DSM-5中有關失智症的新觀念
New concept of major neurocognitive
disorder in DSM-5
歐陽文貞 , M.D., M.P.H., Ph.D.
衛生署嘉南療養院高年精神科主任
台灣老年精神醫學會常務理事,
台灣精神醫學會監事
台灣臨床失智症學會理事
台灣失智症協會理事
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Classification of mental disorders &
diagnostic criteria
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1952
DSM-I
1968
DSM-II &
1977(79)
1980
DSM-III,
1987
DSM-IIIR
1992
1994
DSM-IV
2000
DSM-IV-TR
2013
DSM-5
2014
(ISO 成立1947於日內瓦)
ICD-8
ICD-9(ICD-9-CM)
NINCDS-ADRDA (1984)
ICD-10
ICD-11(revision from 2007)
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from ICD-9 to ICD-10
1. ICD-9 (1977)
• 290-299 Psychosis
– Dementia and organic psychotic condition(290-294)
– Other psychosis
• 295 schizophrenia, 296 MDP, 297 paranoid state
• 298 other psychosis
• 300-314 Neurosis
2. ICD-10(1992) 10 categories
F0 Organic, including symptomatic, mental disorder
F2 schizophrenia, schizotypal, delusional disorder
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ICD-9 290-294: organic psychotic
condition之一 dementia
• 290 老年期及初老期器質性精神病狀態(senile
& pre-senile organic psychotic condition)
– 290.0 senile dementia, simple type
– 290.1 pre-senile dementia
– 290.2 senile dementia, depressed(290.21) or
paranoid type(290.20)
– 290.3 senile dementia with acute confusional state
– 290.4 artheriosclerotic dementia
– (290.5 mixed dementia)
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ICD-10 organic, including
symptomatic, mental disorder
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F00 dementia in Alzheimer’s disease
F01 vascular dementia
F02 dementia in other disease classified elsewhere
F03 unspecified dementia
F04 organic amnesic syndrome, not induced by alcohol and
other psychoactive substance
F05 delirium, not induced by alcohol and other
psychoactive substance
F06 other mental disorder due to brain damage and
dysfunction and to physical disease
F07 personality and behavior disorder due to brain damage
and dysfunction and to physical disease
F09 unspecified organic or symptomatic mental disorder
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ICD-10 dementia
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F00.0 dementia in AD with early onset ,
F00.1 dementia in AD with late onset
F01.0 vascular dementia of acute onset
F01.1 multi-infarct dementia
F01.2 subcortical vascular dementia
F01.3 mixed cortical and subcortical dementia
F02.x Pick’s disease, CJD, Huntington’s disease,
Parkinson’s disease, HIV, other specified
disease
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ICD-10-DCR general criteria for dementia
• G1 evidence of each of the following:
– (1) decline in memory(mild, moderate, severe)
– (2)decline in other cognitive abilities
• G2 awareness of the environment is preserved
• G3 decline in emotional control or motivation,
or a change in social behavior
– (1)emotional lability, (2)irritability
– (3)apathy
(4)corasening of social behavior
• G4 present for at least 6 months
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From DSM-III to DSM-5
• DSM-III (1980), DSM-IV (1994)
• DSM-IV-TR (2000): delirium, dementia, and
amnesic and other cognitive disorders
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Delirium
Substance-induced delirium
Dementia
Amnesic disorder
Amnesic disorder NOS
Other cognitive disorder NOS
Mental disorder due to a general medical condition
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DSM-IV-TR: dementia syndrome
• 294.1x Dementia of the Alzheimer’s type
(原DSM-IV coding 及ICD-9 及健保局 290.0, 290.1x, 290.2x)
• 290.4x Vascular dementia (formerly multi-infarct dementia)
