How 'bout that DSM-5-TR?

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Hey! There's only room for one lobster here! :rage:

To the above though, meh. Haven't seen everything, but adding prolonged grief disorder and the definitions of "mild", "moderate", and "severe" for manic episodes are the only really relevant points I'm seeing. I'd like to see the data on the former that would make it necessary to create a new disorder. I like that there's more concrete definitions for mild/moderate/severe mania, but don't really see how "mild" mania is any different from hypomania. Seems like a needless specifier.
 
You excited for the new episodes coming to Hulu? I am!
 
I want to see the new Autism criteria
 
nexus73 said:
DSM is dead to me until they bring back mood disorder NOS (or unspecified)
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Apparently, they are.

"Additionally, the category “Unspecified Mood Disorder” was restored in DSM-5-TR for mixed mood presentations that do not meet criteria for a bipolar or depressive disorder. The absence of unspecified mood disorder from DSM-5 was an unintentional byproduct of the decision to eliminate the mood disorders diagnostic class from DSM-5 in favor of making bipolar disorders and depressive disorders top-level diagnostic classes."
 
Liquid8 said:
Feel like I'm waiting for a DLC/patch upgrade... which diagnoses get nerfed/buffed?
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I think we can rest assured that whatever they decide, they will continue to make a mess of trauma-related disorders. Pretty soon, seeing Wile E. Coyote fall off a cliff will be a Criterion A qualifying event.
 
WisNeuro said:
I think we can rest assured that whatever they decide, they will continue to make a mess of trauma-related disorders. Pretty soon, seeing Wile E. Coyote fall off a cliff will be a Criterion A qualifying event.
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While we still won’t have a great way to diagnostically differentiate between someone who has PTSD from being sexually assaulted once in college vs trauma related symptoms from being repeatedly assaulted for years in grade school.
 
calvnandhobbs68 said:
While we still won’t have a great way to diagnostically differentiate between someone who has PTSD from being sexually assaulted once in college vs trauma related symptoms from being repeatedly assaulted for years in grade school.
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Oh man, don't get us started over here on the debacle that is "complex PTSD."
 
I'm kind of annoyed that they are calling it the DSM-5 TR because the whole point of switching from Roman to Arabic numerals was that future iterations of the DSM would be iterative point additions (5.1, 5.2, etc). Use the numbering structure you revised with intention you cowards!

As to the changes I need to fully review them before I pass judgment. I've had some prolonged grief patients that make me thankful for that particular inclusion and I'm always a fan of re-adding NOS diagnoses because sometimes people just don't fit in boxes
 
Liquid8 said:
Feel like I'm waiting for a DLC/patch upgrade... which diagnoses get nerfed/buffed?
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For the next big patch I'm predicting a big buff to PTSD that will be an overcorrection and disrupt the meta, while depressive disorders are going to take a big nerf as many of their defining traits are absorbed into the PTSD ability tree. Pharma players are going to scramble to adjust to this new meta to make current player-based economies still function as they did pre-patch, and I have a feeling we'll see some unexpected uses of old consumables to account for the newly redistributed abilities between the PTSD and depression trees.
 
Mad Jack said:
I'm kind of annoyed that they are calling it the DSM-5 TR because the whole point of switching from Roman to Arabic numerals was that future iterations of the DSM would be iterative point additions (5.1, 5.2, etc). Use the numbering structure you revised with intention you cowards!
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I am so glad someone else is as annoyed as I am by this. I thought I was the only one.
 
allantois said:
I want to see the new Autism criteria
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Liquid8 said:
Feel like I'm waiting for a DLC/patch upgrade... which diagnoses get nerfed/buffed?
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Huge nerf to "ASD" and buff to ASD. Now a person must have all 3 parts of criterion A (deficits in social-emotional reciprocity; deficits in nonverbal communicative behaviors and deficits in developing, maintaining and understanding relationships).
 
Forms haven't even gotten over DSM-IV-TR.
Now we're coming out with this revision?

I might just become that older doc, my younger self cringed at, and be a DSM-5'er for life.

I still see people rooted in DSM-IV documentations...
 
