1/8/15 1 Comparing Alcohol Use in the DSM-IV-TR, DSM-5, and ICD-10 Presented by Norman G. Hoffmann, PhD January 8, 2015 Misti Storie, MS, NCC Director of Training & Professional Development NAADAC, the Association for Addiction Professionals www.naadac.org [email protected]Produced By NAADAC, the Association for Addiction Professionals www.naadac.org/webinars In Partnership With The Change Companies www.changecompanies.net www.naadac.org/webinars www.naadac.org/DSMandICD10
Transcript
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Comparing Alcohol Use in the DSM-IV-TR, DSM-5, and ICD-10
Presented by Norman G. Hoffmann, PhD
January 8, 2015
Misti Storie, MS, NCC
Director of Training & Professional Development
NAADAC, the Association for Addiction Professionals
• We will be focusing on the comparisons among diagnostic formulations from the DSM-IV and DSM-5 to the ICD-10 criteria
• However, we will also be covering issues related to how individual groups of criteria may be more important than the formal diagnosis
• This out of the box perspective can be integrated with the concept of an outcomes-based approach to individualized treatment that, in theory, is superior to the common requirement for using evidence-based treatment models
Overview
• The change from the DSM-IV to the DSM-5 marks a shift from a categorical to a dimensional diagnostic perspective
• The mandate to use ICD-10 diagnostic codes in 2015 requires matching the dimensional DSM-5 diagnoses back to a categorical formulation
• Empirical evidence suggests that irrespective of the diagnostic formulation used, some criteria indicate a more severe and chronic condition
• Addiction defined as the inability to go one day without drinking and experiencing withdrawal
• DSM-III (1980-1987)
• Diagnoses: Abuse and dependence
• Dependence defined as having tolerance and/or withdrawal plus pathological use and/or impairment in social or occupational functioning
Historical Background • DSM-III-R (1987-1994)
• Diagnoses: Abuse and Dependence • Dependence defined as having three or more positive criteria out
of nine criteria
• DSM-IV (1994-2000)
• Diagnoses: Abuse and dependence • Dependence defined as having three or more positive criteria out
of seven criteria
• DSM-IV-TR (2000-2013) • Essentially identical to the DSM-IV
Historical Background
• To my knowledge, there is no rigorous evidence to support any of the previous diagnostic formulations
• To a large extent, this is also true for the DSM-5
• Since the DSM-III-R tolerance and withdrawal have moved from required criteria for dependence to being two among 11 with the advent of the DSM-5
• The DSM-5 removes the artificial categorizing of some criteria as being for abuse and others for dependence by eliminating both terms and replacing them with a dimensional concept of severity based on the number of positive criteria
Empirical Perspective 1. Use in larger amounts or longer than intended
2. Desire or unsuccessful effort to cut down
3. Great deal of time using or recovering
4. Craving or strong urge to use
5. Role obligation failure
6. Continued use despite social/interpersonal problems
7. Sacrificing activities to use or because of use
8. Use in situations where it is hazardous
DSM-5 Substance Use Disorder Criteria
9. Continued use despite knowledge of having a physical or psychological problem caused or exacerbated by use
10. Tolerance
11. Withdrawal
Criteria 1-4 relate to use
Criteria 5-8 relate to behavioral issues associated with use
Criteria 9-11 relate to physical/emotional issues
DSM-5 SUD Criteria continued
• Initially the proposed DSM-5 had two diagnostic categories: moderate and severe defined by 2-3 and 4+ positive criteria – conforms best to abuse vs. dependence classification
• Final formulation has three diagnostic categories: mild (2-3), moderate (4-5), and severe 6+ positive criteria)
• Original “moderate” becomes “mild” – no empirical foundation for either distinction
DSM-5 Initial VS. DSM-5 Final
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• Are the divisions among the DSM-5 mild, moderate, and severe diagnoses optimal?
• What are the clinical implications for the matches and mismatches with the DSM-5 and ICD-10 diagnoses?
• What are the financial implications if the DSM-5 proposed matches or the actual ICD-10 criteria are used for reimbursement?
• The ICD-10 has two forms; will that make a difference for reimbursement?
Unresolved Issues
Audience Polling Question #1 Do you feel that the dimensional diagnoses of the DSM-5 are more appropriate than the categories of the DSM-IV-TR?
