STATE OF CALIfOftNIA-OFFICE (~">>^^ ~NI i(~'~ (~~,4. ~~~~~ f ~` f ~ \` ' - ~ ~j,.f ~ ~ ~~' FOP US2 b~( .SBCI'@t8f)/ Of .5'tBtB OfI~Yi ~ ~ ~ ee instructions onNOTICE PUBLIC~F '~~~~t~~'~" 4̀kt~~T~~'11~5 ~AIf~~€1~~9~?~ ~ reverse)STD. 400 fREV. 01-2013)

F•~~-:a:r~~ ~.~ :~"~ L:~•- - -- - .,_ . _

OAL FILE NOTICE FILE NUMBER REGULATORY ACTION NUMBER ~y E+~MERG CY N B R

NUh9BERS Z. ~& ! '~ ~ ~ ° O

For use by Once of Administrative Law (OAS) only

NOTICE REGULATIONS

AGENCY WITH RUI.EMAKING AUTHORITY AGENCY FILE NUMBER (If any)

Department of State Hospitals

A. PUBLICATION OF NOTICE (Complete for publication in Notice Register1. SUBJECT OF NOTICE TITLES) FIRST SECTION AFFECTED 2. REQUESTED PUBLICATIpN DATE

3. NOTICE TYPE 4. AGENCY CONTACT PERSON TELEPHONE NUMBER FAX NUMBER (Optional)

Notice re Proposed~' Regulatory Action ❑' Other

OAL SSE ~'~~IGN c~N PROPOSED NOTICE NgTICE R'~GISTEf2 tiUMBER ~'J BLICATIO~J DATE

~~ ~Y I—? Ap~~~rovecl as Approved as i ~~sa GProveq;

U SuGmitYed ~ Modifed ~ V4!tndrawn

B. SUBMI5510N OF REGULATIONS iComplete when submitting regulations)-- --_

1a. SUBJECT OF REGULATION(5) 1b. ALL PREVIOUS RELATED OAL REGULATORY ACTION NUMBER{S)

Incompetent to Stand Trial Admissions Process 2016-0906-03E, 2017-0375-01 EE

2. SPECIFY CALIFORNIA CODE OF REGULATIONS TIRES) AND SECTIONS) (Including title 26, if toxic related)

SECTIpN(5) AFFECTED(List all section numbers)

individually. Attachadditional sheet if needed.)TITIE(S)

9

4710, 4711, 4712, 4713; 4714, 4715, 4716, 4717vu

!AL

---__3. TYPE OFFlLING

Regular Rulemaking (Gov. ~ certificate of Compliance: The agency o~cer named Emergency Readopt (Gov. Changes Without RegulatoryCode §11346) below certifies that this agency complied with the Code, 411346) (h)) Effect (Cad. Code Regs., title❑ Resubmittal of disapproved or provisions of Gov. Code §§11346.2-113473 either 1, §100)

withdrawn nonemergency before the emergency regulation was adopted orfiling (Gov. Code §§113493, within the time period required by statute.

❑Fide &Print ~ Print Only

11349.4)

Emergency (Gov. Code, ~ Resubmittal of disapproved or withdrawn ~ Other (Specify)§77346.7(b)) emergency filing (Gov. Code, §11346.1)

4. ALL BEGINNWG AND ENDING DATES OF AVAiIABILITY Of MODIFIED REGULATIONS AND/OR MATERIAL ADDED TO THE RULEMAKING FILE (Cal. Code Regs. title 1, §44 and Gov. Code §71347.7)

5. EFfECfIVE DATE OF CHANGES (Gov. Code, §§ 11343.4, 17346.7 (d); Cal. Code Regs., title 7, §100) -

Effective January 1, April 1, July 1, or X Effective on filing with 4t00Changes Without . EffectiveOctober 1 (Gov. Code §11343A(a)) ~ Secretary of State ❑ Regulatory Effect ~ other (Specify)

6. CHECK IF THESE REGULATIONS REQUIRE NOTICE TO, OR REVIEW, CONSULTATION, APPROVAL OR CONCURRENCE BY, ANOTHER AGENCY OR ENTITY

Department of Finance (Form STD. 399) (SAM 46660) ~ Fair Political Practices Commission ~ State Fire Marshal

Other {Specify)

7. CONTACT PERSON TE~EPHpNE NUMBER FAX NUMBER (Optional) E-MAIL ADDRESS (Optional)n_~__i__r_u._ n~c r_ee oeee neG Gc~ onnn .l......~I,.., F..II.~~.J~I~~~.....~

1 certify that the attached copy of the regulation{Sj is a true and correct copyof the regulations) identified on this form, that the information specified on this form

is true and correct, and that 1 am the head of the agency taking this action,

Pam Ahlin, Director

INCOMPETENT TO STAND TRIAL ADMISSIONS PROCESS

TITLE 9. REHABILITATIVE AND DEVELOPMENTAL SERVICESDIVISION 1. DEPARTMENT OF MENTAL HEALTHCHAPTER 16. STATE HOSPITAL OPERATIONS

.:Adopt ARTICLE 7. ADMISSIONS

Adopt Sections 4700, 4710, 47.11,.4712, 4713, 4714, 4715, 4716 and 4717

4700. Definitions.

(a) "Low/moderate security risk" means any individual who has noescape/escape ~attempt(s) history from a locked facility, state hospital, lockedpsychiatric facility, or correctional facility.

(b) "High .security risk" means an individual with a history of escape/escapeattempts) from a locked facility or a successful escape from a state hospital,locked. psychiatric facility, or correctional facility.

