Changes in DSM-5 Could Affect Some Disability Insurance Claims

More than a decade after work began on updating and revising the Diagnostic and Statistical Manual of Mental Disorders, DSM-5 replaced DSM-IV-TR in May 2013.  While some of the changes in diagnostic criteria for disabilities such as intellectual developmental and specific learning disorders or the addition of new diagnoses in DSM-5 for disorders such as hoarding and gender dysphoria are unlikely to affect the private disability insurance claim of a doctor or dentist, the changes in the criteria for diagnosing post-traumatic stress disorder or substance-related and addictive disorders and the addition of the diagnoses of social (pragmatic) communication disorder and mild neurocognitive disorder have potential implications in the context of private disability insurance claims.  Additionally, the elimination of the Global Assessment of Functioning (GAF) scale, widely used by insurance companies in determining the medical necessity of treatment, is likely to have an effect on some disability insurance claim determinations.

Some of the changes in DSM-5 are outlined below.

Social (Pragmatic) Communication Disorder:  This new diagnosis, which cannot be diagnosed unless autism spectrum disorder has been ruled out, is described by the American Psychiatric Association as pertaining to individuals “who have significant problems using verbal and nonverbal communications for social purposes, leading to impairments in their ability to effectively communicate, participate socially, maintain social relationships, or otherwise perform academically or occupationally. . . Symptoms must be present in early childhood even if they are not recognized until later. . .”

Substance-Related and Addictive Disorders:  The categories of substance abuse and substance dependence have been combined, and the criteria for a diagnosis have been strengthened.  Where DSM-IV required only one symptom for a diagnosis of substance abuse, DSM-5 requires 2-3 symptoms from a list of 11 potential symptoms.  Drug craving has been added to the list of symptoms and “problems with law enforcement” has been eliminated due to cultural differences in law enforcement internationally.

Post-Traumatic Stress Disorder:  There are a couple of significant changes in the diagnostic criteria for post-traumatic stress disorder (PTSD).  The requirement of DSM-IV that the person personally experience or witness the traumatic event has been eliminated and DSM-5 allows for a PTSD diagnosis when the person has learned that the traumatic event occurred to a close family member or friend, or experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (from sources other than media, photos, television or movies, unless work-related).  Additionally, the requirement that the person experience “fear, helplessness or horror at the time of the traumatic event” has been deleted.

The criteria has also been changed to require “actual or threatened death, serious injury, or sexual violence.”  The previous manual also allowed for “a threat to the physical integrity of self or others” but did not specify sexual violence.

Mild Neurocognitive Disorder:  The American Psychiatric Association describes this new disorder in DSM-5 as “an opportunity for early detection and treatment of cognitive decline before patients’ deficits become more pronounced and progress to major neurocognitive disorder (dementia) or other debilitating conditions.”  The APA goes on to characterize the disorder as:

Mild neurocognitive disorder goes beyond normal issues of aging.  It describes a level of cognitive decline that requires compensatory strategies and accommodations to help maintain independence and perform activities of daily living.  To be diagnosed with this disorder, there must be changes that impact cognitive functioning.  These symptoms are usually observed by the individual, a close relative or other knowledgeable informant, such as a friend, colleague, or clinician, or they are detected through objective testing.

Global Assessment of Functioning (GAF) Scale:  The GAF scale of 1-100, which was a single global assessment combining separate assessments of symptom severity, danger to self or others, and ability to care for oneself and function socially, has been eliminated from DSM-5.  In the place of assigning a GAF number, separate assessments of severity and disability are recommended.  The World Health Organization Disability Assessment Schedule (WHODAS 2.0) was determined to be the best current measure of disability for routine clinical use by the DSM-5 Disability Study Group.

The changes in DSM-5 are, of course, far more complex and detailed than what we have outlined above, but if you are suffering from a mental disorder and thinking of filing a private disability insurance claim, we recommend that you coordinate with not only your psychiatrist but an attorney before filing your claim with your insurer.

More information related to DSM-5 is available at this link.

Search Our Site