• No positive diagnostic findings (other than craving) for 12 consecutive months
• Substance use is NOT part of the remission definition
• This remission definition is appropriate for both misuse and chronic addiction
• Possible levels of outcome: 1) abstinence without problems; 2) some use without problems; 3) use with sub-diagnostic problems; 4) meets current diagnosis
Sustained Remission
• Remission is clearly defined by the DSM-5: no problems irrespective of continued use
• Recovery has many definitions
• The concept of recovery tends to involve much more than remission
• Treatment is typically not reimbursed for some aspects of recovery – e.g., serenity, interpersonal relationships, employable, etc.
• Payment for treatment has the primarily expectation for remission not recovery
Remission vs. Recovery
• All criteria are not equal in implications
• Some criteria are found predominately among those with the severe alcohol or other substance use disorder diagnoses
• Other criteria are more common among the mild to moderate alcohol use disorder group
• Tolerance and dangerous use are actually common among those with no diagnosis
DSM-5 Criteria Differentials
DSM-IV Criteria Based on SUDDS-IV Results
DSM-5 Designations Pop. Prev.
No Dx Mild Mod. Sev.
1. Unplanned use 2% 8% 11% 79% 27%
2. Unable to cut down <1% 4% 7% 88% 21%
3. Time spent using 2% 6% 11% 81% 28%
4. Craving/compulsion 1% 3% 7% 89% 21%
5. Role failure <1% 3% 9% 88% 25%
6. Social Conflicts 3% 13% 14% 70% 34%
Distribution of Positive Alcohol Criteria for 6,871 Males
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Distribution of Positive Alcohol Criteria for 6,871 Males
Case 1 X X X X X X X X Case 2 X X X Case 3 X X X X X Case 4 X X X X X
Severe
Mild
Moderate Moderate
*Cases 3 & 4 with the same diagnosis may have different prognoses if the Big Five are related to outcomes
3. Great deal of time using
10. Tolerance
1. Unplanned use: more or longer use
8. Use in hazardous situation (impaired driving)
6. Recurrent interpersonal conflicts
CASE 3: Positive DSM-5 Criteria
Conclusions • No loss of control indicated
• Misuse and possible irresponsible behavior
• Moderation may be a reasonable initial goal
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1. Unplanned use: more or longer use
2. Desire/efforts to cut down
4. Craving/compulsion to use
5. Role obligation failures
7. Sacrificing activities to use
CASE 4: Positive DSM-5 Criteria
Conclusions • Loss of control clearly indicated
• Positive on 4 of the “Big Five”
• Abstinence indicated goal for recovery
• Education and brief counseling may be appropriate for majority of mild use disorders
• Abstinence will virtually always be required to achieve remission for those with a severe diagnosis
• For those with a moderate diagnosis, the pattern may be as important as the number of positive criteria
• Those positive on any of the Big Five criteria should be carefully evaluated regarding the current and projected trajectory of their condition
Implications for Disposition
• Loss of control not required for a dependence diagnosis – e.g., tolerance, spending time using, and occasionally drinking more/longer than intended – got the chronic diagnosis
• Some abuse criteria are stronger indications of a serious condition than some dependence criteria
• Role obligation failure is a Big Five criterion
• Tolerance is often seen in mild cases or even among those with no diagnosis
Final Criticism of the DSM-IV
• Persons in the severe designation with positive “Big Five” findings will require a more intensive and longer continuum of care to achieved treatment effectiveness
• Persons in the mild designation typically will benefit from shorter & less intensive interventions to achieve efficiency
• Each treatment plan can be informed by prior empirical outcome data on comparable cases and modified based on the individual’s treatment response
CLINICAL (Medical) NECESSITY
• Hypothesis #1: Clients positive on three or more of the “big five” will require initial residential placement and/or more intensive and longer continuum of care to achieve good results
• Hypothesis #2: Clients in mild or moderate designations without any positive findings on the “big five” may be able to moderate or stop use with less intensive and briefer services
Sample Hypotheses for Clinical Practice
Audience Polling Question #2
Do you plan to use the Big Five in your clinical practice?
