J o sep h M . R o be r t s , P h . D . P PA A u g us t 1 5 , 2 0 1 4

1. Joseph M. Roberts, Ph.D. PPA August 15, 2014 MORETHANJUST WORDSANDNUMBERS: THETOP 15FUNDAMENTALCHANGES TOTHEDSM-5 &THETRANSITIONTOICD-10

2. DISCLAIMERS • Muchofthe informationfoundinthis presentationis adirect reference (oftenverbatim) ofDSM-IVand • DSM-5 criteriafoundineithervolume as wellas the free “bluebook” ofICD-10. • The countdownformat is basedonthe clinical • opinionofthe presenterbasedonthe magnitudeandthe impact ofthe potentialchanges todiagnosis andtreatment. • Selections were made based onlikelihoodof • immediate impact inpractice situations withbothchildrenandadults.

3. OBJECTIVES • 1.Describe the most criticalchanges tothe DSM-5 as comparedtoDSMIV • 2.Analyze the supportive researchtodetermine if the changes are well-validated • 3.Compare DSM5 toICD-10 inregards tothe most commonpsychiatriccategories • 4.Assess howthese changes willlikelyimpact mentalhealthsystems across levels ofcare • 5.Critique areasoffuture diagnosticexplorationhintedat inDSM-5

4. ICD-10

5. THEMASTERTIMELINE • DSM-5 descriptors andcoding canbeusednow(andAPA encourages this). • That being said,the deadline ofOctober1,2014 • where allICD10 codes were tobecome the rule-of • the-land,has nowbeen movedtoOctober2015 (the President signedthis legislationthat was passed bythe Senate andHouse inApril2014). • Additionally,youcanlikelyignore ICD-11.Thoughit is slatedfora2015/2016 release, the US won’t adapt those codes formany(many) years.

6. CENTRALDIFFERENCESBETWEENTHEDSMANDICD

7. WHATDOESTHEAMERICANPSYCHIATRICASSOCIATIONSAYABOUTICD-DSM? • “DSMandthe ICDshouldbethought ofas • companionpublications.DSM-5 containsthe most up-to-date criteriafordiagnosing mentaldisorders, along withextensive descriptive text,providing a • commonlanguage forclinicians tocommunicate about theirpatients.The ICDcontainsthe numbers usedinDSM-5 andallofmedicine,neededforinsurance reimbursement andformonitoring • morbidity andmortality statistics bynationaland internationalhealthagencies” (Insurance • Implications ofDSM-5,p.3). • Butis thatallthereistoit?

8. TRANSITIONCONCERNS • ICD-10 has morecodes and does notalways alignwithDSM-5 (especiallywith new DSM-5 disorderslike Binge-EatingDisorderwhich • mapsto Other EatingDisorder (F50.8) and • HoardingDisorderwhich maps to OCD (F42). • DSM-5 is limitedto what is containedin the ICD-10 because HIPPA follows ICD coding • and so the DSM-Task ForceonInsurance • Implicationsindicated thatboththe NAME and the CODE number should always be • recorded inthe medical record to support BOTHDSM and ICD. • Insurancecompaniesare callingthisthe “largestchange to ever happento • healthcare”and an event that may take years“to recover” from!

9. SOMELASTTHOUGHTS • Federal educationlaws that describe • IndividualizedEducationPrograms(IEPs) and Special Educationdo notspecify thatthe DSM must be used to make thosedeterminations. • There are real concernsrelatedto revenue • disruptionand technologyinterfaceduringthe migration. • DSM-5 is the textpredominatelytaughtin • graduateprogramsin the US, with ICD barely beingmentioned in mostcurricula. • Every countryis permittedto alter the ICD to fit its specific needs. Inthe US, the Center for • Disease Control is charged with thattask.

10. DSM-5

11. CENTRALCONCERNSOFTHEDSM-5 WELCH,KLASSEN,BORISOVA,&CLOTHIER(2013) • Concernsover the influenceof the pharmaceutical industryon workgroupmembers. • Concernsthat the two central pillarsof “paradigm • change” (dimensionalratingsand anetiologicalfocus) were ultimatelynoteffectively implemented. • Concernsover reduced thresholdsonsome disorders • (ADHD) and the potentialadditionof diagnosesthat are • commonto the general population(binge-eatingdisorder). • Concernsover the fact thatthe field trialsdid nothave a second quality-controlphaseand had mass community • therapistattrition. • Concernsover the use of kappa aslow as .2, unlike DSM III and IVthat used Kappaof .4 as the absolutecutoff of diagnosticacceptabilitybetween raters.