FlowRate said:
Huge nerf to "ASD" and buff to ASD. Now a person must have all 3 parts of criterion A (deficits in social-emotional reciprocity; deficits in nonverbal communicative behaviors and deficits in developing, maintaining and understanding relationships).
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Yeah the diagnosis confirm on ASD was just way too easy to land, hopefully this makes autism mains stop just button mashing all day.
 
clausewitz2 said:
Yeah the diagnosis confirm on ASD was just way too easy to land, hopefully this makes autism mains stop just button mashing all day.
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Really poor messaging by the devs on how the ASD trait works. Players aren't supposed to pick it up when their character is actually capable of putting points in CHA. Especially when their class needs CHA for some of its abilities.
 
They definitely should have called this 5.1, or may be 5.01...
 
Mad Jack said:
For the next big patch I'm predicting a big buff to PTSD that will be an overcorrection and disrupt the meta, while depressive disorders are going to take a big nerf as many of their defining traits are absorbed into the PTSD ability tree. Pharma players are going to scramble to adjust to this new meta to make current player-based economies still function as they did pre-patch, and I have a feeling we'll see some unexpected uses of old consumables to account for the newly redistributed abilities between the PTSD and depression trees.
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You are a big nerd, and I'm also a big nerd for understanding this completely
 
comp1 said:
They definitely should have called this 5.1, or may be 5.01...
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5.1 makes it seem like it’s an imperfect system (which of course it is) but might send the wrong message out to the public. Also, are they even planning more revisions before DSM 6?
 
allantois said:
5.1 makes it seem like it’s an imperfect system (which of course it is) but might send the wrong message out to the public. Also, are they even planning more revisions before DSM 6?
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Depends on if they introduced any unrecognized bugs or balance issues in this new version. They seem to be indicating this is the stable branch until the next major release.
 
MedMan80 said:
my understanding is mood disorder is back baby!
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nexus73 said:
The last diagnosis I’ll ever need.
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Don't forget Psychotic Disorder NOS.

"Unspecified Schizophrenia Spectrum and Other Psychotic Disorder". Too wordy, and probably by design. Lay people think it's actually a schizophrenia diagnosis.

Bring back psychotic d/o NOS!
 
Orgone said:
Don't forget Psychotic Disorder NOS.

"Unspecified Schizophrenia Spectrum and Other Psychotic Disorder". Too wordy, and probably by design. Lay people think it's actually a schizophrenia diagnosis.

Bring back psychotic d/o NOS!
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They do have a psychosis unspecified in icd10. F29 I think. And icd 10 is what gets used for billing anyways. They also have a mood unspecified in icd10 F 39 I think. So psychosis unspecified exists and you can be more worldly because it’s the international code.
 
nexus73 said:
They do have a psychosis unspecified in icd10. F29 I think. And icd 10 is what gets used for billing anyways. They also have a mood unspecified in icd10 F 39 I think. So psychosis unspecified exists and you can be more worldly because it’s the international code.
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F29 is unspecified psychotic disorder not due to a substance or known physiological condition. It's a lot narrower than psychotic disorder nos.
 
Well then, have I got some great news for y'all...
20220325_053612.jpg
 
calvnandhobbs68 said:
How...?
As long as you don't have a substance induced psychosis or you think they have some medical condition causing psychosis you'd be able to use it.
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In my patient population from residency, especially the psych ER, 50%+ came in positive for PCP +/- amphetamines and/or cocaine. I always felt uncomfortable specifying that it was not due to a substance when there's the distinct probability that the substances were at least contributing to the psychosis.

We also didn't do any medical workup prior to sending them to IP psych, which I guess we could say it's not a "known" medical condition if we haven't gotten labs or imaging. The IP psych hospitals usually didn't get labs, either.
 
ObsequiousAplomb said:
In my patient population from residency, especially the psych ER, 50%+ came in positive for PCP +/- amphetamines and/or cocaine. I always felt uncomfortable specifying that it was not due to a substance when there's the distinct probability that the substances were at least contributing to the psychosis.

We also didn't do any medical workup prior to sending them to IP psych, which I guess we could say it's not a "known" medical condition if we haven't gotten labs or imaging. The IP psych hospitals usually didn't get labs, either.
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Then call it substance induced psychosis until they go sober up and you see what they're like without PCP on board...sometimes you just gotta try to commit one way or the other.

Why would you assume it was secondary to a medical condition if there's no indication that there's a medical condition contributing? If you're concerned about an underlying medical problem, get the labs and imaging. With that reasoning you can't "know" any psych condition isn't secondary to a medical condition unless you're working up every patient who comes into your office for every possible reason they could have whatever psychiatric symptoms.
 
calvnandhobbs68 said:
Then call it substance induced psychosis until they go sober up and you see what they're like without PCP on board...sometimes you just gotta try to commit one way or the other.

