dsm5

DSM-5 Qu debemos saber?

Rafael E. Oliveras-Rentas, Psy.D. Neuropsiclogo Peditrico Psiclogo Clnico

Catedrtico Auxiliar Departamento de Psiquiatra / Programa de Psicologa Clnica

Escuela de Medicina y Ciencias de la Salud de Ponce

CONTENIDO Introduccin al DSM Cambios Generales Revisiones y Nuevos Diagnsticos

Desrdenes Neuroevolutivos y Neurocognitivos

Otros Desrdenes y Revisiones

DSM vs ICD

INTRODUCCIN AL DSM

Diagnostic and Statistical Manual for Mental Disorders

Publicado por la Asociacin Americana de Psiquiatra (APA) Diferente a la Asociacin Americana de

Psicologa!! (tambin APA!!)

Uso del DSM

Utilidad clnica programar tratamiento Facilita comunicacin entre profesionales Herramienta educativa sobre desrdenes Para investigacin y coleccin de datos

Diagnostic and Statistical Manual for Mental Disorders

1952: DSM-I 1968: DSM-II 1980: DSM-III 1987: DSM-III-R 1994: DSM-IV 2000: DSM-IV-TR 2013: DSM-5

(Versin espaola disponible despus de octubre de 2013)

Proceso de Revisin 1999 Pre-planificacin 2007 Task force 2008-2010 Se formularon y propusieron

revisiones Abril 2010- Estudios de campo en centros

Dec 2011 acadmicos mdicos Oct 2010 Estudios de campo en clnicas Feb 2012 Dic 2012 Junta de Sndicos de la APA aprob el

borrador final May 20, 2013 Publicacin

http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

It became immediately clear that we cannot design a system based on biomarkers or cognitive performance because we lack the data. In this sense, RDoC is a framework for collecting the data needed for a new nosology. But it is critical to realize that we cannot succeed if we use DSM categories as the gold standard.2

RDoC: ejemplos Negative Valence Systems Fear (opposite pole, fearlessness): amygdala, hippocampus, interactions with

ventromedial PFC Potential threat: HPA axis, BNST, hippocampus; CRF, cortisol Positive Valence Systems Approach motivation (opposite pole anhedonia): mesolimbic dopamine pathway Habit-based behavior (including OCD spectrum): orbitofrontal cortex, thalamus,

dorsal striatum Cognitive Systems Working memory: dorsolateral PFC, other areas in PFC Cognitive (Effortful) control (opposite pole impulsivity, disinhibition,

externalizing): anterior cingulate gyrus, various areas of medial and lateral PFC Systems for Social Processes Social dominance: distributed cortical activity, mesolimbic dopamine systems;

testosterone, serotonin Facial expression recognition: ventral visual stream, fusiform gyrus Self-representational circuits: dorsal & posterior ACC, insula Arousal/Regulatory Processes Stress regulation: raphe nuclei circuits; serotonin Facilitated stimulus processing: locus coeruleus circuit; norepinephrine Readiness for stimulus processing and responding: brain resting state network

http://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml

NIMH RDoC

http://www.nimh.nih.gov/research-priorities/rdoc/index.shtml

CAMBIOS GENERALES

Estructura Organizacional

Section I: DSM-5 Basics

Section II: Essential Elements: Diagnostic Criteria & Codes

Section III: Emerging Measures and Models

Appendix

Contenido 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 8. Dissociative D/Os 9. Somatic Symptom & Related D/Os 10. Feeding & Eating D/Os 11. Elimination D/Os 12. Sleep-Wake D/Os

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

Se eliminaron los ejes

No ms ejes para documentar diagnsticos Se combinan Ejes I, II y III Se elimin el Eje IV Utilizar Z codes (ICD-10) Se elimin Eje V: GAF

Se propone utilizar el World Health Organization Disability Assessment Schedule (WHODAS)

Disponible gratis en: http://www.who.int/classifications/icf/whodasii/en/

Ejemplo

Eje I: 314.01 Deficit de Atencin con Hiperactividad, tipo Combinado

Eje II: V71.09 No diagnstico Eje III: Desorden Metablico Eje IV: Problemas relacionados al grupo

primario Eje V: GAF = 45

299.00 314.01 Deficit de Atencin/Hiperactividad, con presentacin Combinada; Desorden Metablico; V62.0 Problema relacionado al ambiente familiar

DSM-IV

DSM-5

Y esos numeritos?

