K. Dayle Jones, Ph.D., LMHC University of Central Florida

daylejones@ucf.edu

Diagnosis with DSM-5 and ICD

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  Introduction   General Classification Changes for DSM-5   New and Revised Disorders   ICD and the DSM   DSM-5 and Implications for Diagnostic

Classification - Discussion

Overview

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Introduction: Diagnostic & Statistical Manual of

Mental Disorders

Purposes:   Clinical utility   Research   Common language   Educational tool

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General Classification Changes

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DSM-5 Organizational Structure

Section I: DSM-5 Basics

Section II: Essential Elements: Diagnostic Criteria & Codes

Section III: Emerging Measures and Models

Appendix

Sections:

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Section II Table of Contents (1)

1. Neurodevelopmental D/Os

2. Schizophrenia Spectrum & Other Psychotic D/Os

3. Bipolar & Related D/Os

4. Depressive D/Os

5. Anxiety D/Os

6. Obsessive-Compulsive & Related D/Os

7. Trauma- & Stressor-Related D/Os

7.  Dissociative D/Os

8.  Somatic Symptom & Related D/Os

9.  Feeding & Eating D/Os

10. Elimination D/Os

11. Sleep-Wake D/Os

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Section II Table of Contents (2)

13. Sexual Dysfunctions

14. Gender Dysphoria

15. Disruptive, Impulse-Control, & Conduct D/Os

16. Substance-Related & Addictive D/Os

17. Neurocognitive D/Os

18. Personality D/Os

19. Paraphilia D/Os

20. Other Mental D/Os

21. Medication-Induced Movement D/Os & Other Adverse Effects of Medication

22. Other Conditions That May Be a Focus of Clinical Attention

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  New nonaxial documentation of diagnosis   Combined former Axes I, II and III   Eliminated Axis IV. Use “Z codes” (V codes)   Eliminated Axis V: GAF.

  Propose use of World Health Organization Disability Assessment Schedule (WHODAS) (in Section III).

Removal of Multiaxial System

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  Changed diagnostic codes from numeric to alphanumeric.   Examples:

New Diagnostic Codes

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ICD-9 ICD-10 OCD 300.3 F42

PTSD 309.81 F43.1

Coding Example in DSM-5

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ICD-9 Code

ICD-10 Code

Current approach:   Categorical (binary): presence or absence of disorder

(DSM-IV) Proposed approach:   Dimensional (ordinal): disorders are dimensions on

continuous distribution

Working Towards Dimensional Classification Approach

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New and Revised Disorders

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  Removed bereavement criterion   Added “anxious distress” specifier   Added “with mixed features”

Major Depressive Disorder

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  Incorporates both Dysthymia and Major Depressive Disorder, Chronic   No longer considered “milder” form of depression

Persistent Depressive Disorder (Dysthymia)

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  Criterion A for Manic Episode and Hypomanic Episode emphasizes changes in activity and energy, as well as mood   Dropped “mixed episode”   Added “mixed specifier”   Added “with anxious distress” specifier

Bipolar I Disorder

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  Temper outbursts involving yelling, rages or physical aggression   Overreacting to common stressors   Temper outbursts occurring on average 3 or more

times a week for at least 12 months (not symptom-free for more than 3 months at a time)   Children age 6 to 18 years

Disruptive Mood Dysregulation Disorder (DMDD)

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  Generalized anxiety disorder   Panic disorder   Agoraphobia   Specific phobia   Social anxiety disorder (social phobia)   Separation anxiety disorder   Selective mutism

Anxiety Disorders

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New grouping:   Obsessive-Compulsive Disorder   Body Dysmorphic Disorder   Hoarding disorder   Trichotillomania (Hair-Pulling Disorder)   Excoriation (Skin-Picking) Disorder

Obsessive-Compulsive & Related Disorders

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  Criterion A is more explicit with regard to how an individual experienced “traumatic” events.   4 symptom clusters:

1.  Re-experiencing 2.  Avoidance 3.  Negative cognitions 4.  Specify

Note: Separate criteria set for “PTSD for Children 6 Years and Under”

Posttraumatic Stress Disorder

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  Eliminated schizophrenia subtypes.

  Two criterion A symptoms (one must include 1-3) 1.  Delusions 2.  Hallucinations 3.  Disorganized speech 4.  Grossly abnormal psychomotor behavior 5.  Negative symptoms

Schizophrenia

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  DSM-5 maintained the 10 personality disorder categories and criteria from DSM-IV

  Axis II eliminated

  A new trait-specific model of personality disorders will be included in Section III to encourage further study.

