DSM-5 Changes
Naval Center for Combat
& Operational Stress Control
July 10th, 2013
Presentation Aims
-- New organizational structure
-- Trauma- and Stressor-Related Disorders
-- Depressive Disorders/Anxiety Disorders/ADHD
-- Substance-Related and Addictive Disorders
DSM-5 Organizational Structure
Chapter organization now represents a
developmental/lifespan approach
In the DSM-5 both ICD-9 and ICD-10 codes are attached to the relevant disorders
DSM-5 Organizational Structure
Non-Axial Documentation of Diagnosis
-- Axis I, II, and III no longer have axial designations; they have been combined
-- Axis IV removed; the DSM-5 recommends the use of V codes and new Z codes contained in the ICD
-- Axis V GAF has also been dropped
Trauma- and Stressor-Related Disorders
Conditions in which symptoms occur after a
distressing or traumatic event
-- Acute Stress Disorder
-- Posttraumatic Stress Disorder
-- Adjustment Disorder
-- Reactive Attachment Disorder
Acute Stress Disorder Criterion A
DSM-IV Criteria -- Groups together whether the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
DSM-5 Criteria -- Requires being explicit about how the event was experienced: directly, witnessed or indirectly* *Does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related
Acute Stress Disorder Criterion A
DSM-IV Criteria
-- The person’s response involved intense fear,
helplessness, or horror
DSM-5 Criteria
-- Subjective reaction has been eliminated
Acute Stress Disorder Criterion B
DSM-IV Criteria
-- Must meet at least 3 (out of 5) dissociative symptoms
DSM-5 Criteria
-- Must meet at least 9 listed symptoms in the following categories: intrusion, negative mood, dissociation, avoidance and arousal
Posttraumatic Stress Disorder Criterion A
DSM-IV Criteria -- Groups together whether the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
DSM-5 Criteria -- Requires being explicit about how the event was experience: directly, witnessed or indirectly*
*Does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related
Posttraumatic Stress Disorder Criterion A
DSM-IV Criteria
-- The person’s response involved intense fear, helplessness, or horror
DSM-5 Criteria
-- Subjective reaction has been eliminated
Posttraumatic Stress Disorder Criterion B – E
DSM-IV Criteria
-- Three symptom clusters: reexperiencing (B), avoidance (C) and arousal (D)
DSM-5 Criteria
-- Four symptom clusters: reexperiencing (B), avoidance (C), negative alterations in cognitions and mood (D) and arousal (E)
Posttraumatic Stress Disorder Criterion B – E
DSM-5 includes new symptoms:
-- Persistent and exaggerated beliefs or expectations about oneself, others or the world (D)
-- Persistent, distorted cognitions about the cause or consequences of the traumatic events that lead the individual to blame himself/herself or others (D)
-- Reckless or self-destructive behavior (E)
Posttraumatic Stress Disorder Criterion E/F
DSM-IV Criteria -- Duration of the disturbance (Criteria B, C and D) is more than 1 month Specify if: Acute: Duration of symptoms is less than 3 months Chronic: Duration of symptoms is 3 months or more Delayed onset: Onset of symptoms is at least 6 months after the stressor
DSM-5 Criteria -- Duration of the disturbance (Criteria B, C, D and E) is more than 1 month Specify if: Delayed expression: Full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate)
Posttraumatic Stress Disorder
DSM-5 Criteria Specify whether:
With dissociative symptoms: The individual experiences persistent or recurrent symptoms of either:
Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body
Derealization: Persistent or recurrent experiences of unreality of surroundings
Adjustment Disorders
DSM-IV
-- Residual category for those exhibiting clinically significant distress without meeting criteria for other disorders
DSM-5
-- Now falls under the category of stress-response syndromes that occur after exposure to a distressing event
Adjustment Disorders
DSM-IV and DSM-5:
-- Symptoms are essentially unchanged
-- Same subtypes: Depressed mood, anxious symptoms, mix of depression and anxiety, disturbances in conduct, mixed disturbance of emotions and conduct and unspecified
DSM-5
-- Does not specify if acute (less than 6 months) or chronic (longer than 6 months)
Depressive Disorders
DSM-5 -- Separated from Bipolar and Related Disorders
-- Contains new diagnoses such as Disruptive Mood Dysregulation Disorder (children up to age 18) and Premenstrual Dysphoric Disorder (women)