International Classification of Diseases (ICD) Numricos = ICD-9 Alfanumricos = ICD-10

OBLIGADO PARA UTILIZARSE DESDE OCTUBRE DE 2014

EJEMPLO: Trastorno del Espectro de Autismo 299.00 (F84.0)

ICD-9 ICD-10

No ms NOS

Se sustituye el Not Otherwise Specified (NOS) por:

1. Other specified disorder (y se da una razn especfica por la cual es otro) Ejemplo: Other specified depressive disorder,

depressive episode with insufficient symptoms 2. Unspecified disorder

Modelos de Clasificacin Categrico (binario)

Presencia o ausencia de un desorden

Dimensional (ordinal) Dimensiones expresados en una distribucin continua

Con la intencin de moverse al uso de un sistema ms dimensional, se aaden inventarios de

severidad a los desrdenes

Dimensional

Solo 2 desrdenes tienen su propia tabla de niveles de severidad: Desrdenes del Espectro de Autismo Discapacidad Intelectual

En la seccin III hay un rango de niveles

propuestos para Esquizofrenia

REVISIONES Y NUEVOS DIAGNSTICOS DESRDENES NEUROEVOLUTIVOS Y NEUROCOGNITIVOS

DSM-5

Nuevos Desrdenes Social Communication

Disorder Disruptive mood

dysregulation disorder Excoriation (skin-picking

disorder) Hoarding disorder Binge eating disorder

Algunas de las Revisiones Discapacidad Intelectual Desorden del Espectro de

Autismo Post-Traumatic Stress

Disorder (PTSD) Trastorno bipolar Problemas Especficos de

Aprendizaje

Contenido 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 8. Dissociative D/Os 9. Somatic Symptom & Related D/Os 10. Feeding & Eating D/Os 11. Elimination D/Os 12. Sleep-Wake D/Os

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

Neurodevelopmental Disorders

Nuevo nombre a Trastornos de inicio en la infancia, niez o adolescencia del DSM-IV.

Incluye: Intellectual Disabilities Communication Disorders Autism Spectrum Disorders Attention Deficit/Hyperactivity Disorder Specific Learning Disorder Motor Disorders Other Neurodevelopmental Disorders

Intellectual Disabilities (Intellectual Developmental Disorder)

Nuevo nombre para Retraso Mental. Deficits en funciones intelectuales, segn medidos por

pruebas estandarizadas y evaluacin clnica. Inicio en periodo de desarrollo. Severidad basada en funcionamiento adaptativo

(conceptual, social, prctico), no en puntaje de IQ. Leve Moderado Severo Profundo


Otros tipos de Discapacidad Intelectual

Global Dvelopmental Delay Para nios 5 aos que no puede estimarse el grado de discapacidad por impedimentos sensoriales, fsicos, conductuales o desrdenes comrbidos.


Communication Disorders Nuevo nombre para Expressive Language

Disorder y Mixed Receptive-Expressive Language Disorder del DSM-IV.

Incluye: Language Disorder

Dificultades en la adquisicin y uso del lenguaje a travs de diversas modalidades por dficits en la comprensin o produccin.

Speech Sound Disorder

Problemas con la produccin del sonido que interfiere con la inteligibilidad o interfiere con la comunicacin


Communication Disorders (Cont) Childhood-Onset Fluency Disorder (Stuttering)

Disturbio en la fluidez y patrn expresivo por uno de los siguientes: repeticin de sonido/slaba; prolongacin de sonido; pausas en medio de palabras; pausas en el habla; circunlocuciones; tensin fsica en habla y repeticiones monosilbicas. Provoca ansiedad.

Social (Pragmatic) Communication Disorder

Dificultades en el uso verbal y no verbal de la comunicacin, incluyendo compartir informacin social apropiada (ej. saludos); no poder alterar la comunicacin para parear con el contexto; problemas para seguir las reglas de la conversacin; y problemas para comprender inferencias.

Unspecified Communication Disorder


Autism Spectrum Disorder Se unifican las categoras de Autismo, Asperger y

PDDNOS

De Triada a Diada; reagrupados de 12 a 7 criterios, donde un mnimo de 5 son requeridos. Dificultades Sociocomunicativas (3) Intereses Restrictos y Conductas Repetitivas (4)

Especificadores del nivel de severidad

Con apoyo Con apoyo sustancial Con apoyo muy sustancial)


Autism Spectrum Disorder (Cont) Se emplean especificadores de la presentacin

Con o sin discapacidad intelectual Con o sin impedimentos del lenguaje Asociado a condiciones mdicas o genticas, o factor

ambiental Asociado a otro desorden neuroevolutivo, mental o

conductual Con catatonia

Criterio de antes de los 3 aos ahora durante la niez o cuando las demandas sociales lo hagan evidente.


A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text):

1. Deficitis in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

Specify current severity: Severity is based on social communication impairments and restricted repetitive patterns

of behavior (see Table 2).