12. ISTHESKYFALLING? • AllenFrances, the Task Force Chairof • DSM-IV,certainlythought soandpostednumerous blogandarticles inboth • popularnews websites andinindustryjournals between 2009 and2013. • He evenwrote abookcalledSaving • Normal that came out the same month as DSM-5 (May2013). • He posited10 ofthe “Worst Changes” of DSM-5 inPsychologyToday(12/2/12), andsuggestedclinicians ignore them intheirdiagnosticdecisions.

13. ALLENFRANCES’TENWORSTCHANGES(2012) • 1)TheadditionofDisruptiveMoodDysregulationDisorder • 2)NormalGriefwillbecomeMDD • 3)EverydayforgettingintheelderlywillbemisdiagnosedasMinorNeurocognitiveDisorder • 4)AdultADHDrateswilllikelyhaveafadsoar-rate • 5)SporadicgluttonycannowbeBingeEatingDisorder • 6)ChangestoAutismwilllowerrates,butimpactschool servicesforthoseinneed • 7)Recreationalandfirst-timesubstanceuserswillbediagnosticallymergedwith“hardcoreaddicts”. • 8)BehavioralAddictions(i.e.gamblingdisorder)willopenthedoortoeverythingwe“liketodoalot”. • 9)PotentialobscuringofGADwithworriesoftheeveryday • 10)GreatermisdiagnosisofPTSDinforensicsettings

14. FRANCESONDSM-ICD • In a Psychiatric Times article(2009), Francesspouted philosophical onthe struggleswith integratingthe two sourcesaswell as where each “shines” • Indicatedthat combiningthe two has always been difficult due to schedulingissues and with each group having • different affections for word-choiceand concepts. • Francesreferenced stats thatsuggest thatDSM IVand • ICD-10 had onlyone diagnosisthat had identical wording (transientticdisorder). • 20% of diagnoseshad reflected different conceptual frames or had significantwordingdifferences. • Ideally,Franceswould liketo see a divisionoflabor,with • ICD being the guidefor cliniciansand DSMbeingthe tome for researchers.

15. NOTREADYFORPRIME-TIME... NOTREADYFORPRIMETIME. .. FromSectionIII EmergingMeasures &Models • SuicidalBehaviorDisorder& NonsuicidalSelf- injury • Coerciveparaphilia • Pedohebephilia Disorder • HypersexualDisorder • Attenuated PsychosisDisorder • PDDimensionalAssessment • PersistentComplexBereavementDisorder

16. #15:GAMBLINGDISORDERJOINS THESUBSTANCEABUSESECTION • 1)Needstogamblewithincreasingamountsofmoneyinordertoachievedesiredexcitement. • 2)isrestlessorirritablewhentryingtocutdowngambling. • 3)Hasmaderepeatedunsuccessfulattemptstocutdown • 4)Isoftenpreoccupiedbygambling. • 5)Oftengambleswhenfeelingdistressed. • 6)Afterlosingmoney,oftenreturnsthenextdaytogeteven--“chasing”one’slosses. • 7)Liestoconcealtheextentofinvolvementingambling. • 8)Hasjeopardizedorlostasignificantrelationship,job, • oreducationalorcareeropportunitybecauseofgambling. • 9)Reliesonotherstoprovidemoneytorelievedesperatefinancialsituationscausedbygambling.

17. WHYITMATTERS • Althoughgambling disorderseems like alogical addition,the introductionofanon-substance use disorderopensthe wayforothernon-consumable considerations (internet,shopping,etc.). • This alsospeaks tothe dramaticchanges that have occurredinthe D&A community overthe past • decade, as it has increasinglymergedwithmental health treatment. • Interestingly,gambling disordermakes it debut as • substance used disordergets amajoroverhaul.More onthat later.

