DSM-5

David Mays, MD PhDdvmays@wisc.edu

A Brief History of the Diagnostic and Statistical Manual

• DSM-I was introduced in 1952, an evolution of a system developed by military psychiatrists. It was issued in conjunction with ICD (International Classification of Disease). Both were medical models of disease. The American Psychiatric Association held the franchise. No one else wanted it.

DSM I History

• The APA sent questionnaires to 10% of its membership and asked for suggestions. Three categories were set up: organic brain syndromes, functional disorder, and mental deficiency. The descriptions were very vague, and based on the theoretical orientation of a handful of academic psychiatrists.

DSM II

• DSM-II was introduced in 1968. Neither DSM-I or DSM-II had much impact on mental health practice.

On Being Sane in Insane Places• In February 1969, David Rosenhan (a

psychology professor) went to a psychiatric hospital in Pennsylvania, complaining that he heard the words “empty”, “thud”, and “hollow.” He had no other symptoms. He was immediately admitted to this hospital and diagnosed with schizophrenia. Over the next 3 years, seven of his friends and students repeated the same exercise in 11 other hospitals. They were medicated and held in hospitals between 8-52 days. The resulting book claimed that psychiatrists had no valid way to diagnose mental illness.

DSM-III

• DSM-III, in 1980, introduced the use of “criteria sets,” and operationalized diagnosis. The DSM became a guideline for insurance coverage.

• DSM-III-R (1987) and DSM-IV (1994) and DSM-IV-TR (2000) continued this tradition, emphasizing empirical evidence to justify diagnosis.

Problems with DSM-IV• 1) Problems with frequent comorbidities:

anxiety/depression, antisocial/ADHD/substance abuse, personality disorders

• 2) Discrete categories vs. spectrum disorders • 3) Increased use of the NOS category. There

are no criteria for an NOS category.

DSM-5: “Repair the plane while keeping it flying.”

• DSM-5 represents the first major overhaul in 30 years. But you can’t just start over.

• DSM-5 is due for publication in May 2013. Presumably, there will be a print version and an electronic version that will be continually updated (DSM 5.1, 5.2, etc..)

Controversies

• Who owns it? Non-psychiatrists are disgruntled

• Is it too revolutionary? There are objections to removing diagnoses (Asperger’s) and making fundamental changes in process (substance use disorders.)

• Is it revolutionary enough? Where’s the biology?

The Process• A DSM-5 Research Planning Conference was held in 1999

(before DSM-IV-TR). Six workgroups were formed:– Nomenclature– Neuroscience and Genetics– Developmental Issues and Diagnosis– Personality and Relational Disorders– Mental Disorders and Disability– Cross-Cultural Issues

• Three other groups included:– Gender– Geriatrics– Infants and Young Children

The Process

• There have been a series of invitation only conferences. A task force of 27 members oversees the process. They represent researchers, clinicians, consumer and family advocates, and other scientists. All members have been required to disclose any conflicts of interest. Several members have been removed. (Nonetheless, reportedly 70% have for-profit industry ties. 56% of DSM-IV task force members had industry ties.)

The Process

• On February 20, the proposed revisions were posted the APA website. Comments were solicited and changes posted. This process is now over.

• All in all, the website received 50,000,000 hits. 8,600 comments were submitted. All these have been reviewed and field trials are underway. So what are they thinking?...

Overview

• Various diagnoses have been merged or renamed.

• There is an assumption that everyone’s mental status falls on a spectrum that stretches from typical to pathological. Consequently, there is an effort to introduce a dimensional scale for virtually all disorders e.g. mild, moderate, severe. Some scales cut across diagnoses (e.g. anxiety, suicide)

Overview• Disorders are no longer clustered as major mental

illnesses, personality disorders, and medical problems related to mental illness (Axis I, II, III.)

• The organization is different in order to correspond better to ICD and to reflect a developmental perspective.

• There are three sections:– 1) Introduction and instructions– 2) The Disorders– 3) Conditions requiring further research, cultural

formulations, dimensional scales, other stuff

Overview

• Although no biological markers are used in any diagnosis (except sleep disorders,) the text will include genetic risk factors and some proposed biological findings.

DSM-5

• Neurodevelopmental Disorders Highlights– Intellectual Disability (Intellectual Development

Disorder)– Communication Disorders– Autism Spectrum Disorders– Attention-Deficit/ Hyperactivity Disorder– Specific Learning Disorder– Motor Disorders

Psych News, 2/3/2012

Neurodevelopmental Disorders Specifics

• Intellectual Disability– (Intellectual Development Disorder) ICD 11• While generally reflecting an IQ<70, any descriptors of

mild, moderate, severe or profound are based on ability to function, rather than on IQ scores. IQ scores become fairly meaningless below 70.