(c) "Psychiatric acuity" means an individual's condition that is evidenced by thefact that an individual's mental illness isleading to complications which. putthe individual at risk of death or serious injury while awaiting admission. 'Forpurposes of assessing psychiatric acuity, the individual would need to exhibitmore than aggressive behavior alone.

Note: Authority cited: Sections 4005.1 and 4027, Welfare and Institutions Code.Reference: Section 1370, Penal Code; and Sections 7228 and 7230, Welfareand Institutions Code.

4710. Admission of Individuals Found Incompetent to Stand Trial

(a) When scheduling admission of individuals committed by the courts to theDepartment of State Hospitals pursuant to Penal Code section 1370, thedepartment will admit such. individuals in relation to the individuals' respectivecommitment date, such that the order of admission will be determined by theearlier of the individuals' respective commitment dates. This order of admissionby commitment date may be changed by the department under :any of the ,following circumstances:

(1) Bed availability at the facility under consideration for the individuaPsplacement;

(2) Whether the psychiatric acuity of the individual indicates the need fora priority admission to a facility;

1

{3) Whether the medical needs of the individual can presently be clinicallyaccommodated by the facility under consideration for the individuaPsplacement;

(4) The transportation ability or timing of the committing countytothefacility under consideration for. the individuaPs placement; or thecommitting county's inability to transport the committed individual forany other reason.

(b) For individuals committed and/or admitted by the courts to the Department ofState Hospitals who are placed in a jail-based competency program pursuant toPenal Code section 1370, if that jail-based competency program determines thatit cannot appropriately serve the individual, the individual shall be admitted to astate hospital in the order of admission that reflects the individuaPs originalcommitment date to the Department of State Hospitals.

Note: Authority cited: Sections 4005.1 and 4027, Welfare and Institutions Code.Reference: Section 1370, Penal Code; and Sections 7228 and .7230, Welfareand Institutions Code.

4711. Admissions Documentation for Individuals Found Incompetent toStand Trial

(a) A county committing an individual to the Depa~ment of State Hospitals under

Penal Code section 1370 shall submit a commitment packet to the departmentfor review and approval prior to the admission of the individual

{b) The commitment packet shall include:

{1) The commitment order, including a specification of the charges.

(2) A computation or statement setting forth the maximum term ofcommitment.

(3) A computation or statement setting forth the amount of credit for timeserved, if any, to be .deducted from the maximum term of commitment.

(4} The state summary criminal history information.

(5) Any arrest reports) from police departments or other law enforcement.agencies.

(6) Any court-ordered psychiatric examination or evaluation reports.

(7) The placement recommendation report prepared by the communityprogram director of the forensic conditional releaseprogram.

2

(8) Records of any finding of mental incompetence pursuant to thischapter arising out of a complaint charging a felony offense specified inPenal Code section 290 or any pending Penal Code section 1368proceeding arising out of a charge of a Penal Code section290offense.

(9) Any medical records as described in section 4712.

Note: Authority cited; Sections 4005.1 and 4027, Welfare and Institutions Code.

Reference: Sections 1370 and 1370.01, Penal Code; Section 7228, Welfare and

Institutions Code; Title 45, Code of Federal Regulations, Section 164:508; and /n

re Loveton (2016) 244 Cal.App.4th 1025.

4712. Medical Records Documentation.

(a) The following medical documentation of the individual shall be supplied in

the individuaPs commitment packet, if available;

(1) Any progress notes by a nurse, psychiatrist, medical doctor, or that

pertain to behavioral incidents, within the Jast 10 days;

(2} Current medications and dosages;

(3) .Medication compliance documentation;

(4) Lab resultsJwork andconsultations,

{5) Recent admission psychiatric evaluation;

(6) Safety cell usage or suicide watch records or incidences of self-

injurious behavior,

(7) Any recent physical exams ar medical history notes,

(8) Any advance health care directive;

(9) Any consent forms for. treatment; .and

(10) Any other court-ordered medical. treatment.

(b) .Other medical documentation, including treatment plans, will be required

for the following conditions, if available:

(1) Renal dialysis (hemodialysis or peritoneal dialysis);

3

(2) Non-ambulation, or where the individual needs prosthetics, walkers,or assistance to ambulate;

(3) Pregnancy, near term (last two months), or any prenatal careinformation or complications;

(4) Continuous oxygen, continuous respiratory monitoring such as pulseoximetry, ventilator devices such as CPAP for sleepapnea, ornebulizer for airway treatment;

(5) Cancer;

(6) Congestive heart failure;

(7) Blood or spinal fluid shunt in place, such as Prot-o-cath, or shunt for

hydrocephalus;

(8) Any required. injections;

(9) Any open wound not yet healed or untreated;

(10) Ostomy;

(11) Cirrhosis of the liver;

(12) Active inflammatory bowel diseases, complications by intestinalobstruction, subocclusion, severe fistulas, or active rectal bleeding;

(13) Inability to provide basic self-care or any other condition. requiringskilled nursing level of care;

(14) HIV/AIDS;

(15) Tuberculosis; and.

(16) Any other significant medical condition..

Note: Authority cited: Sections 4005.1 and 4027, Welfare and. Institutions .Code.

Reference: Section 1370 and 1370.01, Penal Code; Section 7228, Welfare and

Institutions Code; Title 45, Code of Federal Regulations, .Section .164.508; and /n

re Loveton (2016) 244 Cal.App.4th 1025.

