Download DSM-5 OVERVIEW FOR CLINICIANS

DSM-5 OVERVIEW FOR
CLINICIANS
Developed and presented by:
Roland Williams,
MA, LAADC, ICADC, NCACII, CADCII, ACRPS, SAP
President, Free Life Enterprises
Roland Williams Consulting
www.rolandwilliamsconsulting.com
Agenda
• To highlight the major changes from the DSM-IVTR, (text revision) to the DSM-5
• Is based on the assumption participants have a
working knowledge of the DSM-IV
• Will not define each of the almost 300 diagnosis
not including modifiers
• Will discuss some of the skepticism and critique
• Will not read each slide, this handout is intended
as a resource document for participants
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Who is in the Audience?
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How many licensed clinicians?
Primary substance abuse counselors?
Students?
Administrators?
How many have already had some training on
the new DSM-5?
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What is the DSM?
• The Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) is the
2013 update to the APA’s classification and
diagnostic tool. In the US the DSM serves as a
universal authority for psychiatric diagnosis.
Treatment recommendations as well as
payment by health care providers are often
determined by DSM classifications, so the
appearance of a new version has significant
practical importance.
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What is the DSM? (Cont.)
• DSM is the manual used by clinicians and
researchers to diagnose and classify mental
disorders. The American Psychiatric Association
(APA) published DSM-5 in 2013, culminating a
14-year revision process. For more information,
go to www.DSM5.org.
• APA is a national medical specialty society
whose more than 36,000 physician members
specialize in the diagnosis, treatment,
prevention and research of mental illnesses,
including substance use disorders. Visit the APA
at www.psychiatry.org.
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DSM-I (1952)
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132 pages
Mental disorders as “reactions”
Definitions were simple brief paragraphs
with prototypical descriptions
Terms like idiot, moron and imbecile
Blacks referred to as insane in one study
Homosexuality listed as a sociopathic
personality disturbance
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DSM-II (1968)
134 pages
• “Reaction” terminology dropped
• Users encouraged to record multiple psychiatric
diagnoses (in order of importance) and associated
physical conditions
• Coincided with ICD-8
(first time ICD included mental disorders)
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DSM-III (1980)
494 pp
• Descriptive and neutral “atheoretical”)
regarding etiology.
• Coincided with ICD-9.
• Multiaxial classification system.
• Goal to introduce reliability.
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DSM-IV (1994)
886 pp
• Inclusion of a clinical significance criterion
• New disorders introduced
(e.g., Acute Stress Disorder, PTSD
Bipolar II Disorder, Asperger’s Disorder),
• others deleted
(e.g., Cluttering,
Passive-Aggressive Personality Disorder).
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DSM-5 (2013)
947 pp
“5” instead of “V”
Anticipates change
e.g. DSM 5.1 … 5.2 …
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Critique:
10 most potentially harmful changes
• Psychiatrists like Allen Frances have been critical of
the revisions and express concerns that it will
medicalize normality and result in a glut of
unnecessary and harmful drug prescriptions.
– Disruptive Mood Disregulation Disorder, for
temper tantrums
– Major Depressive Disorder, includes normal grief
– Minor Neurocognitive Disorder, for normal
forgetting in old age
– Adult Attention Deficit Disorder, encouraging
psychiatric prescriptions of stimulants
– Binge Eating Disorder, for excessive eating
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Critique:
10 most potentially harmful changes (Cont.)
– Autism, defining the disorder more specifically,
possibly leading to decreased rates of diagnosis
and the disruption of school services
– First time drug users will be lumped in with addicts
– Behavioral Addictions, making a "mental disorder
of everything we like to do a lot."
– Generalized Anxiety Disorder, includes everyday
worries
– Post-traumatic stress disorder, changes opening
"the gate even further to the already existing
problem of misdiagnosis of PTSD in forensic
settings."
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Medicalization and financial conflicts of
interest
• It has also been alleged that the way the categories of
the DSM are structured, as well as the substantial
expansion of the number of categories, are
representative of an increasing medicalization of
human nature, which may be attributed to “disease
mongering” by psychiatrist and pharmaceutical
companies, the power and influence of the latter
having grown dramatically in recent decades. Of the
authors who selected and defined DSM-IV psychiatric
disorders roughly half have had financial relationships
with the pharmaceutical industry at one time, raising
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Medicalization and financial conflicts of
interest (Cont.)
the prospect of conflict of interest. The same article
concludes that the connections between panel
members and the drug companies were particularly
strong in those diagnosis where drugs are the first line
of treatment, such as schizophrenia and mood
disorders, where 100% of the panel members had
financial ties with the pharmaceutical industry. In 2005,
the then APA president Steven Sharfstien released a
statement in which he conceded that psychiatrist had
“allowed the biopsychosocial model to become the biobio-bio model.
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Medicalization and financial conflicts of
interest (Cont.)
• However, although the number of identified
diagnoses has increased by more than 300% (from
106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such
as Zimmerman and Spitzer argue it almost entirely
represents greater specification of the forms of
pathology, thereby allowing better grouping of more
similar patients.[3] However, William Glasser refers to
the DSM as “phony diagnostic categories” arguing
that it was developed by psychiatrists to help
psychiatrist to make more money”. The publishing of
the DSM with tightly guarded copyrights has itself
earned over $100 million for the APA.
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Table Of Contents (Cont.)