– Global Developmental Delay

Neurodevelopmental Disorders Specifics

• Communication Disorders– Language Disorder (expressive and mixed)– Speech Sound Disorder (phonological disorder)– Childhood-onset Fluency Disorder (stuttering)– Social Communication Disorder: captures young

people with autism-like communication problems, but lack repetitive behaviors. These children were diagnosed with PDD–NOS in DSM-IV.

Psych News 1/18/13

Neurodevelopmental Disorders Specifics

• Autism Spectrum Disorders• This category will include Asperger’s,

Childhood Disintegrative Disorder, and Pervasive Developmental Disorder NOS. (Rett’s disorder is dropped.) This is done because the reliability and validity of these 3 disorders is very poor. There is no evidence to support their continued separation.

Neurodevelopmental Disorders Specifics

• Autism spectrum disorders (symptoms present in early childhood, 3 levels of severity)– Deficits in communication and interaction

including these 3: • reciprocity• nonverbal interaction• having relationships

– Repetitive and/or restrictive behaviors– Expanded list of specifiers (e.g. intellectual

impairment)

DSM-5 vs. DSM-IV Autism

• The DSM-5 Autism Spectrum diagnosis differs from DSM-IV primarily in that social and communication (language) deficits are merged into a single domain. There is less emphasis on the importance of language delays/abnormalities. This allows the inclusion of Asperger’s.

What About Asperger’s Disorder?

• DSM-IV Asperger’s Disorder– 1) Impairment in social interaction (2 of the

following): nonverbal behaviors, no peer relationships, lack of shared activities, lack of social reciprocity

– 2) repetitive activities of behavior (1 of the following): pattern of activity, rituals, motor mannerisms, fixation on parts of objects

– 3) no delay in language– 4) no cognitive delay

The Controversy

• Some individuals with Asperger’s do not want to be in the same category as people with autism.

• Some individuals fear that Asperger’s will not meet the criteria for ASD, and they will lose benefits.

• Mental health workers believe that Asperger’s is a qualitatively different illness than autism. The criteria do not capture this.

Neurodevelopmental Disorders Specifics

• Attention Deficit/ Hyperactivity Disorder– The onset age has been changed to “before” 12

rather than 7. – Subtypes have been replaced with specifiers– More symptoms are required in different settings– Fewer symptoms are required if the person is an

adult

Mary Kearl: additudemag.com; Psych News 1/18/13

Neurodevelopmental Disorders Specifics

• Specific Learning Disorder– Combines reading disorder, mathematics disorder,

disorder of written expression, and learning disorder NOS.

– Clinicians will specify the kind: reading, written expression, mathematics, etc.

DSM-5 Depressive Disorders Highlights

• Disruptive Mood Dysregulation Disorder• Major Depressive Episode• Persistent Depressive Disorder (Dysthymic

Disorder) • Premenstrual Dysphoric Disorder• Anxious Distress Specifier (for all mood

disorders, including bipolar)

Depressive Disorders Specifics

• Disruptive Mood Dysregulation Disorder– This diagnosis is created in an effort to diagnose

children with extreme temper dysregulation and rage attacks who do not show manic features or an episodic course. These children have recently been diagnosed with bipolar disorder.

Jabr Sci Am Mind May/june 2012

ADHD

Disruptive Behavior Disorders

BIPOLAR

More aggressive More continuous

More labile

DMDD

DSM-5 Anxiety Disorders Highlights

• Separation Anxiety Disorder• Selective Mutism• Specific Phobia• Social Anxiety Disorder (Social Phobia)• Panic Attack, Panic Disorder• Agoraphobia• Generalized Anxiety Disorder

Is Obsessive-Compulsive Disorder an Anxiety Disorder?

• In the past, OCD has variously been believed to be a “religious melancholy”, a result of repressed sexual drives, or a type of anxiety disorder.

• Most experts now believe that OCD is not the result of anxiety, but rather a kind of neurological “short circuit” that causes repetitive thoughts and behaviors, similar to Body Dysmorphic Disorder, Tourette’s syndrome, and Hypochondriasis.

Moyer Sci Am Mind May/June 2011

Obsessive-Compulsive and Related Disorders Highlights

• Obsessive-Compulsive Disorder• Body Dysmorphic Disorder (from

Somatoform Disorders)• Hoarding Disorder • Trichotillomania (Hair-Pulling)• Excoriation Disorder (Skin-Picking)

Obsessive-Compulsive and Related Disorders Specifics

• Hoarding Disorder– Difficulty discarding or parting with possessions

regardless of the value– The symptoms result in the accumulation of a

large number of possessions that fill up and clutter active living areas of the home so that intended use is no longer possible

– The symptoms cause distress or impairment

Hoarding Disorder, Unclutterer blog

Is PTSD an Anxiety Disorder?