Personality Disorders

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  Combined Abuse and Dependence   Requires 2 of 11 symptoms   Deleted legal criterion   Added “craving” criterion   Severity of a Substance Use Disorder:

  Mild: 2 to 3 symptoms   Moderate: 4-5 symptoms   Severe: 6 or more symptoms

Substance Use Disorder

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  Moved to “Substance Use and Addictive Disorders”   New “behavioral addiction”   Added Internet Gaming Disorder to Section 3

Gambling Disorder

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  Combines autistic disorder, Asperger’s disorder, childhood disintegrative disorder, & pervasive developmental disorder NOS.   Symptoms in two core areas:

1.  deficits in social communication & social interaction 2.  restricted repetitive behaviors, interests, & activities

  New dimensional assessment

Autism Spectrum Disorder

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  Name change   Severity specifiers:

  Determined by adaptive functioning rather than IQ score   Assessed using new dimensional assessment   Severity Levels: Mild, Moderate, Severe, Profound

Intellectual Disability (Intellectual Developmental Disorder)

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  Cognitive decline from previous level of functioning in at least 1 of 6 domains (complex attention, executive function, learning and memory, language, perceptual motor, social cognition)   Specify etiology

Difference:   Major: interferes with independence   Mild: no interference with independence

Major Neurocognitive Disorder Mild Neurocognitive Disorder

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  Feeding disorders: pica, rumination disorder and avoidant/restrictive food intake disorder

  Eating disorders: anorexia nervosa, bulimia nervosa, binge eating disorder

Feeding and Eating Disorders

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Gender Dysphoria   Replaces the term “gender identity disorder”   Separated from Sexual Disorders

Gender Dysphoria

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  Eliminated the term “somatoform”   Drops centrality of “unexplained medical symptoms”   The disorders:   Somatic Symptom Disorder   Illness Anxiety Disorder   Conversion Disorder   Psychological Factors Affecting Other Medical Conditions   Factitious Disorder

Somatic Symptom & Related Disorders

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ICD and the DSM

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  Classification system used to track morbidity and mortality of all diseases.   Developed by the World Health Organization

International Classification of Diseases (ICD)

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In U.S.:   Current version: ICD-9-CM   As of October 2014: ICD-10-CM

DSM-IV lists ICD-9-CM codes DSM-5 lists both ICD-9-CM and ICD-10-CM codes

ICD and DSM

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Questions and Discussion

DSM-5 and Implications for Diagnostic Classification

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References American Psychiatric Association (APA). (2010). American Psychiatric Association DSM-5

development. Retrieved from http://www.dsm5.org/Pages/Default.aspx. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental

disorders, fifth edition (DSM-5). Washington DC: Author. American Psychiatric Association (APA). (2013). Highlights of Changes from DSM-IV-TR to

DSM-5. Retrieved from http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/Changes-from-DSM-IV-TR--to-DSM-5.pdf

First, M. B. (2010). Paradigm shifts and the development of the diagnostic and statistical manual of mental D/Os: Past experiences and future aspirations. The Canadian Journal of Psychiatry, 55, 692-700.

Kraemer, H. C. (2007). DSM categories and dimensions in clinical and research contexts. International Journal of Methods in Psychiatric Research, 16(S1), S8–S15.

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Kupfer, D. J. (2013, March). Psychiatry update: The DSM-5 and more. Retrieved from http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&ved=0CDIQFjAA&url=http%3A%2F%2Fwww.acponline.org%2Fabout_acp%2Fchapters%2Fva%2F13mtg%2Fkupfer_psychiatryupdate.pptx&ei=PRZTUcmyOo3c8wSK4YHQDQ&usg=AFQjCNFCPlZX8LJQfE7uFMKx1mGio1TVig&bvm=bv.44342787,d.eWU

Moran, M. (2013). Continuity and Changes Mark New Text of DSM-5. Psychiatric News, 48(2), 1-6.

Moran, M. (2013). DSM-5 Fine-Tunes Diagnostic Criteria for Psychosis, Bipolar Disorders. Psychiatric News, 48(3), 10-11.

Moran, M. (2013). DSM-5 Provides New Take on Neurodevelopment Disorders. Psychiatric News, 48(2), 6-23.

Moran, M. (2013). DSM-5 updates depressive, anxiety and OCD criteria. Psychiatric News, 48(4), 22-43.

Moran, M. (2013). Somatic chapter drops centrality of unexplained medical symptoms. Psychiatric News, 48(5), 7-7.

Olfson, M., & Marcus, S. C., (2010). National trends in outpatient psychotherapy. American Journal of Psychiatry, 167, 1456-1463.

World Health Organization (2012). WHO Disability schedule assessment 2.0 (WHODAS 2.0). Retrieved from http://www.who.int/entity/classifications/icf/WHODAS2.0_36itemsSELF.pdf

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