-- Contains Persistent Depressive Disorder (Dysthymia), a consolidation of DSM-IV chronic Major Depressive Disorder and Dysthymic Disorder
Persistent Depressive Disorder (Dysthymia)
All symptoms remain essentially unchanged
from DSM-IV to DSM-5 except Criteria D
-- Depressed mood for most of the day, for more days than not…for at least 2 years (A) -- Presence of two or more of the following: poor appetite or overeating, insomnia or hypersomnia, low energy/fatigue, low self-esteem, poor concentration/difficulty making decisions, feelings of hopelessness (B)
Persistent Depressive Disorder (Dysthymia)
-- During the 2-year period of the disturbance, the person has never been without the symptoms in Criteria A or B for more than 2 months at a time (C) -- DSM-IV: No Major Depressive Disorder has been present during the course (D) -- DSM-5: Criteria for Major Depressive Disorder may be present (D)
Major Depressive Episode
DSM-IV Criteria -- The symptoms are not better accounted for by Bereavement (i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation) (E)
DSM-5 Criteria
-- Omitted the bereavement exclusion
Anxiety Disorders
DSM-5 chapter no longer includes: -- Obsessive-compulsive disorder (which is included with the obsessive-compulsive and related disorders) -- Posttraumatic stress disorder and acute stress disorder (which are included with the trauma- and stressor-related disorders)
Attention-Deficit/Hyperactivity Disorder
DSM-IV and DSM-5
-- The same 18 symptoms are used and continue to be divided into two symptom domains (inattention and hyperactivity/impulsivity)
DSM-5
-- The cross-situational requirement has been strengthened from “some” to “several” symptoms in each setting
-- Onset criteria: Symptoms need to be present prior to age 12 (used to be age 7)
Attention-Deficit/Hyperactivity Disorder
DSM-5: -- Comorbid diagnosis with Autism Spectrum Disorder is now allowed -- Only 5 symptoms required for adults compared to 6 for children
Attention-Deficit/Hyperactivity Disorder
DSM-IV and DSM-5 both specify:
-- Combined presentation -- Predominately inattentive presentation -- Predominately hyperactive/impulsive presentation
Substance-Related and Addictive Disorders
DSM-IV -- 11 classes of substances
DSM-5 -- Includes a new diagnosis: Gambling disorder
-- 10 classes of substances
Amphetamines and cocaine combined into single “stimulants” class
PCP placed as its own category in “hallucinogen” class
Addition of “other/unknown substance” class
Substance-Related and Addictive Disorders
DSM-IV -- Included diagnostic criteria for substance dependence and substance abuse
DSM-5 -- Does not differentiate between substance dependence and substance abuse
-- Polysubstance dependence diagnosis eliminated
-- Physiological subtype specifier eliminated
Substance Use Disorders
DSM-IV and DSM-5 criteria are almost identical with some exceptions: -- Recurrent legal problems criterion has been deleted from DSM-5 -- Craving or strong desire/urge to use substance has been added to DSM-5
Substance Use Disorders
DSM-IV and DSM-5 criteria are almost identical with some exceptions (cont): -- DSM-IV Criteria: Must meet at least one criteria for substance abuse and at least three criteria for substance dependence -- DSM-5 Criteria: Must meet at least two criteria
Substance-Related and Addictive Disorders
Other changes to DSM-5:
-- Cannabis and caffeine withdrawal added
-- Tobacco use disorder added
-- Severity of disorders added
Mild: 2-3 criteria met
Moderate: 4-5 criteria met
Severe: 6+ criteria met
Substance-Related and Addictive Disorders
Other changes to DSM-5 (cont):
-- Specifiers
Eliminated “full” and “partial” specifiers
Use “In early remission” if no criteria for substance use disorder (except “craving”) have been met for at least 3 months, but less than 12 months
Use “In sustained remission” if no criteria for substance use disorder have been met for 12 months or longer
Substance-Related and Addictive Disorders
Other changes to DSM-5 (cont):
-- Specifiers
DSM-IV: “On agonist therapy”
DSM-5: “On maintenance therapy”
Substance-Related and Addictive Disorders
Potential implications for clinical practice?
-- SUD screening processes
-- Psychoeducation content/materials
-- “Designer drug SUDs” (e.g., spice, bath salts)
Thank you!
Questions?
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