• Section I: DSM-5 Basics
• Introduction
• Directions on How to Use the Updated
Manual
• Cautionary Statement for Forensic Use of DSM
-5*
• Section II: Essential Elements:
– Outline of the Categorical Diagnosis
– Diagnostic Criteria and Codes
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Table Of Contents
• Section III: Emerging Measures and Models
– Assessment Measures
– Cultural Formulation
– Alternative DSM-5 Model for Personality Disorders
– Conditions for Further Study
• Appendix
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Section I
• Orientation
• Historical back ground
• Development of DSM-5
• How to use it
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*Cautionary Statement
• Although the DSM-5 diagnostic criteria and text are
primarily designed to assist clinicians in conducting
clinical assessment, case formulation, and treatment
planning, DSM-5 is also used as a reference for the
courts and attorneys in assessing the forensic
consequences of mental disorders. As a result, it is
important to note that the definition of mental
disorder included in DSM-5 was developed to meet
the needs of clinicians, public health professionals,
and research investigators rather than all of the
technical needs of the courts and legal professionals.
It is also important to note that DSM-5 does not
provide treatment guidelines for any given disorder.
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Section II
• Diagnostic Criteria and codes
• “Medication-induced Movement Disorders”
• “Other Conditions That May be
a Focus of Clinical Attention.”
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Section III
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Emerging Measures and Models
Assessment measures
Cultural formulation
Alternative DSM-5 model for personality
disorders
• “Criteria Sets for Conditions
for Further Study”
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Appendix
• Highlights of changes
from DSM-IV to DSM-5
• Glossary of technical terms
• Glossary of cultural terms
• Alpha & numeric listings of
diagnoses and codes
• List of advisors and contributors
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STRUCTURE FOR EACH DIAGNOSIS
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Diagnostic Criteria
Subtypes and/or Specifiers
Severity rating
Codes and recording procedures
Explanatory text (new or expanded)
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STRUCTURE FOR EACH DIAGNOSIS
Diagnostic and associated features
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Prevalence
Development and course
Risk and prognosis
Culture- and gender-related factors
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STRUCTURE FOR EACH DIAGNOSIS
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Diagnostic and associated features
Diagnostic markers
Functional consequences
Differential diagnosis
Comorbidity
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SECTION 2: CHAPTERS
• Neurodevelopmental disorders
• Schizophrenia spectrum and
other psychotic disorders
• Bipolar and related disorders
• Depressive disorders
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SECTION 2: CHAPTERS
• Anxiety disorders
• Obsessive-compulsive and related disorders
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Trauma- and stressor-related disorders
Dissociative disorders
Somatic symptom and related disorders
Feeding and eating disorders
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SECTION 2: CHAPTERS
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Elimination disorders
Sleep-wake disorders
Sexual dysfunctions
Gender dysphoria
Disruptive, impulse-control,
and conduct disorders
• Substance-related and addictive disorders
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SECTION 2: CHAPTERS
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Neurocognitive disorders
Personality disorders
Paraphilic disorders
Other Mental Disorders
Medication-induced movement disorders and other
adverse effects of medication
• Other conditions that may be a focus
of clinical attention (V/Z Codes)
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Neurodevelopmental Disorders
• This group of disorders typically refers to those
that manifest during early development, although
diagnoses are sometimes not assigned until
adulthood. Examples of neurodevelopmental
disorders include intellectual disabilities,
communication disorders, autism spectrum
disorders (incorporating the former categories of
autistic disorder, Asperger’s disorder, childhood
disintegrative disorder, and pervasive
developmental disorder), ADHD, specific learning
disorders, motor disorders, and other
neurodevelopmental disorders.
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Schizophrenia Spectrum and Other
Psychotic Disorders.
• The disorders that belong to this section all have one
feature in common: psychotic symptoms, that is,
delusions, hallucinations, grossly disorganized or
abnormal motor behavior, and/or negative
symptoms. The disorders include schizotypal
personality disorder (which is listed again, and
explained more comprehensively, in the category of
Personality Disorders in the DSM-5), delusional
disorder, brief psychotic disorder, schizophreniform
disorder, schizophrenia, schizoaffective disorder,
substance/medication-induced psychotic disorders,
psychotic disorders due to another medical condition,
and catatonic disorders.
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No More Mood Disorders
• Now referred to as Bipolar and Related
Disorders, and Depressive Disorders
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Bipolar and Related Disorders.
• The disorders in this category refer to
disturbances in mood in which the client cycles
through stages of mania or mania and depression.
Both children and adults can be diagnosed with
bipolar disorder, and the clinician can work to
identify the pattern of mood presentation, such
as rapid-cycling, which is more often observed in
children. These disorders include bipolar I, bipolar
II, cyclothymic disorder, substance/medicationinduced, bipolar and related disorder due to
another medical condition, and other specified or
unspecified bipolar and related disorders.
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Depressive Disorders.
• Previously grouped into the broader category
of “mood disorders” in the DSM-IV-TR, these
disorders describe conditions where
depressed mood is the overarching concern.
They include disruptive mood dysregulation
disorder, major depressive disorder, persistent
depressive disorder (also known as
dysthymia), and premenstrual dysphoric
disorder.
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Anxiety Disorders.
• There are a wide range of anxiety disorders,
which can be diagnosed by identifying a general
or specific cause of unease or fear. This anxiety or
fear is considered clinically significant when it is
excessive and persistent over time. Examples of
anxiety disorders that typically manifest earlier in
development include separation anxiety and
selective mutism. Other examples of anxiety
disorders are specific phobia, social anxiety
disorder (also known as social phobia), panic
disorder, and generalized anxiety disorder.
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Obsessive-Compulsive and Related
Disorders.