4

4713. Medical Records Review.

(a) The Department of State Hospitals shall use the medical records provided inthe commitment packet to determine the medical needs of an individual

(b) A department admissions unit's triage nurse shall review all documents

related to an individuaPs medical condition(s).

(c) The department's admissions unit's triage nurse shall consult with the

department's admissions unit's physician or the chief physician and surgeon

to address whether the particular facility, proposed for the individuaPs

placement, is able to provide the necessary care or services needed by the

patient's medical condition(s).

Note: Authority cited: Sections 4005.1 and 4027.Reference: Sections 1370 and 1370.01, Penal Code; and Sections 7228. and

723p, Welfare and. Institutions Code.

4714. Security Risk Q►ssessment for Placement of Individuals FoundIncompetent to Stand Trial

(a) The Department of State Hospitals shall conduct a security risk assessment

of each individual committed to the department pursuant to .Penal Code.

section 1370 prior to admission.

{b) The security .risk. assessment shall include:

{1) The individual's prior history of escape or attempted escapes at any.

locked facility;

{2) Whether, within 30 days prior to the completion of the department's

assessment, the department receives. new .information about the

individual, such as a change in commitment status, divorce. by spouse,

death of a family member, or birth of a child;

(3) The individual's age;

(4) Whether the individual has been diagnosed with an antisocial, borderline,

and/or narcissistic personality disorder based on the Diagnostic and

Statistical Manual of Mental Disorders, 5th edition (May 18, 2013), hereby

incorporated by reference;

{5) The number of the individuaPs prior felony convictions;

(6) The individual's current length of sentence at the time of assessment; and

5

(7) The individual's current medical condition.

Note: Authority cited: Sections 4005.1 and 4027, Welfare and Institutions Code.Reference:.Sections 7228 and 7230, Welfare and Institutions Code.

4715. Placement of Individuals Found Incompetent to Stand Trial

The Department of State Hospitals may not admit an individual under PenalCode section 1370 until the commitment packet specified in section 4711 isreceived, reviewed, and approved by the department in order to determine theproper placement within the department. The department may admit acommitted individual whose commitment packet is incomplete when thedepartment determines, pursuant to section 4716, that the individuaPs psychiatricacuity indicates the need for an .immediate admission to a state facility.

Note: Authority cited: Sections 4005.1 and 4027, Welfare and Institutions Code.

Reference: Section 1370, Penal Code; Section 7228, Welfare and InstitutionsCode.

47'16. Psychiatric Acuity Review.

(a) If an individual committed to the department pursuant to Penal Code section

1370 is psychiatrically acute, the individual may be reprioritized in the order of

commitment in the admission process.

(b) The committing county's clinician responsible for the individual's clinical,

assessment shall contact the Department of State Hospitals'. medical director,

or designee, about an individual's psychiatric acuity and the psychiatric acuity

needs of the individual

{c) The committing county shall provide the medical director, or designee, the

medical information and documentation that supports the psychiatric .acuity..

Such documentation may include, but is not limited to:

(1) Safety cell notes;

(2) Current medications or lack of medication;

(3) Medical lab work; or

(4) Any additional treatment records from local health care providers.

(d) The medical director of the Department of State Hospitals, or designee, is the

final authority for determining psychiatric acuity of an individual for purposes of

expediting admission to a state facility.

6

(e) The medical director of the Department of State Hospitals, or designee, willmake a decision on whether to expedite admission of an individual due to his orher psychiatric acuity within 72 hours of contact by the committing county'sclinician and. when the department receives sufficient documentation.

Note: Authority cited: Sections 4005.1, 4027. and .7225, Welfare. and Institutions.Code. -

Reference: Sections 1370 and 1370.01, Penal Code; and Sections 7228 and7230, Welfare and .Institutions Code..

4717. State Hospital Placements of Individuals Found Incompetent toStand Trial .for Security Risks,

(a) The Department of State Hospitals shall consider an .individual committed tothe department pursuant to Penal Code section 1370, and who thedepartment determines is a low/moderate security risk, only for admission toDepartment of State Hospitals - Atascadero, Department of State Hospitals -Patton, Department of State Hospitals —Napa, or to Department of StateHospitals —.Metropolitan.

{b) The .Department of State Hospitals shall consider an individual committedpursuant to Penal Code section 1370, and who the department determines isa high security risk, only far admission to Department of State .Hospitals -Atascadero or to Department of State Hospitals -Patton.

Note: Authority cited: Sections 4005.1, 4027 and 7225, Welfare and Institutions.Code.

-

Reference: Sections 7228 and 7230, Welfare and Institutions Code.

7

:.... ., ~.

Copyright ~ 2013 American Psychiatric Association.

DSM and DSM-5 are trademarks of the American Psychiatric Association. Use of these termsis prohibited without permission of the American Psychiatric Association.

ALI, RIC,HTS RESERVED, Unless authorized in writing by the APA, no part of #his book maybe reproduced or used in a manner inconsistent with t11e APA's copyrright. This prohibitionapplies to tulautl~orized uses or xeproductioiis in any form, including electronic applications.

C~rresponclence regardizlb copyright permissions should be direcked to DSN1 Per-n~issions,American Psychiatric Publishing, 1000 4Vils~n Boulevard, Suite 1825,.Arlington, VA.22209-3901.

Manufactured in the United States of America on acid-free paper.

ISBN 978-0-89042-55=~-1 (Hardco~~er)

ISBN 978-0-8902-555-8 (P~pert~ack}

American Psychiatric Associltion1000 Wilson 8oiilevardArlington, VA 22209-3901www.psydl.org

The correct citation for. this book is American Psychiatric Association: Diagnostic and Statisti-cal Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Associa-tion, 2013.