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Males N = 6,871
0%
20%
40%
60%
80%
100%
No Dx
Abuse
Depen
denc
e
Severe Mod. Mild No Dx
Females N = 801
0%
20%
40%
60%
80%
100%
No Dx
Abuse
Depen
denc
e
Severe Mod. Mild No Dx
DSM-IV vs DSM-5 Alcohol Diagnoses
• Harmful use: actual physical, mental, cognitive harm (does not count C6 or C8)
• Dependence: any three of the following:
(a) Desire/compulsion to use – C4
(b) Difficulty controlling use – C1 & C2
(c) Withdrawal – C11
(d) Tolerance – C10
(e) Neglect of interests/time spent using – C3, C5, C7
• All DSM-5 criteria are accounted for with the research criteria – but the combinations might not correspond to the DSM-5 matches – e,g. 2 dependence criteria no ICD-10 Dx
ICD-10 Research Diagnostic Criteria
• The criteria for dependence in the ICD-10 encompass the concepts of the Big Five
• Tolerance & harm from use are the exceptions
• The expectation would be that the ICD-10 diagnosis of dependence would likely be equivalent to the severe designation of the DSM-5 or moderate with Big Five positives
• The problem arises with the fact that there are two versions of the ICD-10 where harmful use is defined differently
ICD-10 and the Big Five
• The ICD-10 has a code F1x.9 Unspecified Mental and Behavioral Disorder in the substance use disorder section (p. 76 of the WHO bluebook for ICD-10 criteria) for “misuse”
• This diagnosis could be used for problems related to substances that are not included in clinical version of the ICD-10 – interpersonal conflicts, use in dangerous circumstances, arrests, etc.
• 2 or more such problems for “misuse” coded F1x.9 (x = substance code) could be compatible with mild DSM-5 diagnosis
More Thoughts on ICD-10
Option 1: Use any positive finding on the DSM-5 criteria to match on the basis of where each criterion loads on the ICD-10
• Likely to over diagnosis as some components of the DSM-5 category are not part of ICD-10
• Example: Job problems (DSM Criterion 5) or interpersonal conflicts (DSM Criterion 6) due to use do not neglect of interests for the dependence criteria nor necessarily a “dysfunctional behavior” for harmful use
• Global match based on DSM-5 criteria most likely to produce a good fit.
Compatibility from Two Views
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Option 2: Use items that definitely load on the respective ICD-10 criteria as an independent determination of the ICD-10 diagnosis
• Likely to be more conservative and compatible with the intent and spirit of the ICD-10
• Allows for more detailed comparison of where the DSM-5 and ICD-10 are compatible and where not
• Less likely to produce a good fit.
Compatibility from Two Views
0%
20%
40%
60%
80%
100%
No Dx Mild Moderate Severe
Dependence Harmful use Misuse No Dx
ICD-10
DSM-5 VS. ICD-10 Clinical Alcohol Diagnoses for 6,871 Males
DSM-IV-5 Diagnoses
0%
20%
40%
60%
80%
100%
No Dx Mild Moderate Severe
Dependence Harmful use No Dx
ICD-10 Diagnosis
DSM-5 VS. ICD-10 Research Alcohol Diagnoses for 6,871 Males
DSM-IV-5 Diagnoses
0%
20%
40%
60%
80%
100%
No Dx Mild Moderate Severe
Dependence Harmful use No Dx
ICD-10 Diagnosis
DSM-5 VS. ICD-10 Research Dx Based on DSM-5 Criteria for 6,871 Males
DSM-IV-5 Diagnoses
0%
20%
40%
60%
80%
100%
No Dx Mild Moderate Severe
Dependence Harmful use Misuse No Dx
ICD-10
DSM-5 VS. ICD-10 Clinical Alcohol Diagnoses 801 Females
DSM-IV-5 Diagnoses
0%
20%
40%
60%
80%
100%
No Dx Mild Moderate Severe
Dependence Harmful use No Dx
ICD-10 Diagnosis
DSM-5 VS. ICD-10 Research Alcohol Diagnoses 801 Females
DSM-IV-5 Diagnoses
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0%
20%
40%
60%
80%
100%
No Dx Mild Moderate Severe
Dependence Harmful use No Dx
ICD-10 Diagnosis
DSM-5 VS. ICD-10 Research Dx Based on DSM-5 Criteria for 801 Females
DSM-IV-5 Diagnoses
• Those who do not get a DSM-5 diagnosis will not get an ICD-10 diagnosis
• Regardless of ICD-10 clinical or research version, fewer will get an ICD-10 diagnosis
• Virtually all with a severe DSM-5 diagnosis meet dependence for ICD-10
• 60% to 100% of those with a moderate DSM-5 diagnosis meet dependence criteria depending on the method of comparison
DSM-5 vs ICD-10 Diagnostic Prevalence
0%
20%
40%
60%
80%
100%
No Dx Abuse Dependence
Dependence Harmful use Misuse No Dx
ICD-10
DSM-IV VS. ICD-10 Clinical Alcohol Diagnoses for 6,871 Males
DSM-IV-5 Diagnoses
0%
20%
40%
60%
80%
100%
No Dx Abuse Dependence
Dependence Harmful use No Dx
ICD-10 Diagnosis
DSM-IV VS. ICD-10 Research Alcohol Diagnoses 6,871 Males
DSM-IV-5 Diagnoses
• Almost all with no DSM-IV diagnosis will not get an ICD-10 diagnosis
• Almost all with a DSM-IV diagnosis of dependence will get and ICD-10 diagnosis of dependence
• Those with a DSM-IV diagnosis of abuse will divide up similarly to those with a mild DSM-5 diagnosis
• As with the DSM-5 fewer people will get a diagnosis with the ICD-10
DSM-IV and the ICD-10
Audience Polling Question #3
Are you or your program prepared to use the ICD-10 coding for billing?