• Disorders in this category all involve obsessive
thoughts and compulsive behaviors that are
uncontrollable and the client feels compelled
to perform them. Diagnoses in this category
include obsessive-compulsive disorder, body
dysmorphic disorder, hoarding disorder,
trichotillomania (or hair-pulling disorder), and
excoriation (or skin-picking) disorder.
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Trauma- and Stressor-Related
Disorders.
• A new category for DSM-5, trauma and stress
disorders emphasize the pervasive impact that
life events can have on an individual’s
emotional and physical well-being. Diagnoses
include reactive attachment disorder,
disinhibited social engagement disorder,
posttraumatic stress disorder, acute stress
disorder, and adjustment disorders.
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Dissociative Disorders.
• These disorders indicate a temporary or
prolonged disruption to consciousness that
can cause an individual to misinterpret
identity, surroundings, and memories.
Diagnoses include dissociative identity
disorder (formerly known as multiple
personality disorder), dissociative amnesia,
depersonalization/derealization disorder, and
other specified and unspecified dissociative
disorders.
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Somatic Symptom and Related
Disorders.
• Somatic symptom disorders were previously
referred to as “somatoform disorders” and are
characterized by the experiencing of a physical
symptom without evidence of a physical cause,
thus suggesting a psychological cause. Somatic
symptom disorders include somatic symptom
disorder, illness anxiety disorder (formerly
hypochondriasis), conversion (or functional
neurological symptom) disorder, psychological
factors affecting other medical conditions, and
factitious disorder.
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Feeding and Eating Disorders
• This group of disorders describes clients who
have severe concerns about the amount or
type of food they eat to the point that serious
health problems, or even death, can result
from their eating behaviors. Examples include
avoidant/restrictive food intake disorder,
anorexia nervosa, bulimia nervosa, binge
eating disorder, pica, and rumination disorder.
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Elimination Disorders.
• These disorders can manifest at any point in a
person’s life, although they are typically
diagnosed in early childhood or adolescence.
They include enuresis, which is the
inappropriate elimination of urine, and
encopresis, which is the inappropriate
elimination of feces. These behaviors may or
may not be intentional.
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Sleep-Wake Disorders.
• This category refers to disorders where one’s
sleep patterns are severely impacted, and they
often co-occur with other disorders (e.g.,
depression or anxiety). Some examples include
insomnia disorder, hypersomnolence disorder,
restless legs syndrome, narcolepsy, and
nightmare Disorder. A number of sleep-wake
disorders involve variations in breathing, such as
sleep-related hypoventilation, obstructive sleep
apnea hypopnea, or central sleep apnea. See the
DSM-5 for the full listing and descriptions of
these disorders.
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Sexual Dysfunctions.
• These disorders are related to problems that
disrupt sexual functioning or one’s ability to
experience sexual pleasure. They occur across
sexes and include delayed ejaculation, erectile
disorder, female orgasmic disorder, and
premature (or early) ejaculation disorder,
among others.
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Gender Dysphoria.
• Formerly termed, “gender identity disorder,”
this category includes those individuals who
experience significant distress with the sex
they were born and with associated gender
roles. This diagnosis has been separated from
the category of sexual disorders, as it is now
accepted that gender dysphoria does not
relate to a person’s sexual attractions.
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Disruptive, Impulse Control, and
Conduct Disorders.
• These disorders are characterized by socially
unacceptable or otherwise disruptive and
harmful behaviors that are outside of the
individual’s control. Generally, more common in
males than in females, and often first seen in
childhood, they include oppositional defiant
disorder, conduct disorder, intermittent explosive
disorder, antisocial personality disorder (which is
also coded in the category of personality
disorders), kleptomania, and pyromania.
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Substance-Related and Addictive
Disorders.
• Substance use disorders include disruptions in
functioning as the result of a craving or strong urge.
Often caused by prescribed and illicit drugs or the
exposure to toxins, with these disorders the brain’s
reward system pathways are activated when the
substance is taken (or in the case of gambling
disorder, when the behavior is being performed).
Some common substances include alcohol, caffeine,
nicotine, cannabis, opioids, inhalants, amphetamine,
phencyclidine (PCP), sedatives, hypnotics or
anxiolytics. Substance use disorders are further
designated with the following terms: intoxication,
withdrawal, induced, or unspecified.
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Neurocognitive Disorders.
• These disorders are diagnosed when one’s decline in
cognitive functioning is significantly different from the
past and is usually the result of a medical condition
(e.g., Parkinson’s or Alzheimer’s disease), the use of a
substance/medication, or traumatic brain injury,
among other phenomena. Examples of neurocognitive
disorders (NCD) include delirium, and several types of
major and mild NCDs such as frontotemporal NCD, NCD
due to Parkinson’s disease, NCD due to HIV infection,
NCD due to Alzheimer’s disease, substance- or
medication-induced NCD, and vascular NCD, among
others.
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Personality Disorders.
• The 10 personality disorders in DSM-5 all
involve a pattern of experiences and behaviors
that are persistent, inflexible, and deviate
from one’s cultural expectations. Usually, this
pattern emerges in adolescence or early
adulthood and causes severe distress in one’s
interpersonal relationships. The personality
disorders are grouped into three following
clusters based on similar behaviors:
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• Cluster A: Paranoid, schizoid, and schizotypal. These
individuals seem bizarre or unusual in their behaviors
and interpersonal relations.
• Cluster B: Antisocial, borderline, histrionic, and
narcissistic. These individuals seem overly emotional,
are melodramatic, or unpredictable in their behaviors
and interpersonal relations.
• Cluster C: Avoidant, dependent, and obsessivecompulsive (not to be confused with obsessivecompulsive disorder). These individuals tend to
appear anxious, worried, or fretful in their behaviors.