Library of Congress Cataloging-in-Publication DataDiagnostic ai d statistical mant~.al of mental disorders : DSM-5. — 5t11 ed,~, ; cm.

DSM-5DSM-Vincludes index.ISBN 978-0-8902-554-1 (hardco~~er : alk. paper) -ISBN 978-0-8902-555-8 (pbk.: alk. ~~aper)I, American Psychiatric Association. II. American Psychiatric AssociatiozZ. DSM-5 Task Force.IIL Title: DSM-5. IV. Title: DSM-V.{DNLM:1. Diagnostic and statistical manual of mental disorders. 5th ecl. 2. Mental Disorders—classification. 3. Mental Disorders diagl~osis. WM 15]RC455.2.C4:616.89'075—dc23

.201301"1061

British Library Cataloguing in Publication DataA CIP record is available from the British Library.

..Text Design—Tamzity J. Cordova

Mantrf~cturiilg—Edwards Brothels M~11oy

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From Wikipedia, the free encyclopedia

The Diagnostic and Statistical Manual of MentalDisorders, Fifth Edition (DSM-S) is the 2013 Diagnostic and Statistical Manual of Mental

update to the American Psychiatric Association's ~isorde~s, Fifth. Edition

(APA) classification and. diagnostic tool In the (DSM:S)

United States the DSM serves as a universal ~ ~ ~ ~ ~~authority for psychiatric diagnoses. Treatmentrecommendations, as well as payment by health care ~ ~ ~,~ ~ ~~+ ~ ~ ~~'..a+ 4 ~... ».

providers, are often determined by DSM ~~~'~~"~~~ ~~ ~, r . ~

classifications, so the appearance of a new version ~ ~~has significant practical importance.

The DSM-5 was published on May 18, 2013,superseding the DSM-IV-TR, which was publishedin 2000. The development of the new edition beganwith a conference in 1999, and proceeded with theformation of a Task Force in 2007, which developedand field-tested a variety of new classifications. Inmost respects DSM-5 is nat greatly changed from Y~~-~;~~~4~-'~~?~ ~~~~vwr°~~e~,DSM-IV-TR. Notable changes include dropping - - `~Asperger syndrome as a distinct classification; loss `Author ~nerican Psychiatric Associationof subtype classifications for variant farms of Country United Statesschizophrenia; dropping the "bereavement exclusion"for depressive disorders; a revised treatment and 'Language English

naming of gender identity disoNder to gender Series Diagnostic and Statistical Manual ofdysphoria, and removing the A2 criterion for Mental Disordersposttraumatic stress disorder (PTSD) because itsrequirement for specific emotional reactions to

€Subject Classification and diagnosis of mental

trauma did not apply to combat veterans and first disorders

responders with PTSD. In addition, the DSM-5 is the ~ Published May 18, 2013.~ ~first "living document" version of a DSM.~~~ ~ Media type Print (hardcover, softcaver); e-book

Various authorities criticized the fifth edition both t Pages 947

before and after it was formally published. Critics ;ISBN 978-0-89042-554-1

assert, for example, that many DSM-5 revisions or ~ OCLC $3080378additions lack empirical support; inter-raterreliability is low for many disorders; several sections ~

(https://www.worldcat.org/ocic/830807378) ~

contain poorly written, confusing, or contradictory ~ Dewey 616.89'075

information; and the psychiatric drug industry unduly ~ Decimal

influenced the manual's content. Many of the LC Ciass RC455.2.C4

members of work groups for the DSM-5 had ~ Preceded by DSM IV TRconflicting interests, including ties to pharmaceutical ~,~, ~ __ µ~_,_

companies.~2~ Various scientists have argued that the

DSM-5 forces clinicians to make. distinctions that. are not. supported by solid. evidence, distinctions that have

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;1-lentat Dr~~~rdr'rs (DSM) is a classification of mel~tal disorders with associated criteria de-

s;~.;,zed to facilitate more reliable diagnoses of. these disarders. With successive editions

~,~~ ~~r the pa ~t h0 years, it has became a standard reference for clinical practice in the mental

health tic ld. since a complete description of the underlying pathological processes is not

possible f<~r most mental disorders, it is important to emphasize that the current diagnos-

tic criteria are the best availaUle description of how mental disorders are expressed and

can be recognized by trained clulicialls. DSM is intended to serve as a practical, functional,

and fle~i~le guide for organizing information that can aid in the accurate diagnosis and

treamie~lt of mental disorders. It is a tool for clinicians, an essential educational resource

for students and practitioners, and a reference for researchers in the field.

Although this edition of DSM was designed first and foremost to be a useful guide to

clinical practice, as an official nomenclature it must be applicable in a wide diversity of

cc~ntcxts. DSM has been used by clinicians and researchers from different orientations (bi-

o1o~ieal, psychodynamic, cognitive, behavioral, interpersonal, family/systems), all of

~vhnm strive for a common language to communicate the essential characteristics of men-

tal disorders presented by their patients. The information is of value to all professionals

atisociated with various aspects of mental health care, including psychiatrists, other

physicians, psychologists, social workers, nurses, counselors, forensic and legal special-

ists,occupational and rehabilitation therapists, and other health professionals. The criteria

a re concise and explicit anduttended to facilitate an objective assessment of symptom pre-

~entations in a variety of clinical settings—inpatient, outpatient, partial hospital, consul-

tation-liaison, clinical, private practice, and primary care—as well in general community

epidemiological studies of mental disorders. DSM-5 is also a tool for collee~ing and com-

rnunicating accurate public health statistics on mental disorder morbidity and mortality

rates. Finally, the criteria and corresponding text serve as a textbook for students early u1

their profession who need a structured way to understand and diagnose mental disorders

as well as for seasoned professionals encountering rare disorders for the first time. Fortu-

nately, aIl of these uses are mutually compatible.