18. DSM-5ICD-10CROSSWALKGAMBLINGDISORDER • In ICD-10, pathologicalgambling,fire-setting, and • stealingare interestinglylocated with the personality disorders. • PathologicalGambling(F63)is considered aHabit and ImpulseDisorderin ICD-10 as compared to a Non- • Substance-RelatedDisorder(under the SubstanceUsed DisorderCategory) inDSM-5. • The diagnosticdescriptionis quitesimple:Persistent, • repeated gamblingwhich continuesand oftenincreases despiteadverse socialconsequencessuch as • impoverishment,impairedfamily relationships,and disruptionsto personal life. • Rule-outs include:normativegambling,mania-induced • gambling,and gamblingby sociopathicpersonalitytypes.

19. #14:MULTIPLE PERSONALITY DISORDER CONTINUES TO FADE FROM HISTORY (DID) • Criterion Bfrom DSM IVDissociativeIdentity • Disorderhas been completelyremoved(Atleasttwoofthese identities or personalitystates recurrently • take control ofthe person’sbehavior.) • One ofthe more embarrassing (andrefuted) chapters inpsychologyiscoming toits ultimate demise as • dissociationisalignedwithtraumaticreactions andawayfromMPDfolklore. • Rates ofDIDhave droppedsubstantiallysince the 1990s toless than2%(andthisislikelytoohigh). • Manyculturalelements including direct comparisonto religious possessionare addedto the diagnosticcategoryforDID.

20. THISNOTTHAT • Disruptionofidentitybytwoor moredistinctpersonalitystates,whichmaybedescribed insomeculturesasanexperienceofpossession.Thisdisruptioninidentityinvolvesmarked discontinuityinsense of selfandsense ofagency, accompaniedbyalterations inaffect, behavior,consciousness,memory, perception,cognition,and/orsensorymotorfunctioning. • Thepresenceof twoormoredistinctidentitiesorpersonalitystates(eachwithitsownrelativelyenduringpatternofperceiving, relatingto,andthinking aboutenvironment &self.

21. WHYITMATTERS • Other specified DID covers:Identitydisturbancedue to prolongedand intensivecoercivepersuasionthrough • brainwashing,torture,and politicalimprisonment. • DSM-5 offers insightinto triggersfor decompensation throughadevelopmental lensincludinga DID-afflicted client’s:1) removalfrom a traumatizingsituation;2) • childrenreachingthe same age as they were when • abused;3) later (additive)trauma;and 4) the abuser’s death. • It is interestingthat the DSM-5 states:“the dissociative disordersare placed nextto, butare notpartof, the • traumaand stressor relateddisorders,reflectingthe close relationshipbetween these diagnosticclasses”.

22. DSM-5ICD-10CROSSWALK DISSOCIATIVE IDENTITY DISORDER • DissociativeDisordersappear inseveral places inthe ICD-10, and insome ways representa holdoverfrom classichysteriadefinitions. • ICD-10 makes linkages between dissociativedisorders • and conversionsymptomsand explainthat“it alsoseems reasonableto presume thatthe same (or very similar) • psychologicalmechanismsare commonto bothtypes of symptoms” (p. 18). • Multiplepersonalitydisorderstill exists ascode F44.81 under Other Dissociative(Conversion)DisordersinICD- 10—a code thatmaps onto DID inDSM-5. • But thiscaveat is given:“If multiplepersonalitydisorder (F44.81) does exist assomethingother thana culture- • specific or even iatrogeniccondition,then itis • presumablybest placed amongthe dissociativegroup”.

23. #13:SEPARATIONANXIETY&ODDARENOTJUSTFORCHILDRENANYMORE • Notonlyhas SeparationAnxiety been expanded to • includeadults,otherdisorderssuch as ODD, Specific Phobia,Selective Mutismand ADHD have become • moreeasily diagnosablein thoseover 18 yearsof age. • This shift inthinkingconsidersdevelopmental thresholdsover chronologicalage. • Adultsymptoms of SeparationAnxiety Disorder include: • Discomfortintravellingalone • Increasedcardiovascularsymptoms • Increasedappearanceofdependencyandoverprotection • Overconcernwithpartnersandchildren

24. THISNOTTHAT ●ChildrenhaveaCriterionB duration requirementof 4weeks of symptoms comparedto6 monthsormore for adults. ●Aspecialexclusionismadefor consideringresistancetochange as connectedtoautism. ●CriterionCinDSM-IV(Theonsetis beforeage18 years)hasbeen removedasthedisordercannow applytoadults.