• In addition to these clusters, one can be diagnosed
with other specified or unspecified personality
disorder, as well as a personality change due to
another medical condition, such as a head injury.
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Paraphilic Disorders.
• These disorders are diagnosed when the client is
sexual aroused to circumstances that deviate
from traditional sexual stimuli and when such
behaviors result in harm or significant emotional
distress. The disorders include exhibitionistic
disorder, voyeuristic disorder, frotteuristic
disorder, sexual sadism and sexual masochism
disorders, fetishistic disorder, transvestic disorder,
pedophilic disorder, and other specified and
unspecified paraphilic disorders.
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Other Mental Disorders.
• This diagnostic category includes mental
disorders that did not fall within one of the
previously mentioned groups and do not have
unifying characteristics. Examples include
other specified mental disorder due to
another medical condition, unspecified
mental disorders due to another medical
condition, other specified mental disorder,
and unspecified mental disorder.
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Medication-Induced Movement
Disorders and Other Adverse Effects of
Medications
• These disorders are the result of adverse and
severe side effects to medications, although a
causal link cannot always be shown. Some of
these disorders include neuroleptic-induced
parkinsonism, neuroleptic malignant syndrome,
medication-induced dystonia, medicationinduced acute akathisia, tardive dyskinesia,
tardive akathisia, medication-induced postural
tremor, other medication-induced movement
disorder, antidepressant discontinuation
syndrome, and other adverse effect of
medication.
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Other Conditions That May Be a Focus
of Clinical Assessment.
• Reminiscent of Axis IV of the previous edition of
the DSM, this last part of Section II ends with a
description of concerns that could be clinically
significant, such as abuse/neglect, relational
problems, psychosocial, personal, and
environmental concerns,
educational/occupational problems, housing and
economic problems, and problems related to the
legal system. These conditions, which are not
consider mental disorders, are generally listed as
V codes, which correspond to ICD-9, or Z codes,
which correspond to ICD-10.
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DSM-5 and ICD-10
• Codes in the DSM-IVTR were ICD-9CM codes
• e.g. Generalized Anxiety Disorder (300.02)
• Because U.S. healthcare providers will be
Required to use ICD-10CM (alphanumeric) codes
effective October 1, 2015, the DSM-5 includes
ICD-10 codes in parentheses
• e.g. Generalized Anxiety Disorder
300.02 (F41.1)
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Changes from the DSM IV-TR to the
DSM 5
• Terminology
• The phrase “general medical condition” is
replaced in DSM-5 with “another medical
condition” where relevant across all disorders.
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Neurodevelopmental Disorders
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Major Changes
Change
Comment
Elimination of multi-axial system and GAF
Clinicians wanted simplified, diagnosis-based
system; distinctions between Axis I and Axis
II disorders were never clearly justified;
clinicians can still specify external stressors;
new assessment measures will be
introduced
Establishes 20 diagnostic classes or
categories of mental disorders
Categories based on groupings of disorders
sharing similar characteristics; some
categories represent spectrums of related
disorders
Introduction of new diagnostic category
Neurodevelopmental Disorders to include
Autism Spectrum Disorder and ADHD and
other disorders reflecting abnormal brain
development
Increasing emphases on neurobiological
bases of mental disorders and the
developing understanding that abnormal
brain development underlies many types of
disorders
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Major Changes
Change
Comment
Introduces more dimensionality (severity
ratings) but does not restructure personality
disorders as some had proposed
Major changes in personality disorders held
over until next revision, the DSM 5.1 (or
maybe 5.2) in Section III identifies
alternative methods to Diagnose Personality
Disorders
Roman numerals dropped: DSM-5,
not DSM-V
Allows for easier nomenclature for
midcourse revisions, 5.1, 5.2, etc.
Removes obsessive-compulsive disorder
from category of Anxiety Disorders and
places it in new category of ObsessiveCompulsive and Related Disorders
Recognizes a spectrum of obsessivecompulsive type disorders, including body
dysmorphic disorder; however, anxiety
remains the core feature of OCD, so
questions remain about separating it from
anxiety disorders
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Major Changes
Change
Comment
Removes ASD (Acute Stress Disorder)
and PTSD from Anxiety Disorders and
places them in new category of Trauma
and Stressor-Related Disorders
Groups all stress-related psychological
disorders under the same umbrella;
Adjustment Disorders may now be coded
in context of traumatic stressors
Substance use disorder will combine the
DSM-IV categories of substance abuse
and substance dependence.
In this one overarching disorder, the
criteria have not only been combined, but
strengthened. Previous substance abuse
criteria required only one symptom while
the DSM-5’s mild substance use disorder
requires two to three symptoms.
Eliminates distinction between substance
abuse and dependence disorders,
collapsing them into single category of
substance use disorders
Recognizes that there is no clear line
between substance abuse and
dependence disorders; also brings
certain compulsive patterns of behavior
into a spectrum of addictive disorders
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Major Changes
Change
Comment
Hoarding disorder is new to DSM-5
Its addition to DSM is supported by
extensive scientific research on this disorder.
This disorder will help characterize people
with persistent difficulty discarding or
parting with possessions, regardless of their
actual value. The behavior usually has
harmful effects—emotional, physical, social,
financial and even legal— for a hoarder and
family members.
Now includes Gambling Disorder
(previously Pathological Gambling)
Other forms of nonchemical addiction,
such as compulsive Internet use, sexual
behavior and compulsive shopping,
don’t make it into the manual and
remain under study.
