DSM 5: TOP 10 Changes Justin K. Hughes, MA, LPC, NCC
Transcription
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 Stay Up to Date through my Website! Click on Professionals [email protected] 972-387-3898 Ext. 206 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 – – – 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 – • • • • • 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: – – – – 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 • • • • • • • 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 • • • • • • • 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 • • • • • • • 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 • • • 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 www.JustinKHughes.com Stay Up to Date through my Website! Click on Professionals [email protected] 972-387-3898 Ext. 206