Why would you assume it was secondary to a medical condition if there's no indication that there's a medical condition contributing? If you're concerned about an underlying medical problem, get the labs and imaging. With that reasoning you can't "know" any psych condition isn't secondary to a medical condition unless you're working up every patient who comes into your office for every possible reason they could have whatever psychiatric symptoms.
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They might have lupus for example
 
calvnandhobbs68 said:
Then call it substance induced psychosis until they go sober up and you see what they're like without PCP on board...sometimes you just gotta try to commit one way or the other.

Why would you assume it was secondary to a medical condition if there's no indication that there's a medical condition contributing? If you're concerned about an underlying medical problem, get the labs and imaging. With that reasoning you can't "know" any psych condition isn't secondary to a medical condition unless you're working up every patient who comes into your office for every possible reason they could have whatever psychiatric symptoms.
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I would like if I had that option. As a resident I was told to just use F29 because insurance covers that better. The attendings also said there was no definitive proof it was substance induced.

If there were indicators of a medical problem it still would not have made it possible to get blood work at a facility with no option for blood work or imaging. In the interim while working it up, what do you call it? I would prefer to just be able to say NOS.
 
calvnandhobbs68 said:
Then call it substance induced psychosis until they go sober up and you see what they're like without PCP on board...sometimes you just gotta try to commit one way or the other.

Why would you assume it was secondary to a medical condition if there's no indication that there's a medical condition contributing? If you're concerned about an underlying medical problem, get the labs and imaging. With that reasoning you can't "know" any psych condition isn't secondary to a medical condition unless you're working up every patient who comes into your office for every possible reason they could have whatever psychiatric symptoms.
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This is classic Occam's razor. If PCP is on board it is PCP until proven otherwise. If presenting with a condition, rule out the likely medical causes first then assume psych unless odd stuff is present that tends toward a medical diagnosis, such as in patients presenting with purely visual hallucinations but no other psychotic symptoms.
 
Mad Jack said:
This is classic Occam's razor. If PCP is on board it is PCP until proven otherwise. If presenting with a condition, rule out the likely medical causes first then assume psych unless odd stuff is present that tends toward a medical diagnosis, such as in patients presenting with purely visual hallucinations but no other psychotic symptoms.
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I agree. The most reasonable thing to do is act as if it's substance induced.

It's not like these patients are first episode. They're mostly engaged with ACT teams in the community, receiving SSI for schizophrenia. Of course, the urine is almost always positive for PCP and a host of other things. The times it isn't positive, based on clinical presentation it seems to be at least partial malingering.

That said, the diagnosis used in that psych ER for that patient population with those UDS results is almost always F29. Not once during training did I ever see someone use the substance induced psychosis diagnosis, in any setting.
 
ObsequiousAplomb said:
I agree. The most reasonable thing to do is act as if it's substance induced.

It's not like these patients are first episode. They're mostly engaged with ACT teams in the community, receiving SSI for schizophrenia. Of course, the urine is almost always positive for PCP and a host of other things. The times it isn't positive, based on clinical presentation it seems to be at least partial malingering.

That said, the diagnosis used in that psych ER for that patient population with those UDS results is almost always F29. Not once during training did I ever see someone use the substance induced psychosis diagnosis, in any setting.
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We used the appropriate diagnosis even if it wasn't billable, for ethical reasons. Formulation would show F29 as a ruleout, as well as brief psychotic disorder if it was a first episode. Usually they would have a billable secondary diagnosis that led to admission, but if not it was no big deal. We had a *lot* of obvious substance-induced psychosis in our community that would rapidly resolve spontaneously with some elapsed time and no meds or just benzos for agitation in the ER (mostly cocaine and meth)
 
Stagg737 said:
I'm still waiting for the day that they do something about the dumpster fire that is conduct disorder, imo the most worthless "disorder" in the DSM.
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Conduct disorder is pretty useful in some cases. I've had quite a few kids that have sadistic behavior with no regard for others (torturing animals, abusing others, attempted murder and the like) where it is a good stand-in for "this one has nothing that is conventionally treatable, they hurt others because they enjoy it or have no regard for the wellbeing of others and have no moral compass as we understand it." Often they will have a first-degree relative with a history of prolonged incarceration for significant violence who had similar traits throughout their life.