25. ODDREFORMATED • A. A patternof angry/irritablemood, argumentative/defiant behavior,or vindictivenesslastingat least6 monthsand • evidenced by 4+ of these symptoms ininteractionwith • anotherindividualwhoisnota sibling. • Angry/IrritableMood • oftenlosestemper • Isoftentouchyoreasilyannoyed • Isoftenangryorresentful • Argumentative/DefiantBehavior • Oftenargues withauthorityfigures/adults • Oftendefies orrefuses tocomplywithrules • Oftendeliberatelyannoysothers • Oftenblames othersforhisorhermistakes orbehaviors • Vindictiveness • Hasbeen spitefulorvindictive atleasttwiceinlast6months

26. ODDSPECIFIERS Mild(1setting) Moderate(2settings) Severe(3settings) AccordingtheDSM-5,itisnotuncommonforonewithODDtoonlyshowsymptomsathome.

27. WHYITMATTERS • The DSM-5 claims tobemore developmentallyfocusedandonewayit shows that is throughextending historicallychild-baseddisorders intoadulthood. • Before one balks at diagnosing anadult with • SeparationAnxietyDisorderorOppositionalDefiant Disorder,considerthat the alternatives are often • Dependent PDandAntisocialPDforadults--evenwhendiagnosticallyinaccurate. • Interestingly,familysystems ideas ofenmeshment have enhancedutility whenconsideringadults with SeparationAnxietyDisorder.

28. DSM-5ICD-10CROSSWALK SEPARATIONANXIETYDISORDER • Althoughthe DSM-5 has movedSAD(F93.0) tothe AnxietyDisorders,it remains inICD-10 Sectionfor BehavioralandEmotionalDisorders withonset • usuallyoccurring inchildhoodandadolescence withHyperkineticdisorders (ADHD),Conduct disorders, anddisorders ofsocialfunctioning. • ICD-10 does not elaborate onexceptions madeforadults andindicates that the diagnosis shouldnot beused unless “it constitutes anabnormalcontinuationofdevelopmentallyappropriate separationanxiety”. • This language suggests that separationanxietyinrelationtospouses andchildrenis less supported here.

29. #12:GENDERDYSPHORIAADDRESSESINCONGRUENCEOVERIDENTIFICATION • Genderdysphoriarefers to:distress that mayaccompanythe incongruence between one’s • experiencedorexpressed genderandone’s assignedgender. • The DSMIVdescribedGenderIdentityDisorderas requiring bothacross genderidentificationpiece • andpersistent discomfort about one’s assignedsex. • GenderDysphoriainDSM-5 has separate diagnosticcriteriaforchildrenvs. adolescents andadults. • Ofinterest:DSM-5 makes it apoint toreject social constructivist theories that denythe influence of biologyongenderexpression.

30. DEVELOPMENTALNORMS

31. WHATITISNOT Nonconformityto genderroles Gender Dysphoria Transvesticdisorder Schizophrenia BodyDysmorphic disorder

32. WHYITMATTERS • Proponentsof the new diagnosisstate thatit is • nota permanentcondition,buta temporarystate. • This helpsto reduce stigmaoftendirected at • transgenderedindividuals,and refutes the idea that simplybeing transgenderedis, in itself, a disorder. • Opponentsof the disorderare split. Some believe that GD should notbe considereda mental • disorderat all,and instead be more alignedwith a strictbio-medicaldesignation(as sex • reassignmentsurgeryisbeyond the psychiatric field). • Others worrythat a shiftaway from the conceptual natureof GID might reduce insurance • reimbursementof suchsurgeries.