Binge eating disorder will be moved from
DSM-IV’s Appendix B
Criteria Sets and Axes Provided for Further
Study to DSM-5 Section 2. The change is
intended to better represent the symptoms
and behaviors of people with this condition.
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Major Changes
Change
Comment
Provides a means of rating severity of
symptoms.
Encourages clinicians to recognize the
dimensionality of disorders
Greater emphasis on comorbidity; e.g., use
of anxiety ratings in diagnosing depressive
and bipolar disorders
Provides more explicit recognition of comorbidity in having clinicians rate level of
anxiety in mood disorders
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Major Changes
Change
Comment
Elimination of term “somatoform
disorders” (now Somatic Symptom and
Related Disorders)
Eliminates a term few people
understood (somatoform disorders) and
now emphasizes the psychological
reactions to physical symptoms, not
whether they are medically based
Reorganization of mood disorders into
two separate diagnostic categories of
Depressive Disorders and Bipolar and
Related Disorders
No additional major changes
anticipated.
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Major Changes
Change
Comment
Removal of developmental
trajectory in organizing
classification of disorders:
Eliminates category of
“Disorders Usually First
Diagnosed in Infancy,
Childhood, or Adolescence”
May make it easier to diagnose traditional childhood
disorders like ADHD and even separation anxiety
disorder in adults. Conversely, it may also make it
easier to diagnose disorders typically seen in adults,
like bipolar disorder, in children.
Elimination of bereavement
exclusion from major
depression
Recognizes that a major depressive episode may
overlay a normal reaction to loss; critics claim it may
pathologize bereavement
The new category of Neurodevelopmental Disorders
includes many disorders previously classified as
childhood onset disorders, however it excludes
disorders involving abnormal emotional development,
such as separation anxiety disorder and selective
mutism.
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Major Changes
Change
Comment
Hypochondriasis dropped as distinct
disorder
Eliminates the pejorative term
“hypochondriasis”; people formerly
diagnosed with hypochondriasis may now
be diagnosed with Somatic Symptom
Disorder if their physical symptoms are
severe or with Illness Anxiety Disorder if
their symptoms are moderate or mild,
Factitious Disorder moved to Somatic
Symptom and Related Disorders
Associated with other somatic symptom
disorders, but is distinguished by
intentional fabrication of symptoms for no
apparent gain other than assuming
medical patient role
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Intellectual Disability (Intellectual
Developmental Disorder)
• Diagnostic criteria for intellectual disability
(intellectual developmental disorder)
emphasize the need for an assessment of both
cognitive capacity (IQ) and adaptive
functioning.
• Severity is determined by adaptive functioning
rather than IQ score.
• The term mental retardation has been
replaced with intellectual disability.
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Communication Disorders
• The DSM-5 communication disorders include:
• language disorder (which combines DSM-IV
expressive and mixed receptive-expressive language
disorders),
• speech sound disorder (a new name for phono-logical
disorder), and
• childhood-onset fluency disorder (a new name for
stuttering).
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Communication Disorders (Cont.)
• Also included is social (pragmatic) communication
disorder, a new condition for persistent difficulties in
the social uses of verbal and nonverbal
communication.
• Because social communication deficits are one
component of autism spectrum disorder (ASD), it is
important to note that social (pragmatic)
communication disorder cannot be diagnosed in the
presence of restricted repetitive behaviors, interests,
and activities (the other component of ASD).
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Autism Spectrum Disorder
• Autism spectrum disorder is a new DSM-5 name
that reflects a scientific consensus that four
previously separate disorders are actually a single
condition with different levels of symptom
severity in two core domains.
• ASD now encompasses the previous DSM-IV
• autistic disorder (autism),
• Asperger’s disorder,
• childhood disintegrative disorder, and
• pervasive developmental disorder not otherwise
specified.
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• ASD is characterized by 1) deficits in social
communication and social interaction and 2)
restricted repetitive behaviors, interests, and
activities (RRBs). Because both components
are required for diagnosis of ASD, social
communication disorder is diagnosed if no
RRBs are present.
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Attention-Deficit/Hyperactivity Disorder
• The diagnostic criteria for attentiondeficit/hyperactivity disorder (ADHD) in DSM5 are similar to those in DSM-IV. The same 18
symptoms are used as in DSM-IV, and
continue to be divided into two symptom
domains (inattention and
hyperactivity/impulsivity), of which at least six
symptoms in one domain are required for
diagnosis. However, several changes have
been made in DSM-5:
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• 1) examples have been added to the criterion
items to facilitate application across the life span;
• 2) the cross-situational requirement has been
strengthened to “several” symptoms in each
setting;
• 3) the onset criterion has been changed from
“symptoms that caused impairment were present
before age 7 years” to “several inattentive or
hyperactive-impulsive symptoms were present
prior to age 12”;
• 4) subtypes have been replaced with
presentation specifiers that map directly to the
prior subtypes;
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• 5) a comorbid diagnosis with autism spectrum
disorder is now allowed; and
• 6) a symptom threshold change has been made
for adults, to reflect their substantial evidence of
clinically significant ADHD impairment, with the
cutoff for ADHD of five symptoms, instead of six
required for younger persons, both for
inattention and for hyperactivity and impulsivity.
• Finally, ADHD was placed in the
neurodevelopmental disorders chapter to reflect
brain developmental correlates with ADHD and
the DSM-5 decision to eliminate the DSM-IV
chapter that includes all diagnoses usually first
made in infancy, childhood, or adolescence.
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Specific Learning Disorder
• Specific learning disorder combines the DSMIV diagnoses of reading disorder, mathematics
disorder, disorder of written expression, and
learning disorder not otherwise specified.
