DSM-5 OVERHAULWHAT’S IN, OUT, AND RELEVANT IN THE GP’S WORLD
Presented by Jaana Kastikainen, MD, FRCPCSMH General Practitioner RoundsMarch 31, 2015
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
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
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
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
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.