These diverse needs and interests were taken into consideration in planning DSM-5.

The classification of disorders is harmonized with. the World Health Organization's 1~2tei^-

nr~tion~al Ctassification of Diseases (ICD), the official coding system used in the United States,

so that the DSM criteria define disorders identified by ICD diagnostic names and code

numbers. In DSM-5, both ICD-9-CM and ICD-IO-CM codes (the latter scheduled for ado~-

tion in October 2014) are attached to the relevant disorders in the classification.

Although DSM-5 remains a categorical classification of separate disorders, we recog-

nize that mental disorders do not always fit completely within the boundaries of a single

disorder. Some symptom domains, such as depression and anxiety, involve multiple di-

agnostic categories and may reflect common underlying vulnerabilities for a larger group

of disorders. In recob ition of this reality, the disorders included in DSM-5 were reordered

into a revised organizational structure meant to stimulate new clinical perspectives. This

new structure corresponds with the organizational arrangement of disorders planned for

ICD-11 scheduled for release in 2015.Other enhancements have been introduced to pro-

mote ease of use across all. settings:

t

f

xlii Preface

• Representation of developmental issues related to diagnosis. Tile change in chapter

organization better reflects. a lifespan approach, with disorders more frequently diag-

nosed in childhood {e.g., neurodevelopmental disorders) at the beginning of the man-

ual and disorders more applicable to older adulthood (e.g., neurocognitive disorders)

at the end of the manual. Also, within the text, subheadings on development and course

provide descriptions of how. disorder presentations may change across the lifespan.

.Age-related factors specific to diagnosis (e.g., symptom presentation and prevalence

differences in certain age groups) are also included in the text. For added emphasis,

these age-related factors have been added to the criteria themselves where applicable

{e.g., in the criteria sets for insomnia disorder and posttraumatic stress disorder, spe-

cificcriteria describe how symptoms might be expressed in children). Likewise, gender

and cultural issues have been integrated into the disorders where applicable.

o Integration of scientific findings from the latest research in genetics and neuroimag-

ing.The revised :chapter structure was informed by recent research in neuroscience and

by emerging genetic linkages between diagnostic groups.. Genetic and physiological

risk factors, prognostic indic~~lors, and some putative diagnostic markexs are high-

lighted in the #ext. This n~~~~ structure should improve clinicians' ability to identify di-

agnoses i~l a disorder specirumbased on common neurocircuitry, genetic vulnerability,

anden~°ironmental expo~tu~as. ~

• Consolidation o£ autistic disorder, Asperger's disorder, and pervasive developmen-

tal disorder into autism spectrum disorder, Symptoms of these disorders represent a

single continuum ut mild to severe impairments in the t~n~o domains of social commu-

nication and restrictive repetitive behaviors/interests rather than being distinct disor-

ders. This change is designed to improve t}le sensiti~~ t~ ~ncl specificity of the criteria for

the diagnosis of autism spectrum disorder and to identity mare focused t~ c,ltment tar-

gets for the specific impairments identified. ~

• Streamlined classification of bipolar and depressive disorders. Bipolar and depres-

sivedisorders ~~re the ~ne~s t commonly,dia~nosed conditions in psychiatry. It was there-

foreimportantio~treamlin~ the ~resentati~~pofrhese~li5urc3erstoenhaneebothclinical

anc~ ec~ucaLion~l u~c. Rath~~c then seplrat~n~ the definition cif manic, hypomanic; and

major de ptc~si~,~c epis~~dt~s fr<~r~~ the definition of bipolar I disarder, bipolar II disorder,

anti ~n~jor depres5i~ e di~~~rder ns in the pre~~iuu~ cdil~ic~n, we included all of the com-

p~iiei~t criteria ~~~itl~in the ~ rspe~ti~ e eriteri~ to< <~adz di~c~rcler. This approach will faeil-

hate be~i5id~ dia:;no~is and Treatment of tl~e,c izz~portant disorders. Likewise, the

exp1a111tor~ notes for dific~rerl[iat2ngberea~~emcnt in~j „1~jordepressivedisorderswill

provide far ~;r~ater clinical ~~uiaance than was pre~~~~>u~lyprovided in thesimplebe-

rea~~en~ent exclusion criterion. The new specifiers of anxious distress and mixed fea-

ture~ are now fully described in the narrative on specifier variations that accompanies

the criteria far these disorders.

s Restructuring of substance use disorders for consistency and clarity. The categories

of substance abuse and substance dependence have been eliminated anti replaced with

an overarching ne~v c~tegory,of substance use disorders—with the specific substance

used d~tir~ing the specific disorders. "Dependence" has been easily confused with the

I ~ term "addiction" when, in fact, the tolerance and withdrawal that previously defined

dependence are actually very normal responses to prescribed medications that affect

the central nervous system and do not necessarily indicate the presence of an addiction.

By revising and clarifying these criteria in DSM-5, we hope to ~lieviate some of the

widespread misunderstanding about these issues.