33. DSM-5ICD-10CROSSWALKGENDERDYSPHORIA • The current DSM-5 Adult GenderDysphoriacodecurrentlymaps tothe ICD-10 codefordual-role transvestism (F64.1). • APA has petitionedthat this be change tothe code that correspondstotranssexualism ...But ineither case theyare not conceptualequals andthe ICD-10 maintainsthe trait-basedlanguage commontoDSMIVGenderIdentityDisorder. • It remains tobe seen howthe complex interplaybetween genderdysphoria,transvestism, • transvestism disorder,andeventhe continuedmurkylabelsattributedtoparaphilias willplayout withthe integration.

34. #11:TRAITBASEDPDDIAGNOSISIS OFFEREDASANALTERNATIVEINSECIII • Thoughthetraditional,categorical approachtodiagnosingPersonality • DisordersremainsintactinDSM-5,thereisanadditionalapproachoffered(SectionIII: EmergingMeasures&Models)thatreflects amoretrait-basedapproach. • Thismodelemergesoutofresearch • suggestingthatpersonalitydisordersarebothcharacterizedbyoverallfunctional • impairmentandtrait-basedpathology. • Becausemostclientsthatmeetthe • standardsforonepersonalityoftenmeetcriteriaformore,other-specified • personalitydisorderisoftencorrect,butityieldslittleadditionalinformationfor • cliniciansinwhichtoaddresstreatmentdirections.

35. GENERALCRITERIAFORPDINTHEALTERNATIVEMODEL • A.Moderateorgreaterimpairmentsinpersonalityfunctioning • B.Oneormorepathologicalpersonalitytraits • 5Domainsorderthetraitfacetsincluding:Negative Affectivity, Detachment,Antagonism,Disinhibition,andPsychoticism. • There are25traitfacets(pg.779)thatsupport theredesigneddisorders.Thoughtheyaretooextensive todiscuss infullhere, some examples include: • HostilityDepressivityEmotionalLabilityGrandiosity • C.Theimpairmentsinpersonalityfunctioningandtraitexpressionarerelativelyinflexibleandpervasiveacrosssituations • D.Theimpairmentsinpersonalityfunctioningandtraitexpressionarerelativelystableacrosstimewithonsetstraceabletoatleastadolescenceorearlyadulthood.

36. CRITERION(A)PERSONALITYFUNCTIONING • Elements • Self • Identity • Self-Direction • Interpersonal • Empathy • Intimacy • ImpairmentSeverityScale • Level0 =none • Level1 =minor • Level2 =moderate • Level3 =severe • Level4 =extreme

37. FAMILYTREE:PROPOSED NEWPDMODEL

38. DSM-5ICD-10CROSSWALKPERSONALITYDISORDERS • The ICD uses a rathersimple descriptiveapproachto personalitydisordersthatare described asa severe disturbanceinthe characterologicalconstitutionand • behavioraltendencieswith a focus on socialdisruptions. • Furtherdiagnosticguidelinesdemand that the patternis enduring,of longstanding,and notlimited to episodesof mental illness. • Some key differences between DSM-5 and ICD-10 are in the specific disorders.ICD-10 endorsesthe following • specific personalitydisorders.Therearesomekey • differencesthatmayhaveutilitytoclinicians(especiallyastheyrelatetoDissocialoverAntisocialPD,Emotionally • UnstablePDoverBorderlinePD,andAnxiousPDoverAvoidantPD.

39. DSM-5ICD-10CROSSWALKPERSONALITYDISORDERS-2 Dissocial ParanoidSchizotypal Emotionally Unstable ParanoidSchizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent OCPD Anxious Dependent Anankastic Histrionic Other

40. #10:AGORAPHOBIAREDEFINEDANDPANICSPECIFIEREXPANDED 2 needed Being in enclosed spaces Standing in lineor beingin a crowd Beingoutside of thehome alone Public Transportation Being in open spaces

41. AGORAPHOBIADSM-IVTO DSM-5VERSION • DSM-5 • A) Markedfear or anxiety about2 or more of the • five situations(listed on priorslide) • B) Personfears or avoids these situationsbecause of thoughtsthatescape mightbe difficult or help mightnotbe available. • C) The agoraphobic • situationalmostalways provokefear or anxiety • DSM IV • A) Anxiety aboutbeingin placesor situationsfrom which escape mightbe • difficult or embarrassing • or in where help mightnot be availablefrom a • predisposedpanicattack. • B) The situationsare avoided or else endured with marked distress.