Because learning deficits in the areas of
reading, written expression, and mathematics
commonly occur together, coded specifiers for
the deficit types in each area are included.
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Motor Disorders
• The following motor disorders are included in the
DSM-5 neurodevelopmental disorders chapter:
• developmental coordination disorder,
• stereotypic movement disorder,
• Tourette’s disorder, persistent (chronic) motor or
vocal tic disorder,
• provisional tic disorder, other specified tic disorder,
and unspecified tic disorder. The tic criteria have been
standardized across all of these disorders in this
chapter.
• Stereotypic movement disorder has been more
clearly differentiated from body-focused repetitive
behavior disorders that are in the DSM-5 obsessivecompulsive disorder chapter.
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Schizophrenia Spectrum and Other
Psychotic Disorders
• Two changes were made to DSM-IV Criterion A
for schizophrenia. The first change is the
elimination of the special attribution of bizarre
delusions and Schneiderian first-rank auditory
hallucinations (e.g., two or more voices
conversing). In DSM-IV, only one such symptom
was needed to meet the diagnostic requirement
for Criterion A, instead of two of the other listed
symptoms. This special attribution was removed
due to the nonspecificity of Schneiderian
symptoms and the poor reliability in
distinguishing bizarre from non-bizarre delusions.
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Schizophrenia Spectrum and Other
Psychotic Disorders (Cont.)
• Therefore, in DSM-5, two Criterion A
symptoms are required for any diagnosis of
schizophrenia.
• The second change is the addition of a
requirement in Criterion A that the individual
must have at least one of these three
symptoms: delusions, hallucinations, and
disorganized speech.
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Schizophrenia subtypes
• The DSM-IV subtypes of schizophrenia (i.e.,
paranoid, disorganized, catatonic,
undifferentiated, and residual types) are
eliminated due to their limited diagnostic
stability, low reliability, and poor validity. These
subtypes also have not been shown to exhibit
distinctive patterns of treatment response or longitudinal course.
• Instead, a dimensional approach to rating
severity for the core symptoms of schizophrenia
is included in Section III.
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Schizoaffective Disorder
• The primary change to schizoaffective disorder,
(schizophrenia and a mood disorder) is the
requirement that a major mood episode be present
for a majority of the disorder’s total duration after
Criterion A has been met. It makes schizoaffective
disorder a longitudinal instead of a cross-sectional
diagnosis more comparable to schizophrenia, bipolar
disorder, and major depressive disorder, which are
bridged by this condition.
• The change was also made to improve the reliability,
diagnostic stability, and validity of this disorder, while
recognizing that the characterization of patients with
both psychotic and mood symptoms, either
concurrently or at different points in their illness, has
been a clinical challenge.
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Delusional Disorder
• Criterion A for delusional disorder no longer has
the requirement that the delusions must be
nonbizarre. A specifier for bizarre type delusions
provides continuity with DSM-IV. The
demarcation of delusional disorder from
psychotic variants of obsessive-compulsive
disorder and body dysmorphic disorder is
explicitly noted with a new exclusion criterion,
which states that the symptoms must not be
better explained by conditions such as obsessivecompulsive or body dysmorphic disorder with
absent insight/delusional beliefs.
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Delusional Disorder (Cont.)
• DSM-5 no longer separates delusional
disorder from shared delusional disorder. If
criteria are met for delusional disorder then
that diagnosis is made. If the diagnosis cannot
be made but shared beliefs are present, then
the diagnosis “other specified schizophrenia
spectrum and other psychotic disorder” is
used.
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Catatonia
• The same criteria are used to diagnose catatonia
whether the context is a psychotic, bipolar,
depressive, or other medical disorder, or an
unidentified medical condition. In DSM-IV, two out of
five symptom clusters were required if the context
was a psychotic or mood disorder, whereas only one
symptom cluster was needed if the context was a
general medical condition.
• In DSM-5, all contexts require three catatonic
symptoms (from a total of 12 characteristic
symptoms).
• In DSM-5, catatonia may be diagnosed as a specifier
for depressive, bipolar, and psychotic disorders; as a
separate diagnosis in the context of another medical
condition; or as an other specified diagnosis.
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Bipolar and Related Disorders
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Bipolar Disorders
• Criterion A for manic and hypomanic episodes now
includes an emphasis on changes in activity and
energy as well as mood.
• The DSM-IV diagnosis of bipolar I disorder, mixed
episode, requiring that the individual simultaneously
meet full criteria for both mania and major depressive
episode, has been removed.
• Instead, a new specifier, “with mixed features,” has
been added that can be applied to episodes of mania
or hypomania when depressive features are present,
and to episodes of depression in the context of major
depressive disorder or bipolar disorder when features
of mania/hypomania are present.
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Other Specified Bipolar and Related
Disorder
• DSM-5 allows the specification of particular
conditions for other specified bipolar and related
disorder, including categorization for individuals
with a past history of a major depressive disorder
who meet all criteria for hypomania except the
duration criterion (i.e., at least 4 consecutive
days).
• A second condition constituting an other
specified bipolar and related disorder is that too
few symptoms of hypomania are present to meet
criteria for the full bipolar II syndrome, although
the duration is sufficient at 4 or more days.
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Anxious Distress Specifier
• In the chapter on bipolar and related disorders
and the chapter on depressive disorders, a
specifier for anxious distress is delineated.
This specifier is intended to identify patients
with anxiety symptoms that are not part of
the bipolar diagnostic criteria.
