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
Neurodevelopmental Disorders
Otros tipos de Discapacidad Intelectual
Global Dvelopmental Delay
Para nios <5 aos que no pueden evaluarse su
severidad de forma confiable, y requieren
reevaluacin.

Unspecified Intellectual Disability
Nios >5 aos que no puede estimarse el grado de
discapacidad por impedimentos sensoriales,
fsicos, conductuales o desrdenes comrbidos.
Neurodevelopmental Disorders
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
Neurodevelopmental Disorders
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

Neurodevelopmental Disorders
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)
Neurodevelopmental Disorders
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.

Neurodevelopmental Disorders

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.


ASD DSM-5 Criteria (Cont)
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.)
ASD DSM-5 Criteria (Cont)
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
Table 2 Severity levels for autism spectrum disorder
Severity level Social communication Restricted, repetitive
behaviors




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.
Severity level Social communication Restricted, repetitive
behaviors

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.
Table 2 Severity levels for autism spectrum disorder
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.
Neurodevelopmental Disorders
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
Neurodevelopmental Disorders
Motor Disorders
No hubo cambios significativos.

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

Unspecified Neurodevelopmental Disorder
Neurodevelopmental Disorders
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
Neurocogntitive Disorders
Delirium
Disturbios en atencin, consciencia y cognicin
Causado por condicin mdica, uso de sustancias
o retiro
Opciones de Other Specified y Unspecified
Delirium
Neurocogntitive Disorders
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.
neuropsicologiapr@gmail.com

GRACIAS