• 294.1x Dementia due to other general medical
condition, head injury, Pick’s disease, ,,,,
• 292.8x, 291.2x Substance-induced persisting dementia
• Dementia due to multiple etiologies
• 294.8 Dementia NOS
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DSM-IV-TR dementia of
Alzheimer’s type
• A. both
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(1)memory impairment,
(2)aphasia, agnosia, apraxia, disturbing in executive function
B. significant impairment in …..
C . Gradual onset
D. not due to other causes
E. not occur exclusively during the course of a delirium
F. not better accounted for by anther Axis I
diagnosis, MDD or schizophrenia
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DSM-5: Neurocognitive disorder
• S 00 - 02 Delirium
– S 00 Delirium
– S 01 Substance-Induced Delirium
– S 02 Delirium Not Elsewhere Classified
• S 03 Mild Neurocognitive Disorder
• S 04 Major Neurocognitive Disorder
• Subtypes of Major and Mild Neurocognitive
Disorders
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DSM-5: neurocognitive disorder
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S XX.01 Neurocognitive Disorder due to Alzheimer's Disease
S XX.02 Vascular Neurocognitive Disorder
S XX.03 Frontotemporal Neurocognitive Disorder
S XX.04 Neurocogntive Disorder due to Traumatic Brain Injury
S XX.05 Neurocognitive Disorder due to Lewy Body Dementia
S XX.06 Neurocognitive Disorder due to Parkinson's Disease
S XX.07 Neurocognitive Disorder due to HIV Infection
S XX.08 Substance-Induced Neurocognitive Disorder
S XX.09 Neurocognitive Disorder due to Huntington's Disease
S XX.10 Neurocognitive Disorder due to Prion Disease
S XX.11 Neurocognitive Disorder due to Another Medical
Condition
• S XX.12 Neurocognitive Disorder Not Elsewhere Classified
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DSM-5: major neurocognitive disorder
• A. Evidence of substantial cognitive decline from a previous level of
performance in one or more of the domains outlined above based
on:
• 1. Concerns of the individual, a knowledgeable informant, or the
clinician that there has been a substantial decline in cognitive
function; and
• 2. A decline in neurocognitive performance, typically involving test
performance in the range of 2 or more standard deviations below
appropriate norms (i.e., below the 3rd percentile) on formal testing or
equivalent clinical evaluation. (太寬了??)
• B. The cognitive deficits are sufficient to interfere with
independence (i.e., requiring assistance at a minimum with
instrumental activities of daily living [more complex tasks such as
paying bills or managing medications]).
• C. The cognitive deficits do not occur exclusively in the context of a
Delirium.
• D. The cognitive deficits are not primarily attributable to another
mental disorder (e.g., Major Depressive Disorder, Schizophrenia).
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修改的理由1
• 1.Major Neurocognitive Disorder (including what was formerly known as
Dementia) is a disorder with greater cognitive deficits in at least one
(typically two or more) of the following domains:
• Complex attention (sustained attention, divided attention, selective attention,
processing speed),
• Executive ability (planning, decision-making, working memory, responding to
feedback/error correction, overriding habits, mental flexibility),
• Learning and memory(immediate memory, recent memory [including free
recall, cued recall, and recognition memory])
• Language(expressive language [including naming, fluency, grammar and
syntax] and receptive language),
• Visuoconstructional-perceptual ability (construction and visual
perception),and
• Social cognition (recognition of emotions, theory of mind, behavioral
regulation).
• 2.The cognitive deficits must be sufficient to interfere with functional
independence. Important changes from the DSM-IV criteria include:
change in nomenclature (MNCD or Dementia), not necessarily requiring
memory to be one of the impaired domains, allowing cognitive deficit
limited to one domain.
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NINCDS-ADRDA 的 AD
• The NINCDS-ADRDA Alzheimer's Criteria specify 8
cognitive domains that may be impaired in AD:
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memory,
language,
perceptual skills,
constructive abilities,
orientation, (DSM-5沒有此名詞)
attention,
problem solving and functional abilities(DSM-5沒有此
名詞, 但是 DSM -5多了social cognition ).
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NINCDS-ADRDA-1984, 最常用的診斷標準之一
• Definite Alzheimer's disease: The patient meets the criteria for
probable Alzheimer's disease and has histopathologic evidence of
AD via autopsy or biopsy.
• Probable Alzheimer's disease: Dementia has been established by
clinical and neuropsychological examination. Cognitive impairments
also have to be progressive and be present in two or more areas of
cognition. The onset of the deficits has been between the ages of
40 and 90 years and finally there must be an absence of other
diseases capable of producing a dementia syndrome.
• Possible Alzheimer's disease: There is a dementia syndrome with
an atypical onset, presentation or progression; and without a
known etiology; but no co-morbid diseases capable of producing
dementia are believed to be in the origin of it.
• Unlikely Alzheimer's disease: The patient presents a dementia
syndrome with a sudden onset, focal neurologic signs, or seizures or
gait disturbance early in the course of the illness.