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Depressive Disorders
• DSM-5 contains several new depressive
disorders, including disruptive mood
dysregulation disorder and premenstrual
dysphoric disorder. To address concerns about
potential overdiagnosis and overtreatment of
bipolar disorder in children, a new diagnosis,
disruptive mood dysregulation disorder, is
included for children up to age 18 years who
exhibit persistent irritability and frequent
episodes of extreme behavioral dyscontrol.
Based on strong scientific evidence,
premenstrual dysphoric disorder has been
moved from DSM-IV Appendix B, “Criteria Sets
and Axes Provided for Further Study,” to the
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Depressive Disorders (Cont.)
main body of DSM-5. Finally, DSM-5
conceptualizes chronic forms of depression in a
somewhat modified way. What was referred to
as dysthymia in DSM-IV now falls under the
category of persistent depressive dis- order,
which includes both chronic major depressive
disorder and the previous dysthymic disorder.
An inability to find scientifically meaningful
differences between these two conditions led
to their combination with specifiers included to
identify different pathways to the diagnosis and
to provide continuity with DSM-IV.
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Major Depressive Disorder
• Neither the core criterion symptoms applied to
the diagnosis of major depressive episode nor the
requisite duration of at least 2 weeks has
changed from DSM-IV.
• Criterion A for a major depressive episode in
DSM-5 is identical to that of DSM-IV, as is the
requirement for clinically significant distress or
impairment in social, occupational, or other
important areas of life, although this is now listed
as Criterion B rather than Criterion C.
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Major Depressive Disorder (Cont.)
• The coexistence within a major depressive
episode of at least three manic symptoms
(insufficient to satisfy criteria for a manic
episode) is now acknowledged by the specifier
“with mixed features.” The presence of mixed
features in an episode of major depressive
disorder increases the likelihood that the illness
exists in a bipolar spectrum; however, if the
individual concerned has never met criteria for a
manic or hypomanic episode, the diagnosis of
major depressive disorder is retained.
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Bereavement Exclusion
• In DSM-IV, there was an exclusion criterion for a
major depressive episode that was applied to
depressive symptoms lasting less than 2 months
following the death of a loved one (i.e., the
bereavement exclusion). This exclusion is omitted in
DSM-5 for several reasons:
– The first is to remove the implication that
bereavement typically lasts only 2 months when
both physicians and grief counselors recognize that
the duration is more commonly 1–2 years.
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Bereavement Exclusion (Cont.)
– Second, bereavement is recognized as a severe
psychosocial stressor that can precipitate a major
depressive episode in a vulnerable individual,
generally beginning soon after the loss. When
major depressive disorder occurs in the context of
bereavement, it adds an additional risk for
suffering, feelings of worthlessness, suicidal
ideation, poorer somatic health, worse
interpersonal and work functioning, and an
increased risk for persistent complex bereavement
disorder, which is now described with explicit
criteria in Conditions for Further Study in DSM-5
Section III.
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Bereavement Exclusion (Cont.)
– Third, bereavement-related major depression is
most likely to occur in individuals with past
personal and family histories of major depressive
episodes. It is genetically influenced and is
associated with similar personality characteristics,
patterns of comorbidity, and risks of chronicity
and/or recurrence as non–bereavement-related
major depressive episodes.
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Specifiers for Depressive Disorders
• A new specifier to indicate the presence of mixed
symptoms has been added across both the
bipolar and the depressive disorders, allowing for
the possibility of manic features in individuals
with a diagnosis of unipolar depression. A
substantial body of research conducted over the
last two decades points to the importance of
anxiety as relevant to prognosis and treatment
decision making. The “with anxious distress”
specifier gives the clinician an opportunity to rate
the severity of anxious distress in all individuals
with bipolar or depressive disorders.
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Anxiety Disorders
• The DSM-5 chapter on anxiety disorder no
longer includes obsessive-compulsive disorder
(which is included with the obsessivecompulsive and related disorders) or
posttraumatic stress disorder and acute stress
disorder (which is included with the traumaand stressor-related disorders). However, the
sequential order of these chapters in DSM-5
reflects the close relationships among them.
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Agoraphobia, Specific Phobia, and Social
Anxiety Disorder (Social Phobia)
• Changes in criteria for agoraphobia, specific
phobia, and social anxiety disorder (social
phobia) include deletion of the requirement
that individuals over age 18 years recognize
that their anxiety is excessive or
unreasonable. This change is based on
evidence that individuals with such disorders
often overestimate the danger in “phobic”
situations and that older individuals often
misattribute “phobic” fears to aging.
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Agoraphobia, Specific Phobia, and Social
Anxiety Disorder (Social Phobia) (Cont.)
• Instead, the anxiety must be out of proportion
to the actual danger or threat in the situation,
after taking cultural contextual factors into
account.
• In addition, the 6-month duration, which was
limited to individuals under age 18 in DSM-IV,
is now extended to all ages. This change is
intended to minimize overdiagnosis of
transient fears.
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Panic Attack
• The essential features of panic attacks remain
unchanged, although the complicated DSM-IV
terminology for describing different types of panic
attacks (i.e., situationally bound/cued, situationally
predisposed, and unexpected/uncued) is replaced
with the terms unexpected and expected panic
attacks.
• Panic attacks function as a marker and prognostic
factor for severity of diagnosis, course, and
comorbidity across an array of disorders, including
but not limited to anxiety disorders. Hence, panic
attack can be listed as a specifier that is applicable to
all DSM-5 disorders.
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Panic Disorder and Agoraphobia
• Panic disorder and agoraphobia are unlinked in DSM5. Thus, the former DSM-IV diagnoses of panic
disorder with agoraphobia, panic disorder without
agoraphobia, and agoraphobia without history of
panic disorder are now replaced by two diagnoses,
panic disorder and agoraphobia, each with separate
criteria.