• Careful study of clinical, biochemical, and fMRI data has lead investigators to conclude that PTSD is not a fear and anxiety-based disorder. PTSD is one of a wide array of disorders that arise in response to traumatic events. The disorders are characterized by symptoms of avoidance, and negative alterations of mood.

Negative Alterations in Mood or Cognition

• Several of the following:– Inability to remember important aspects of the

trauma– negative expectations of the self, others, or the world– persistent distorted blame of the self– pervasive negative emotional state– diminished interest in significant activities– feeling detachment from others– inability to experience positive emotions

DSM-5 Trauma and Stressor-Related Disorders (Moran Psych News 4/6/12)

• Reactive Attachment Disorder of Infancy• Disinhibited Social Engagement Disorder• Posttraumatic Stress Disorder• Acute Stress Disorder• Adjustment Disorder (moved from its own

category in DSM-IV)– Bereavement related– Acute stress (depressed mood, anxiety, PTSD-like)

DSM-5 Trauma and Stressor-Related Disorders Specifics

• Posttraumatic Stress Disorder– Trauma does not include witnessing events on TV

or other electronic media– PTSD no longer requires that an individual have a

subjective experience of fear or horror, since that has not been useful in determining who develops PTSD. Well-trained emergency workers, for instance, often do not show emotions during the crisis, but may develop PTSD.

DSM-5 PTSD Highlights

• The 3 symptom clusters of DSM-IV– re-experiencing– avoidance and numbing– arousal

• become 4 symptom clusters in DSM-5 – re-experiencing– avoidance– negative alterations in mood and cognition– arousal

DSM-IV Substance Use Disorders• Substance Abuse: 1 or more of the following– Failure to fulfill role obligations– Physically hazardous– Legal problems– Recurrent social or interpersonal problems

• Substance Dependence: 3 or more of the following– Tolerance– Withdrawal– More use than intended– Unsuccessful efforts to cut down– Much time spent trying to obtain substance– Social, occupational, or recreational activities given up– Continued use despite physical or mental health problems

• Specifiers: with or without physiologic dependence

Substance Related and Addictive Disorders Specifics

• DSM-5 combines abuse and dependence into a single disorder graded by severity. The disorder requires 2 criteria, with 2-3 criteria indicating moderate and 4+ criteria indicating severe. Specifiers for physiologic dependence and course remain.

• Some clinicians believe this is losing a crucial distinction between dependence and abuse.

• The task force argues that reliability of diagnosing substance abuse is low, and that there is substantial evidence showing abuse and dependence as a continuum.

DSM-5 Substance Use and Addictive Disorders

• Stimulant-Related: use, intoxication, withdrawal• Tobacco-Related: use, withdrawal• Unknown Substance• Gambling Disorder• Neurobehavioral Disorder Due to Prenatal

Alcohol Exposure (Fetal Alcohol Syndrome) in Section III

• Internet Use Disorder in Section III

Non-Suicidal Self-Injury (Section III)• In the last year, the individual has on 5 or more days

engaged in intentional self-inflicted damage to the surface of the body, for purposes not socially sanctioned, but with the intention that the injury will only lead to minor or moderate physical harm (not suicidal.)

• The intentional injury is associated with a least 2 of:– Negative feelings/thoughts prior to injury– Preoccupation with the intended behavior that is difficult

to resists– The urge occurs frequently.– Activity is engaged in to get relief from negative feeling

Disorders Suggested by Outside Groups

• Apathy Syndrome• Body Integrity Disorder• Developmental Trauma Disorder• Disorders of Extreme Stress• Melancholia• Parental Alienation Syndrome• Seasonal Affective Disorder• Sensory Processing Disorder

Some Other Suggestions From Me

• Public Whining Disorder• Shameless Body Display Disorder• Narcissistic Airline Seat-Reclining Disorder• DSM-5 Anticipation Disorder

Other Things…• GAF Scale? • V and Z codes are in Section III• How long insurance companies will accept DSM-

IV? Probably a year.• ICD-10 correlations. ICD-10 was completed in

1992. The final date for implementation of ICD-10 for CMS (Centers for Medicare and Medicaid Services) is October 2014. There is an effort to make DSM-5 ICD-10 and ICD-11 friendly.

• Suicide scale probably in Section III with the other Cross-Cutting Dimensional Measures