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修改的理由2
• 3.The term “dementia” is replaced by Major Neurocognitive Disorder,
which is conceptualized as including what was formerly known as
dementia as well as entities like amnestic disorder. “Dementia” is an
accepted term for older adults (e.g., with Alzheimer’s disease)—although
even in this setting it has acquired a pejorative or stigmatizing connotation,
it is less well accepted among younger adults with deficits related to e.g.,
HIV or head injury. (去汙名化)
• 4.This rewording focuses on decline (rather than deficit—consistent with
the requirement in the basic definition of an acquired disorder) from a
previous level of performance. (和ICD-10 一致, 變寬)
• 5.The previous criteria for dementia used Alzheimer’s disease as their
prototype and thus required memory impairment as a criterion for all
dementias. There is growing recognition that, in other neurocognitive
disorders (e.g., HIV-related cognitive decline, cerebrovascular disease,
frontotemporal degeneration, traumatic brain injury, etc.), other domains
such as language or executive functions may be impaired first, or
exclusively, depending on the part of the brain affected and the natural
history of the disease.
• 6. The terminology for the cognitive domains has been updated to reflect
current usage in neuropsychology and neurology.
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修改的理由3
• 7.The new definition, consistent with DSM-wide changes, focuses first on
performance rather than disability. In the introductory table, we provide
for each domain examples of specific symptoms or observations
consistent with the Major level of decline and objective assessments. This
encourages the use of objective measures, including formal
neuropsychological testing where feasible with lesser exclusive reliance
on individual judgment.
• 8.The presence of both symptoms/observations and objective assessment
is included to ensure specificity. This is a larger issue for Minor
Neurocognitive Disorder but included here for parallel structure of the
criteria.
• NOTE: …. refining criteria A1 and A2 to achieve a balance between
preferred formal neuropsychological test 及臨床判斷…..
• 9. The new language preserves the traditional function-based threshold
for dementia but tries to operationalize it more clearly as a loss of
independence.
• NOTE: The committee is still refining criterion D and discussing to what
extent Major Neurocognitive Disorder should be diagnosed in the setting
of disorders like schizophrenia and depression (although this concern
applies primarily to Minor Neurocognitive Disorder). (不排斥精神分裂病
可以有”重大認知障礙症”)
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DSM-5 Major neurocognitive disorder
• 增加 DLB, FTD診斷, 維持MNCD due to
Traumatic brain injury
• AD仍保有以記憶力早期受影響的症狀, 緩慢
發病
• VaD不強調focal neurological sign, sudden
onset, stepwise course
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DSM-5 vascular MNCD
• B. The clinical features are consistent with a
vascular etiology as suggested by one of the
following:
• 1. The onset of the cognitive deficits is
temporally related to one or more vascular
events
• 2. Evidence for decline is prominent in speed
of information processing, complex attention
and/or frontal-executive functioning
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DSM-5 vascular MNCD, specify if
• 1. Probable: Vascular Neurocognitive Disorder is considered
probable if:
– a) Clinical criteria are supported by neuroimaging
evidence of significant parenchymal injury due to
cerebrovascular disease (neuroimaging-supported)
– b) The neurocognitive syndrome is temporally related to
one or more cerebrovascular events and there is
documented evidence of these events
– c) If both clinical and genetic (e.g. cerebral autosomal
dominant arteriopathy with subcortical infarcts and
leukoencephalopathy, CADASIL) evidence of
cerebrovascular disease are present.
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MNCD due to Lewy Body dementia
• Core Diagnostic Features of Lewy Body Disease include the following:
– a) Fluctuating cognition with pronounced variations in attention and
alertness.
– b) Recurrent visual hallucinations that are typically well-formed and
detailed.
– c) Spontaneous features of parkinsonism with onset at least 1 year
later than the cognitive impairment.
• Suggestive Diagnostic Features of Lewy Body Disease include the
following:
• a) REM sleep behavior disorder
• b) Severe neuroleptic sensitivity
• c) Low dopamine transporter uptake in basal ganglia
demonstrated by SPECT or PET imaging.
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Summary and take home message
• Dementia was renamed as MNCD
• Major vs minor NCD
• Criteria of MNCD are different from those of
dementia in DSM-IV-TR or ICD-10,
approaching those of NINCDS-ADRDA.
– Amnesia is not the only core symptom of MNCD.
• Add Dx of FTD and DLB in DSM-5.
• Some of concept of vascular NCD was changed
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Thank you for your attention!
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