Enhanced specificity for majar and mild neurocognitive disorders. Gi~~en the explo-

sion inneuroscience, neuropsychology, and brain imaging over the past 20 years, it was

critical to con~rey the current state-of-the-art in #le diagnosis of specific types of disor-

tiers that were previously referred to as the "clenlentias" or organic brain diseases. Bi-

ologic~~l markers identified by imaging for vascular and :traumatic brawl disorders and

i

~r xx ~- - ..~.

-- -_ _ . :,

Preface xliii

s~~ecific molecular genetic findings for rare variants of Alzheimer's disease and Hun-

tington's disease have greatly advanced clinical diagnoses, and these disorders and

others Have 11ow been separated into specific subtypes.

~s

• Transition in conceptualizing personality disorders. ~1lthrntgll the benefits of a snore

dimensional approach to personaliEy disorders have been identified in previous edi-

}

bons, the transition from a categorical diagnostic system of individual disorders to one

n

based can the relative distribution of personality traits has not been widely accepEed. In

`~

DSM-5, t11e categorical personality disorders are virtually unchanged from the previous

~~

edition. However, an alternative "hybrid" lnodei has been proposed in Section III to

guide firture research that separates interpersonal functioning assessments and the ex-

}

pression of pathological personality traits for six specific disorders. A more dimensional s;

profile of personality trait expression is also proposed for atrait-specified ap~roadl.

Section III: new disorders and features. A new section (Section III) has been added to

highlight disorders that require further study bLiE are i~ot sufficielltiy well established to

be a part of the official classification of mental disorders for routine clinical use. Dimen-

~;

sional measures of symptom severity in 13 symptom domains have also been incorpo-

rated to allow for the measurement of symptom levels of varying severity across all

diagnostic groups. Likewise, the WHO Disability Assessment Schedule (WHODAS), a

standard method for assessing global disability levels for mental disorders that is based

on Elie International Classification of Functioning, Disability and Health (ICF) and is ap-

placable in all of medicine, has been provided to replace the more limited Global As-

`-r

sessment of Functioning scale. Tt is our Hope t11at as these measures are implemented

aver tinge, they will provide greater accuracy and flexibility in the clinical description of

<<

individual symptomatic presentations ~1d associated disability during diagnostic as-

~,

sessinents. ~ "'s

• Online enhancements. DSM-5 features online supplemental information. ~'~~

Additional cross-cutting and diagnostic severity measures are available online

(w~~v~v.psychiatry.org/dsm5), linked to the relevant disorders. In addition, the Cul-

~~;

tural Formulation Interview, Cultural ForinulationInterview—Informant Version, and

`~~

supplementary modules to the core Cultural Formulation Interview are also included

online at www.psychiatry.org/dsm5. ' "

These innovations were designed by the leading authorities on mental disorders in the

`

world and were implemented on the basis of their expert review, public commentary, and

independent peer review. The 13 work groups, under the direction of the DSM-5 Task

~ ~

Force, in conjunction with other review bodies and, eventually, the APA Board of Trust-

''

ees, collectively represent the global expertise of the specialty. This effort was supported

f ;`

by an extensive base of advisors and by the professional staff of the APA Division of Re-

seardl; the Haines of e~~eryone involved are too numerous to mention here but are listed in

the Appendix. We owe tremendous thanks to those who devoted countless hours and in

-

valuable expertise to this effort to improve the diagnosis of mental disorders.

~

We would especially like to acknowledge the chairs, text coordinators, and members of

` ,~ .,

the 13 work groups, listed in the front of the manual, who spent many hours in this vol-

k , ,

unteer effort to improve the scientific basis of clinical practice over a sustained h-year pe-

riod. Susan K. Schultz, M.D., who served as text editor, worked tirelessly with Emily A.

Kuhl, P11.D., senior science writer and DSM-5 staff text editor, to coordinate the efforts of

the work groups into a cohesive whole. William E. Narrow, M.D., M.P.H., led the research

-~

group that developed the overall research strategy for DSM-5, including the field trials,

that greatly enhanced the evidence base for this revision. In addition, we are grateful to

those wl~o contributed sa much time to the independent review of the revision proposals,

including Keruletll S. Kendler, M.D., and Robert Freedman, M.D., co-chairs of the Scien-

titic Review Committee; John S. McIntyre, M.D., and Joel Yager, M.D., ec~-chairs of the

~~:;

Cliilic~l and Public Health Committee; and Glerul Martin, M.D., chair of the APA Assem-

~'~~~

~~` °`.

j

xiiv Preface

bly review process. Special thanks go to Helena C. Kraemer, Pi1.D., for her expert stati

stical

~ consultation; Michael B. First, M:D., for his valuable input on the coding and review of

cri-

~ teria; and Paul S..Appelbaum, M.D., for

feedback on forensic issues. Maria N. Ward,

~ M.Ed., RHIT, CCS-P, also helped in verifying ail ICD coding. The Summit Group,

which

` ~ included these consultants, the chairs of all review groups, the task force chairs, and

the ~=

APA executive officers, chaired by Dilip V, Jeste, M.D.; provided leadership and vis

ion in ~

helping t~ achieve compromise and consensus. This level of commitment has cont

ributed

to the balance andobjectivity that we feel are hallmarks of DSM-5.

~'Ve s pecially wish to recognize the outstanding APA Division of R~~se<~rrh staff—

identified in the Task Force and Work Group listing at the front of this m iWaal

—who

worked tirelessly to interact with'the task force, work groups, advisors, ~1nc~ re~•ie~,~

ers to

resolve issues, ser~~e as liaisons betti~~een the groups, direct Ind «~an~~e the ac~~rlemic

and

routnle clinfcal practice field t~~ial~, and record decisions ire this important prods. in

par-

tieula~r, ~~~~e ~ppr<:ci~te the sup~~~~rt and h~~idance pr~~~ic~ed b~~ )amPsH. Seull~~ Jr.