Autism Spectrum Disorder 299.00 (F84.0) Diagnostic Criteria

Autism Spectrum Disorder Diagnostic Criteria

ASD DSM-5 Criteria (Cont)

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).

4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns

of behavior (see Table 2).

C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Aspergers disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.


Specify if: - With or without accompanying intellectual impairment - With or without accompanying language impairment - Associated with a known medical or genetic condition or environmental factor (Coding note: Use additional code to identify the associated medical or genetic condition.) - Associated with another neurodevelopmental, mental, or behavioral disorder (Coding note: Use additional code[s] to identify the associated neurodevelopmental, mental, or behavioral disorder[s].) - With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119-120, for definition) (Coding note: Use additional code 293.89 [F06.1] catatonia associated with autism spectrum disorder to indicate the presence of the comorbid catatonia.)


Severity level Social communication Restricted, repetitive behaviors

Level 1 "Requiring support Without supports in place,

deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful response to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to- and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful.

Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.

Table 2 Severity levels for autism spectrum disorder



Level 2 "Requiring substantial support

Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and how has markedly odd nonverbal communication.

Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action.


Level 3 "Requiring very substantial support

Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches

Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action.


Attention Deficit/Hyperactivity Disorder

2 dominios de sntomas: Inatencin Hiperactividad/impulsividad

Al menos 6 sntomas en un dominio requerido. Adultos 5 sntomas

Inicio previo a los 12 aos Subtipos ahora son especificadores Other Specified y Unspecified ADHD como

opciones.


Specific Learning Disorder Combina desrdenes separados en el DSM-IV. Requiere evaluacin clnica y medidas estandarizadas. Especificadores

Lectura Precisin de lectura de palabras Fluidez o velocidad Compresin lectora

Expresin escrita Precisin para deletrear Precisin en gramtica y puntuacin Claridad u organizacin en la expresin escrita

Matemticas Sentido de los nmeros Memorizacin de datos aritmticos Precisin y fluidez en el clculo Precisin en razonamiento matemtico

No incluye lenguaje oral


Motor Disorders

No hubo cambios significativos.

Incluye Developmental Motor Coordination Disorder Stereotypic Movement Disorder Tic Disorders Other Specified Tic Disorder Unspecified Tic Disorder


Other Neurodevelopmental Disorders

Other Specified Neurodevelopmental Disorder

Unspecified Neurodevelopmental Disorder


Neurocognitive Disorders Reemplaza el trmino Demencia por Major and Mild

Neurocognitive Disorders. Aunque el trmino puede utilizarse como especificador

para Major ND (ej. Alzheimers Dementia)

Decline cognoscitivo en al menos 1 de 6 dominios Atencin compleja Funciones ejecutivas Memoria y Aprendizaje Lenguaje Perceptual-Motor Cognicin Social

Neurocognitive Disorders (Cont)

Major Neurocognitive Disorder Decline en al menos 1 de 6 dominios Interfiere con independencia Especificar etiologa

Mild Neurocognitive Disorder

Decline en al menos 1 de 6 dominios No interfiere con independencia Especificar etiologa

Neurocogntitive Disorders

Etiologas: Alzheimers Frontotemporal Lewy Bodies Mild Vascular Traumatic Brain Injury Substance/Medication Induced HIV Infction Prion Disease Parkinsons Hungtintons Due to Another Medical Condition Due to Multiple Etiologies Unspecified


Delirium Disturbios en atencin, consciencia y cognicin Causado por condicin mdica, uso de sustancias

o retiro Opciones de Other Specified y Unspecified

Delirium


REVISIONES Y NUEVOS DIAGNSTICOS OTROS DESRDENES Y REVISIONES

Otras Revisiones

Mutismo Selectivo Ahora pertenece a los Desrdenes de Ansiedad.

OCD & Trauma estn agrupados como 2

grupos aparte de los Desrdenes de Ansiedad.

Trastornos del Estado de nimo ahora se dividen en Bipolar & Related Disorders y Depressive Disorders

Otras Revisiones (Cont)

Premenstrual Dysphoric Disorder En el DSM-IV estuvo bajo Desrdenes que

ameritaban mayor estudio. Reconocido como un Desorden Depresivo,

relacionado a sntomas afectivos, irritabilidad, disforia y ansiedad que ocurre en la mayora de los ciclos menstruales.

Disruptive Mood Dysregulation Disorder (DMDD) Gritos, agresin y explosiones de coraje. Sobrerreaccin a estresores comunes Promedio de 3/semana por 1 ao (no sin sntomas

por mas de 3 meses) 6-18 aos Propsito: reducir el sobrediagnstico de

bipolaridad en poblacin peditrica

Otras Revisiones

Desordenes Obsesivo-Compulsivo y Relacionados Clasificacin aparte, que incluye

OCD Body Dysmorphic Disorder Hoarding Disorder Trichotillomania (Hair-Pulling) Excoriation (Skin Picking)

Otras Revisiones

Se combin abuso y dependencia en el Uso de Sustancias, y se aadi criterio de craving. Se aadi Gambling Disorder a esta seccin

como behavioral addiction; y no como Desorden de Control de Impulsos como el DSM-IV.