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• Almost all who do not get a diagnosis with the DSM-IV will not get one with either the DSM-5 or ICD-10 criteria
• Almost all who get a dependence diagnosis with the DSM-IV will get a severe diagnosis with the DSM-5 or dependence with ICD-10
• The abuse diagnosis of the DSM-IV tend to be scattered among the mild to moderate diagnoses of the DSM-5 and harmful use or unspecified diagnoses of the ICD-10 or will not get a diagnosis with either
Diagnostic Formulation Comparison
• Provides a more detailed documentation of diagnostic constructs/criteria
• Allows for consistent documentation for distinguishing between potentially chronic vs. transient conditions
• Avoids artificial division of criteria as is the case with the DSM-IV and ICD-10
• The issue of whether the distinctions among mild, moderate, and severe are appropriate can be determined by systematic documentation
Advantages of the DSM-5
• The “Big Five” seem to be important for identifying empirical severity and prognosis
• These five criteria may be critical in differentiating those with a chronic condition from those where it is more transient
• Consistent documentation of assessment findings and treatment response and outcomes can refine routine clinical practice
• Such documentation does not require a research protocol
Clinical Implications
• Days of use is NOT a severity indication – the number of positive diagnostic criteria is the basic DSM-5 severity measure
• Individualized treatment planning requires more than just a diagnosis – need to know which diagnostic criteria are positive
• Days of use is irrelevant to documenting remission
• Matching assessment with treatment response and initial outcomes can refine the effectiveness and efficiency of treatment
Assessment Implications
• Diagnoses are only part of the formula for treatment planning for individualized treatment
• The pattern of positive findings for individual diagnostic criteria may be as important in some cases as the diagnosis itself
• Many other clinical, demographic, and societal issues may often be overlooked in treatment planning
• Linking intake and ongoing assessment with treatment response and outcomes during a treatment continuum of 90 days can inform treatment innovation and outcome improvement
Thinking Outside the Box
• Four demographic characteristics have been found to predict risk for relapse
• Among those referred to treatment as a diversion by courts, the demographics also predict risk for criminal recidivism
• The Demographic Risk Scale is formed by adding one point for each of the following?
• Being under the age of 25
• Never married
• Not a high school graduate or having a GED
• Unemployed
The Demographic Risk Scale
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• Implementing so-called evidence-based treatment modes does not guarantee good treatment outcomes
• Initial outcomes during treatment and during the period of maintenance/aftercare can inform programs about level of effectiveness
• Linking such outcomes with assessment information and other data typically collected at intake and/or reviewed prior to transfer/discharge forms a strategy for continuous quality improvement
• Findings can focus attention on where improvements might be made or where the program has strengths
Outcomes-based Treatment
• None of the diagnostic formulations match perfectly with another
• The best agreement is with those who have no diagnosis or a severe/chronic diagnosis
• The greatest discrepancies are with the milder condition(s)
• A few criteria appear related to greater chronicity and more guarded prognosis – documenting the need for greater detail in diagnostic documentation
• Monitoring of treatment response and initial outcomes can refine prognosis and inform treatment plans
