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DSM-5 and Neurocognitive Disorders

DSM-5 and Neurocognitive DisordersJoseph R. Simpson, MD, PhDThe newest edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5 ) introduces severalchanges in the diagnostic criteria for dementia and other cognitive Disorders . Some of these changes may provehelpful for clinical and forensic practitioners, particularly when evaluating less severe cognitive impairments. Themost substantial change is that the cognitive disorder-not otherwise specified category found in prior editions hasbeen eliminated. Those Disorders that do not cause sufficient impairment to qualify for a diagnosis of dementia arenow defined as Neurocognitive Disorders and placed on a spectrum with the more severe conditions.

a mild decline in cognitive function; and 2. A modest impairment in cognitive perfor-mance, preferably documented by standard-ized neuropsychological testing or, in its ab-sence, another quantified clinical assessment. B. The cognitive deficits do not interfere with ca-pacity for independence in everyday activities

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Transcription of DSM-5 and Neurocognitive Disorders

1 DSM-5 and Neurocognitive DisordersJoseph R. Simpson, MD, PhDThe newest edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5 ) introduces severalchanges in the diagnostic criteria for dementia and other cognitive Disorders . Some of these changes may provehelpful for clinical and forensic practitioners, particularly when evaluating less severe cognitive impairments. Themost substantial change is that the cognitive disorder-not otherwise specified category found in prior editions hasbeen eliminated. Those Disorders that do not cause sufficient impairment to qualify for a diagnosis of dementia arenow defined as Neurocognitive Disorders and placed on a spectrum with the more severe conditions.

2 The conceptof social cognition is also introduced as one of the core functional domains that can be affected by a neurocognitivedisorder. This concept may be particularly significant in the evaluation of patients with non-Alzheimer s dementias,such as frontotemporal dementia. With the aging of the population and the increasing recognition of the possibilityof long-lasting cognitive deficits after traumatic brain injury, the need for assessment of cognitive Disorders inmedicolegal contexts is certain to increase. Forensic psychiatrists who perform these evaluations should under-stand the conceptualization of Neurocognitive Disorders as presented in DSM-5 and how it differs from priordiagnostic Am Acad Psychiatry Law 42:159 64, 2014 The importance of dementia in the field of forensicpsychiatry cannot be exaggerated.

3 It affects numer-ous core areas of civil and criminal forensic practice,such as testamentary capacity, capacity to consent tomedical treatment, competence to stand trial, andcriminal responsibility, to name but a few. For manypracticing forensic psychiatrists and psychologists,diagnosing dementia, determining its severity, andreaching a conclusion about its effect on the medico-legal capacity in question is a regular component oftheir work. As the average age of the population con-tinues to increase in most industrialized countries,the demand for mental health professionals who havethe expertise in dementia to address medicolegal con-cerns is certain to addition to dementia, another type of acquiredcognitive disorder, cognitive impairment after braininjury, is also becoming more and more relevant inthe forensic arena.

4 The population of people whohave sustained brain trauma at some point in theirlives is increasing. Part of the increase is related to21st century military conflicts, where tactics such asplacing improvised explosive devices under passingvehicles have produced a higher proportion of braininjuries than in previous wars. In addition, the sur-vival rate for both military and civilian brain traumahas increased relative to earlier eras when medicaltechnologies were less 3 Neurologists, neuropsychologists, and psychia-trists have also begun to examine the potential cumu-lative effects on cognition of less drastic but repeatedbrain injuries. Persistent cognitive impairment re-sulting from repeated concussions ( , mild trau-matic brain injuries) has been linked to chronictraumatic encephalopathy (CTE), a neuropatho-logical finding associated with a dementing condi-tion long known in boxers (dementia pugilistica) andnow thought to have affected some Introduced by DSM-5 The Diagnostic and Statistical Manual of MentalDisorder, Fifth Edition ( DSM-5 ),5contains revi-sions of the diagnostic criteria and nomenclature fordementia and other cognitive Disorders .