What do you think is the issue with conduct disorder? And what would you change?
 
Mad Jack said:
We used the appropriate diagnosis even if it wasn't billable, for ethical reasons. Formulation would show F29 as a ruleout, as well as brief psychotic disorder if it was a first episode. Usually they would have a billable secondary diagnosis that led to admission, but if not it was no big deal. We had a *lot* of obvious substance-induced psychosis in our community that would rapidly resolve spontaneously with some elapsed time and no meds or just benzos for agitation in the ER (mostly cocaine and meth)
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If it was rapidly resolving in under 5 days, doesn't sound like it was methamphetamine induced psychosis, but simply methamphetamine intoxication. One of the frustrating aspects of the PCP patients is that it tends to last a bit longer than the meth patients. And of course almost all of my attendings believed it was inappropriate to admit anyone without giving them an antipsychotic, despite a fair amount of evidence that APs are not helpful in PCP psychosis.
 
ObsequiousAplomb said:
If it was rapidly resolving in under 5 days, doesn't sound like it was methamphetamine induced psychosis, but simply methamphetamine intoxication. One of the frustrating aspects of the PCP patients is that it tends to last a bit longer than the meth patients. And of course almost all of my attendings believed it was inappropriate to admit anyone without giving them an antipsychotic, despite a fair amount of evidence that APs are not helpful in PCP psychosis.
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Occasionally we had a few with true amphetaminr psychosis, but usually it was more intoxication with psychotic features. Rare was the patient that would last longer than 3-5 days, and benzos were the go-to specifically to prove that it was related to substance use and avoid chalking it up to an underlying psychotic disorder. If you use antipsychotics you'll never be sure- do they have bipolar disorder or schizophrenia that is acting up due to substance use, or is this just the drugs? It obfuscates diagnostic clarification.

Thankfully we didn't have much PCP around, was 80% meth, 15% cocaine, 5% other (excluding marijuana, which I feel like is a different animal when it comes to substance-induced psychosis).
 
Mad Jack said:
Occasionally we had a few with true amphetaminr psychosis, but usually it was more intoxication with psychotic features. Rare was the patient that would last longer than 3-5 days, and benzos were the go-to specifically to prove that it was related to substance use and avoid chalking it up to an underlying psychotic disorder. If you use antipsychotics you'll never be sure- do they have bipolar disorder or schizophrenia that is acting up due to substance use, or is this just the drugs? It obfuscates diagnostic clarification.

Thankfully we didn't have much PCP around, was 80% meth, 15% cocaine, 5% other (excluding marijuana, which I feel like is a different animal when it comes to substance-induced psychosis).
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Far too many folks jump to antipsychotics in stimulant intoxication and it's baffling to me.
 
docksan said:
Far too many folks jump to antipsychotics in stimulant intoxication and it's baffling to me.
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Yeah it always makes my skin crawl seeing that. A little bit of Klonopin goes a long way. A moderate amount takes care of the acute problem altogether.
 
Mad Jack said:
Conduct disorder is pretty useful in some cases. I've had quite a few kids that have sadistic behavior with no regard for others (torturing animals, abusing others, attempted murder and the like) where it is a good stand-in for "this one has nothing that is conventionally treatable, they hurt others because they enjoy it or have no regard for the wellbeing of others and have no moral compass as we understand it." Often they will have a first-degree relative with a history of prolonged incarceration for significant violence who had similar traits throughout their life.

What do you think is the issue with conduct disorder? And what would you change?
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It's been discussed in other threads, but the breadth of what we can technically call conduct disorder is ridiculous. There's a significant difference between the truly "psychopathic" kids who are sadistic and cruel and the kids that just don't have appropriate environments or role models and have behavioral outbursts that reflect that. I think an obscene number of kids within the foster system that I've treated technically meet criteria for "conduct disorder", but most kids who get diagnosed with that don't end up with ASPD like is often taught.

Imo it either needs to be a lot more specific or split into separate disorders. The specifiers help, but are still inadequate.
 
SeniorWrangler said:
It's weird that they just keep coming out with new iterations of the DSM as people take the DSM less and less seriously. At least D&D 5th Edition is widely liked and brought a lot of new fans to the hobby.
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Best roll your saving throws now.
 
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