, M.D.,

Mediczll Director ~~~~-1 CEO of the AI'A, lhrott~h the years end tr~cails of tl~e de~°elopm

ent

pY~cess. Pu~a~]y,1ve think the editorial and production staff ~t Amelic~n 1'svchi~t~

-ic Ptab-

fishing—specifically,Re~ecca Rinehart,i'L~blishei;JohnMcDutfie, [~ditorial~irecic

~r; inn

Eng, Senior Editor; Greg Kul, •, ~~1~znaging ~,ditor; and Tammv Cordova, Graphi~~

Desig,l

Manager—fur Pheir ~uiclan~ ~ in br~naing this all together and~creating the final pi~udu

ct. It

is the eulnllllaL~~~n ~>t ctf~~rts of is~an~° tale~ltedindividuals ~~ h~~ de~li~ atec~ their time,

exper-

tise, and. passion that made DSM-5 possible.

~

Dnz~i~j ). KuJ~f~~r, lv'I.D.

DSM-5 Task Force ClZair

Dnrrel A. Regier, ~1I.D., M.P.H.

DSM-5 Task Force Vice-Chair

December 19, 2012

~. :.~."~

r~p~FETY 7~,~,?~

~"i.

,, t~'

FINDWG OF EMERGENCY

A. Finding of Emergency Regulatory Action Is Necessary

The proposed regulations are being readopted for a second time on an emergency basis for theimmediate preservation of the public peace, health and safety, or general welfare, within themeaning of Government Code section 11346.1.

B. Description of Specific Facts Which Constitute the Emergency

NECESSITY OF THE PROPOSED REGULATIONS

Over the past four years, there have been a .large increase in Penal .Code section 1370.("Incompetent to Stand Trial" or "IST") commitments by county courts to DSH for treatment. Asthe referrals from around the state have increased, the waitlist for patients to be admitted hasalso grown, .despite expansion of capacity by DSH. In response to the growing waitlist, manycourts responded by issuing standing orders with a set admission period or by issuing Orders toShow Cause (OSC). The standing orders and OSCs resulted in inconsistent admission periodsamong counties, consumption of valuable court time, increased threat of the State being foundin contempt, and longer wait times for admission to DSH during which defendants remain incounty jails without treatment.

In practice, issuance of standing orders or 05Cs slow down the admissions process for ISTdefendants statewide for logistic and administrative reasons. logistically, a standing order orOSC forces DSH to admit a patient ahead of earlier referrals to avoid legal. penalties, causingother referrals to wait longer for admission and disrupting the flow of the waitlist, creating longer.wait times overall. Administratively, astanding order or OSC takes away staff time from focusingon: (1) coordinating with counties to receive commitment referral. packets; (2) reviewing receivedcommitment packets; and (3) coordinating with counties to transport IST defendants foradmission to the hospital. To comply, admission staff must redirect work on one IST defendantto the IST defendant who is the subject of a standing order or OSC.

On April 12, 2016, the Court of Rppeal for the First Appellate District upheld the Contra CostaCounty Superior Court's standing order to admit patients. to DSH within 60 days of commitment(/n re Loveton (2016) 244 Cal.App.4th 1025.) This decision provided the first clear guidance on .a reasonable admissions timeframe. If courts throughout the state follow the precedent set forthin /n re Loveton and case issuing standing orders. and OSCs not in line with the decision, DSHanticipates that the problems described above would be ameliorated and that admission waittimes would decrease.

However, DSH has not seen courts statewide adhere to Lovefon. Courts continue to issueOSCs not in line with /n re Loveton. Therefore, it is necessary to promulgate the proposedregulations to outline DSH's admissions process for IST defendants and to show that standingorders and OSCs will no longerexpedite admission of one county's IST defendant over anothercounty's IST defendant.

In re Loveton also discussed the need for courts to provide complete commitment referralpackets to DSH. Prior to /n re Loveton, DSH received many incomplete commitment packetsfrom various counties, and incomplete packets contribute to some delays in the. admission of

5/25/2017 Page 1 of 4

IST defendants. To provide clear guidance on what a complete commitment packet is, DSHspent a number of months speaking to hospital forensic experts, medical directors, executivemanagement, and the Health and Human Services Agency that oversees DSH, to draft clear,comprehensive regulations.

DSH proposes the emergency regulations to create a statewide, uniform admissions process forIST defendants committed to DSH. The proposed emergency regulations will also ensure that acomplete commitment packet is provided to DSH. Implementation of this uniform processthrough these regulations will preserve the public peace, health and safety, or general welfareby streamlining the admissions process for IST defendants, resulting in expedient access totreatment, removal from the county jail where space is critical and treatment is not alwaysavailable, decreased use of criminal court time, and equity for IST defendants awaitingadmission throughout the state.