Nuevo Binge eating disorder

Parte de los Desrdenes de la Alimentacin.

Otras Revisiones

Revisiones menores Depresin y subtipos Ansiedad y subtipos Esquizofrenia y subtipos Desrdenes del Sueo Desrdenes Somticos Desrdenes Disociativos Desrdenes de la Eliminacin Parafilias Disfunciones Sexuales Desrdenes de la Personalidad

Otras Revisiones

Desrdenes que requieren mayor estudio

Attenuated Psychosis Syndrome Depressive Episodes with Short-Duration

Hypomania Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Neurobehavioral Disorder Associated with Prenatal

Alcohol Exposure Non-suicidal Self-Injury Suicidal Behavioral Disorder

Desrdenes Propuestos y Rechazados

Anxious Depression

Hypersexual Disorder

Parental Alienation Syndrome

Sensory Processing Disorder

DSM VS ICD

International Classification of Diseases (ICD)

ICD

Desarrollado por la Organizacin Mundial de la Salud.

Sistema de clasificacin internacional utilizada para el registro de morbilidad y mortalidad de todas las enfermedades.

ICD (Cont) Actualmente vigente: ICD-9CM

Desarrollado en el 1975

En OCTUBRE 2014 ser requisito utilizar el ICD-10 CM para facturar a planes mdicos. (ICD-10 se desarroll en 1989) Cdigos gratis en: http://www.cdc.gov/nchs/icd/icd10cm.htm

Actualmente se desarrolla el ICD-11.

CM = Clinical Modification

ICD-10

DSM & ICD

DSM-IV utiliza cdigos del ICD-9 CM Versin espaola del DSM-IV posee ambos

DSM-5 enlista ICD-9 CM e ICD-10 CM

ICD solo describe de forma narrativa la

condicin, no establece criterios diagnsticos.

Conclusiones

Hubo muchos intentos de revisiones drsticas que culminaron en revisiones menores.

Existe mucha controversia sobre su validez y su uso.

Muchos clnicos se mueven al uso del ICD-10 como descripcin de condiciones y no como manual diagnstico.

Es el libro del DSM el que debe dictar la prctica clnica?

Debe slo utilizarse para uso de facturacin?

Y qu del acercamiento a los hallazgos biolgicos de las funciones especficas y los constructos?

DSM-5 Qu debemos saber?

Rafael E. Oliveras-Rentas, Psy.D. [email protected]

GRACIAS

DSM-5Qu debemos saber?CONTENIDOIntroduccin al DSMDiagnostic and Statistical Manual for Mental DisordersUso del DSMDiagnostic and Statistical Manual for Mental Disorders(Versin espaola disponible despus de octubre de 2013)Proceso de Revisinhttp://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtmlSlide Number 11Slide Number 12RDoC: ejemplosNIMH RDoCCambios generalesEstructura OrganizacionalContenidoSe eliminaron los ejesEjemplo Y esos numeritos?No ms NOSModelos de ClasificacinDimensionalRevisiones y Nuevos diagnsticos Desrdenes Neuroevolutivos y NeurocognitivosDSM-5ContenidoNeurodevelopmental DisordersIntellectual Disabilities (Intellectual Developmental Disorder)Otros tipos de Discapacidad IntelectualCommunication DisordersCommunication Disorders (Cont)Autism Spectrum DisorderAutism Spectrum Disorder (Cont)ASD DSM-5 Criteria (Cont)ASD DSM-5 Criteria (Cont)ASD DSM-5 Criteria (Cont)Slide Number 38Slide Number 39Slide Number 40Attention Deficit/Hyperactivity DisorderSpecific Learning DisorderMotor DisordersOther Neurodevelopmental DisordersNeurocognitive DisordersNeurocognitive Disorders (Cont)Slide Number 47Slide Number 48Revisiones y Nuevos diagnsticos Otros desrdenes y revisionesOtras RevisionesOtras Revisiones (Cont)Slide Number 52Slide Number 53Slide Number 54Revisiones menoresDesrdenes que requieren mayor estudioDesrdenes Propuestosy RechazadosDsm vs icdInternational Classification of Diseases (ICD)ICDICD (Cont)ICD-10DSM & ICDSlide Number 64ConclusionesSlide Number 66DSM-5Qu debemos saber?

dsm5

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