at the time of the event
Critique: Clients can receive PTSD diagnosis even though symptoms are not related to event
Critique: Most individuals who experience severe trauma never develop PTSD, indicating that the issue is not trauma related, per se, but rather an underlying personality trait
Critique: Heterogeneity and dimensionality are also at issue with this diagnosis
Biggest, and most controversial, change in this category is the addition of Binge Eating Disorder
- Moved from appendix to Section II

- Rationale: many ED NOS would fit criteria for Binge Eating Disorder

- Change: two binges weekly for 6 months -> 1 binge weekly for the last 3 months
Critique
Symptoms are fairly common and may or may not represent a true mental disorder

Loosening of criteria may lead to overdiagnosis

Another example of "Mission Creep?"

More research needed to study boundaries between diagnoses
Primary Change
Substance abuse and substance dependence merged into a substance use disorder
Substance use disorder is a continuum of mild, moderate, and severe substance use
Critique
Concern that the reduced criteria (2/11 criteria) may be too low of a threshold
Some of the criteria are mild, not indicative of pathology, and/or misunderstood
Increase in substance use disorders diagnosis is likely to occur
Little distinction between different degrees of dysfunction (lifelong problems vs. relatively new concerns, for example) and normalcy
Gambling disorder replaces gambling in "Impulse-Control Disorders NES"
Critique: Is this the start of a slippery slope?
Internet addiction was proposed and rejected.
DSM-IV-TR
Premature Ejaculation
DSM-5
Premature Early Ejaculation
But...
DSM-5 offers an alternative diagnostic model
- meant to address shortcomings with present system

- based on a dimensional approach to diagnosis

- found in Section III of DSM-5
The direction to be taken is unknown
- Keep present model
- Move to alternate model
- Advance to proposed IDC-11 model
- Some fourth option

This category was "leading edge" in dimensional diagnosis before it was rolled back
DSM-5 offers an alternative diagnostic model
Level 1 and Level 2 Cross-Cutting Symptom Measures
- Designed to assess mental health domains that cut across diagnostic categories
- May be used to track symptom change over time
- Based on client report of symptoms over the previous two weeks
- Level 2 Measure is one way of gathering more in-depth information when needed
Clinician-Rated Dimensions of Psychosis Symptom Severity
World Health Organization Disability Assessment Schedule 2.0 (WHO-DAS 2.0)
- Suggested as an alternative for what the GAF score was supposed to accomplish in DSM-IV-TR
- Self-administered
- Assesses disability across six domains
Cultural Formulation Interview
"Historically, sexual orientation played a role in the treatment of transsexualism. A person born a man and attracted to women might not be allowed to transition because clinicians didn't want to create lesbians!...Today, sexual orientation not considered relevant to clinical decisions regarding transition..."
Dr. Jack Drescher, M.D.
Past President of the Group for the Advancement of Psychiatry
Member of the DSM-5 Workgroup on Sexual and Gender Identity Disorders
Set of questions used during an assessment that related to the impact of culture on key areas of clinical presentation
Brief, semi-structured interview
What do we do
as Christian therapists with these movements?
Effort to reduce misdiagnosis, obtain useful clinical information and improve therapeutic efficacy
HIGHLY CONTROVERSIAL
Full transcript