42. FROMSUBTYPESTOSPECIFIERS Blood Injection- Injury Natural- Environmental Animal Situational Other

43. PANICATTACKSPECIFIER • SamesymptomsasPanicDisorder(CriterionA) • Depressive Disorders PanicAttacks Medical Conditions PTSD Substance UseDisorder

44. WHYITMATTERS • 1) The changes helpgive claritytothe differences between specificphobias andagoraphobia,andit willnowbe its owndisorderseparate from the • notorious profile ofpanicattacks. • 2) Panicattacks as aspecifierwillhave addedutilityandlikelypermit betterdiagnosis ofdepressionandtraumaticdisorders thaninthe past.

45. DSM-5ICD-10CROSSWALKAGORAPHOBIA • In thiscase, DSM-5 has morecloselyfollowed the groundworklaid by ICD-10. • The ICD-10 Agoraphobiadiagnosisdemandsthat allof the followingcriteriashouldbe fulfilled: • (a)thepsychologicalorautonomicsymptomsmustbe primarilymanifestationsofanxietyandnotsecondary symptoms • (b)theanxietymustberestrictedto(oroccurmainlyin)at leasttwoofthefollowingsituations:crowds,publicplaces, travellingawayfromhome,andtravellingalone;and • (c)avoidanceofthephobicsituationmustbe,orhavebeen,a prominentfeature. • ICD still differentiates AgoraphobiaWithPanic(F41.0) and WithoutPanic (F40.0)--ButDSM-5mapstoF41.0.

46. #9: PREMENSTRUAL DYSPHORIC DISORDER IS ADDED FOR WOMEN • A.Inthe majorityofmenstrualcycles, at least 5 symptoms must be present inthe finalweek • before the onset ofmenses, improve withinafewdays aftermenses, andbecome minimalorabsent postmenses.

47. TRACKINGPMDD • CriterionAshouldbeconfirmedbydailyratingsoverthe • courseof2menstrualcycles.Subjectivememoryshouldnotbereliedupon,butaprovisionaldiagnosiscanbemadeuntil dataiscollected. 7 6 5 4 3 2 1 0 PMDDOTHERDEP

48. THEODDTALEOFSDPDVS.DDPD • TheDSMIIIRhadbeenstronglycriticizedfor beingsexistandforpathologizingnormativefemalesocializationandbiologicalprocesses. • TheseissuescametoaheadwhiletheworkgroupsconsideredaddingSelf-DefeatingPD(SDPD)andLateLutealPhaseDysphoricDisorder(LLPDD)to • theDSMIV. • Pantony&Caplan(1991)arguedthatthedisorder DelusionalDominatingPD(DDPD)shouldbe addedtodescribementhatshowaclusterof • personalityissuesthatemergefromapressuretoconformtoarigidmasculinerole.

49. WHYITMATTERS • The additionofPMDDandsome changes tothe perinatalspecifiers need tobe consideredwhenworkingwith females that arestrugglingwith depressionoranxietysymptoms. • With peripartum onset (as opposedtopostpartum)- DSM-5 notes that as manyas 50% ofpostpartum, MDDepisodes actuallybeginbefore delivery • The concern:the DSM hasahistoryofmarginalizing andpathologizing female experiences.Ifthis new • diagnosisisnot consideredwithacriticaleye inbothform andfunction,normative biologicalprocesses • couldme wronglylabeledas dysfunction

50. DSM-5ICD-10CROSSWALKPMDD • Try thiscodingdilemmaon for size. PMDD currently mapsto the normalphysiologicalconditionof ICD-10 • premenstrualtensionsyndrome (N94.3). These aretwo very different thingsand APA has sincepetitioned that PMDD alignina more directway with the depressive • disordersgoingforward. • It would not be customaryfor ICD-10 (which addresses bothphysicaland mental disorders)to shift a • phenomenonthat has historicalbiologicalrootsto thatof a categoricaldepressivedisorder. • Since the conditionis evidenced in the currentICD code, and the conceptual battlegroundisover whether it • should be regardedas a depressivedisorder,one • wonders what the completemotivemightbe here . . .