5 The name ofthe diagnostic category has been changed; the sectionentitled delirium, dementia and amnestic and othercognitive Disorders in the fourth edition and subse-quent text revision (DSM-IV6and DSM-IV-TR7)isnow Neurocognitive Disorders , or NCDs. The de-mentias, if the clinician prefers, can still be referred toby their traditional names ( , Alzheimer s demen-Dr. Simpson is Staff Psychiatrist, Los Angeles County Jail MentalHealth Services, and clinical Associate Professor, Department of Psy-chiatry and Behavioral Sciences, University of Southern CaliforniaKeck School of Medicine, Los Angeles, CA. Address correspondenceto: Joseph R. Simpson, MD, PhD, Box 818, Hermosa Beach, CA90254. E-mail: of financial or other potential conflicts of interest: 42, Number 2, 2014 SPECIAL SECTIONtia, vascular dementia, dementia due to Hunting-ton s disease).

6 All the diagnostic entities found in theprior section are subsumed under the new NCD ru-bric, and therefore cognitive impairments that arenot severe enough to qualify for a diagnosis of de-mentia are now also defined as belonging to the cat-egory of NCDs. They are no longer referred to by thedescriptor not otherwise specified (NOS) found the previous classification system, cognitiveimpairments not meeting the criteria for dementiawere labeled cognitive disorder NOS, or perhaps age-related cognitive decline. The non-DSM term mildcognitive impairment (MCI) has also been in wide-spread use in the elderly population, despite its lim-ited clinical value. Patients identified as having MCIare known to progress to dementia at a higher ratethan age-matched patients without MCI, but thereare currently no therapeutic interventions to delay orprevent progression, nor are there any reliable pre-dictors of which patients with MCI will the new system, cognitive impairments that donot reach the threshold for a diagnosis of dementiaare termed mild NCDs, whereas the dementias con-stitute nearly all of the major diagnostic criteria for mild NCD include:A.

7 Evidence of modest cognitive decline from a pre-vious level of performance in one or more cogni-tive domains (complex attention, executive func-tion, learning and memory, language, perceptualmotor, or social cognition) based on:1. Concern of the individual, a knowledgeableinformant, or the clinician that there has beena mild decline in cognitive function; and2. A modest impairment in cognitive perfor-mance, preferably documented by standard-ized neuropsychological testing or, in its ab-sence, another quantified clinical The cognitive deficits do not interfere with ca-pacity for independence in everyday activities( , complex instrumental activities of daily liv-ing such as paying bills or managing medicationsare preserved, but greater effort, compensatorystrategies, or accommodation may be required[Ref.)]

8 5, p 605].The concept of a continuum between mild andmajor NCDs is explicitly noted. Major and mildNCDs exist on a spectrum of cognitive and func-tional impairment (Ref. 5, p 607). The distinctionbetween major and mild NCD is inherently arbi-trary, and the Disorders exist along a continuum. Pre-cise thresholds are therefore difficult to determine (Ref. 5, p 608).The use of standardized neuropsychological test-ing is specifically discussed in the context of distin-guishing between major and mild NCDs. Evidenceof impairment on standardized testing is CriterionA2 for both types of NCDs (substantial for major,modest for minor NCD), although other quantifiedclinical assessments can be used when standardizedtesting is not practical.

9 It is noted that standardizedtesting is particularly important when evaluating pa-tients with suspected mild NCD, and suggested cut-offs are provided: For major NCD, performance istypically 2 or more standard deviations below appro-priate norms (3rd percentile or below). For mildNCD, performance typically lies in the 1 2 standarddeviation range (between the 3rd and 16th percen-tiles) (Ref. 5, p 607).The mild -major continuum will undoubtedlytake some getting used to. Under the new schema,any cause of dementia can also produce mild , both major and mild NCD due to Alzheimer sdisease are diagnosable conditions. Clinicians mayfind it awkward to apply the Alzheimer s label topatients who do not meet criteria for dementia, asAlzheimer s has heretofore been essentially synony-mous with senile dementia.

10 This type of usage maybe less confusing for mild NCD due to, for example,Parkinson s or Huntington s disease, in which othersymptoms are often much more prominent than thecognitive impairments, particularly early in thecourse of adding to the confusion, the term mildhas been retained as a specifier of severity for themajor NCDs, along with moderate and severe. So,for example, in DSM-5 we find this sentence: Apa-thy is common in mild and mild major NCD ( , p. 607). It seems unwieldy that the same adjective, mild , can be used either in reference to an NCD notsevere enough to qualify as a dementia or when de-scribing the severity of a particular clinical case ofdementia ( , a major NCD). In other words, apatient can have mild NCD (not a dementia), mildmajor NCD, moderate major NCD, or severe majorNCD (these latter three are all dementias).


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