DSH duplicates Penal Code section 1370, subdivision (a)(3) in section 1370, subdivision (a)(3),in section 4711 pursuant to the California Code of Regulations, title 1, section 12, subdivision(b)(1), in order to provide clarity and meet the clarity standard. Duplication is .necessary becausethe Penal Code section 1370 commitment packet documents listed in this section .are clearlydefined except for "medical records" under Penal Code section 1370, subdivision (a)(3)(I).Setting out a regulation only defining medical records could indicate this is the onlydocumentation necessary for a complete Penal Code section 1374 commitment packet whenthe 1370 statute lists nine individual categories of documents that make-up a complete PenalCade section 1370 commitment packet

BENEFITS OF THE PROPOSED EMERGENCY REGULATIONS

The benefits of the regulations will be to prevent discrimination, to promote fairness and socialequity, and to increase openness and transparency in government. By implementing the ./n reLoveton decision, the proposed emergency regulations will provide a uniform admissions criteria.and help all the counties understand the admission process and allow uniformity within thevarious counties. The proposed emergency regulations will help DSH better serve those ISTdefendants committed to DSH and provide clarification as to what documents areneeded andwhat will be reviewed. These regulations should reduce overall wait time for admission. to DSH,help remove IST defendants from county jails, reduce time on criminal court calendars, andprovide equity in admission process to defendants throughout the state. The regulations specifythe documentation and records required by the Department to evaluate each committedindividual for admission to a state. hospital .Further, the regulations lay out the factors that theDepartment considers in assessing each committed individual for medical needs, psychiatric

..acuity, and security risk. Clearly laying out the objective metric that the Department will use inadmitting committed individuals safeguards from the preferential treatment of one county over .another or one committed individual over another, thereby preventing discrimination andpromoting fairness. With a regulated standard, state-wide admissions process, the expectationsof courts, counties, counsel, and committed individuals about the admissions. process will bebetter managed and met, fostering openness and transparency in government,.

EFFECT OF THE PROPOSED EMERGENCY REGU~ATtONS

(1) DSH has done a search of existing statutes and regulations. These proposed regulationsare consistent with existing statutes and regulations and will implement and comply with /nre Lovetan.

(2) There are no federal regulations previously adopted or amended that prohibit the.proposed regulations.

5/25/2017 Page 2 of 4

{3) These regulations will provide uniform rules to all counties and will provide clarification inthe admission process for all counties. and IST defendants committed to DSH pursuant toPenal Code section 1370.

THE FINDING OF EMERGENCY

DSH finds that the proposed regulatory action is necessary to address an emergency. Anemergency is "a situation that calls for immediate .action to avoid serious harm to the publicpeace, health, safety, or general welfare." (Gov. Code, § .11342.545.)

DSH currently is attempting to simultaneously and timely admit. patients from all 58 counties,while IST referrals from many of #hese counties have been .increasing substantially each week..The second readoption of the proposed emergency regulations will continue to ensureconformity with the process set forth in /n re Loveton. While DSH is also working on system-wide bed expansion, DSN has been sued by the ACLU in Alameda Superior Court as well asbeing sued in a potential class action lawsuit in federal. court from Ventura County patients, bothlawsuits challenging the admissions timeline, standards, and process for 1ST defendants.Further, when a patient has not been admitted to DSH after. a period of time, some courts havereleased the. patient into the community.

Readoption of the proposed emergency regulations is the immediate action required to avoidserious harm to the public peace, health, safety, or general .welfare. Should the proposedemergency regulations not be readopted, there would be serious harm to the counties, thecourts, the IST defendants, and the public. Counties, court, and counsel would be without clearand standard guidance on the admissions process for IST defendants. Some IST defendants,after waiting a period of time, may be released by the courts to the community. As a result, theremay also be an increase in courts issuing standing orders or OSCs not in line with /n reLoveton, further diverting State time and resources from a standardized admissions process toaddressing standing orders or OSCs and further increasing wait times for IST defendants.

C. Summary of Proposed Regulations

ADOPT SECTION 4700

This regulatory action would add Title 9, Division 1, Chapter 16, Article 7, Section 4700 toprovide definitions of terminology that is used by current statutes and by the proposed

...:.regulations.

ADOPT SECTION 4710

This regulatory action would add Title 9, Division 1, Chapter, 16, Article 7, Section 4710 toprovide the factors which may affect the actual date of admission of an IST patient to DSH.

ADOPT SECTION 4711

This regulatory action would add Title 9, Division 1, Chapter 16, Article 7, Section 4711 to clarifythe specific documents to be included in a complete commitment packet which are required for..the admission of an IST patient to DSH.

5/2 512 0 1 7 Page 3 of 4

ADOPT SECTION 4712

This regulatory action would add Title 9, Division 1, Chapter 16, Article 7, Section 4712 to clarifywhich medical documentation and information is required for the admission of an IST patient toDSH.

ADOPT SECTION 4713.

This regulatory action would add Title 9, Division 1, Chapter 76, Article 7, Section 4713 to clarifyhow an IST defendant's medical needs may affect to which state. hospital he or she is admitted.

ADOPT SECTION 4714

This regulatory action would add Title 9, Division 1, Chapter 96, Article 7, Section 4714 to clarifyhow DSH will evaluate an IST defendant's security. risk.

ADOPT SECTION 4715

This regulatory action would add Title 9, Division 1, Chapter 16, Article 7, Section 4715 to clarifyhow an 1ST defendants security risk .may affect to which state hospital he or she is admitted.

ADOPT SECTIC3N 4716..

This regulatory action would add Title 9, Division 1, Chapter 16, Article 7, Section 4716 to.provide that DSH will admit an IST defendant with a complete commitment packet and how

DSH retains discretion as to the admission of an IST defendant with an incomplete packet.

ADOPT SECTION 4717

This regulatory action would add Title 9, Division 1, Chapter 16, Article 7, Section 4717 toprovide that DSH may admit an IST defendant notwithstanding the date the court committed himor her if DSH determines that the IST defendant suffers from psychiatric acuity.

fl. Technical, Theoretical, and Empirical Study or Report

None.

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