• The co-occurrence of panic disorder and agoraphobia
is now coded with two diagnoses. This change
recognizes that a substantial number of individuals
with agoraphobia do not experience panic
symptoms.
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Separation Anxiety Disorder
• Although in DSM-IV, separation anxiety disorder
was classified in the section “Disorders Usually
First Diagnosed in Infancy, Childhood, or
Adolescence,” it is now classified as an anxiety
disorder.
• The core features remain mostly unchanged,
although the wording of the criteria has been
modified to more adequately represent the
expression of separation anxiety symptoms in
adulthood.
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Separation Anxiety Disorder (Cont.)
• Also, in contrast to DSM-IV, the diagnostic criteria
no longer specify that age at onset must be before
18 years, because a substantial number of adults
report onset of separation anxiety after age 18.
Also, a duration criterion—“typically lasting for 6
months or more”—has been added for adults to
minimize overdiagnosis of transient fears.
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Selective Mutism
• In DSM-IV, selective mutism was classified in
the section “Disorders Usually First Diagnosed
in Infancy, Childhood, or Adolescence.”
• It is now classified as an anxiety disorder,
given that a large majority of children with
selective mutism are anxious. The diagnostic
criteria are largely unchanged from DSM-IV.
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Obsessive-Compulsive and Related
Disorders
• The chapter on obsessive-compulsive and related
disorders, which is new in DSM-5, reflects the
increasing evidence that these disorders are related
to one another.
• New disorders include hoarding disorder, excoriation
(skin-picking) disorder, substance-/medicationinduced obsessive-compulsive and related disorder,
and obsessive-compulsive and related disorder due to
another medical condition. The DSM-IV diagnosis of
trichotillomania is now termed trichotillomania (hairpulling disorder) and has been moved from a DSM-IV
classification of impulse-control disorders not
elsewhere classified to obsessive-compulsive and
related disorders in DSM-5.
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Specifiers for Obsessive-Compulsive
and Related Disorders
• The “with poor insight” specifier for obsessivecompulsive disorder has been refined in DSM-5 to
allow a distinction between individuals with good or
fair insight, poor insight, and “absent
insight/delusional” obsessive-compulsive disorder
beliefs (i.e., complete conviction that obsessivecompulsive disorder beliefs are true).
• Analogous “insight” specifiers have been included for
body dysmorphic disorder and hoarding disorder.
• The “tic-related” specifier for obsessive-compulsive
disorder reflects a growing literature on the diagnostic
validity and clinical utility of identifying individuals
with a current or past comorbid tic disorder.
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Body Dysmorphic Disorder
• For DSM-5 body dysmorphic disorder, a diagnostic
criterion describing repetitive behaviors or mental
acts in response to preoccupations with perceived
defects or flaws in physical appearance has been
added, consistent with data indicating the prevalence
and importance of this symptom.
• The delusional variant of body dysmorphic disorder
(which identifies individuals who are completely
convinced that their perceived defects or flaws are
truly abnormal appearing) is no longer coded as both
delusional disorder, somatic type, and body
dysmorphic disorder; in DSM-5 this presentation is
designated only as body dysmorphic disorder with
the absent insight/delusional beliefs specifier.
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Hoarding Disorder
• Hoarding disorder is a new diagnosis in DSM-5. DSMIV lists hoarding as one of the possible symptoms of
obsessive-compulsive personality disorder and notes
that extreme hoarding may occur in obsessivecompulsive disorder. However, available data do not
indicate that hoarding is a variant of obsessivecompulsive disorder or another mental disorder.
Instead, there is evidence for the diagnostic validity
and clinical utility of a separate diagnosis of hoarding
disorder, which reflects persistent difficulty discarding or parting with possessions due to a
perceived need to save the items and distress
associated with discarding them. Hoarding disorder
may have unique neurobiological correlates, is
associated with significant impairment, and may
respond to clinical intervention.
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• Trichotillomania (Hair-Pulling Disorder)
• Trichotillomania was included in DSM-IV,
although “hair-pulling disorder” has been
added parenthetically to the disorder’s name
in DSM-5.
• Excoriation (Skin-Picking) Disorder
• Excoriation (skin-picking) disorder is newly
added to DSM-5, with strong evidence for its
diagnostic validity and clinical utility.
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• Substance/Medication-Induced ObsessiveCompulsive and Related Disorder and ObsessiveCompulsive and Related Disorder Due to Another
Medical Condition
• DSM-IV included a specifier “with obsessivecompulsive symptoms” in the diagnoses of anxiety
disorders due to a general medical condition and
substance-induced anxiety disorders. Given that
obsessive-compulsive and related disorders are now a
distinct category, DSM-5 includes new categories for
substance medication-induced obsessive-compulsive
and related disorder and for obsessive-compulsive and
related disorder due to another medical condition.
This change is consistent with the intent of DSM-IV,
and it reflects the recognition that substances,
medications, and medical conditions can present with
symptoms similar to primary obsessive-compulsive
and related disorders.
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• Other Specified and Unspecified ObsessiveCompulsive and Related Disorders
• DSM-5 includes the diagnoses other specified
obsessive-compulsive and related disorder, which
can include conditions such as body-focused
repetitive behavior disorder and obsessional
jealousy, or unspecified obsessive-compulsive and
related disorder. Body-focused repetitive behavior
disorder is characterized by recurrent behaviors
other than hair pulling and skin picking (e.g., nail
biting, lip biting, cheek chewing) and repeated
attempts to decrease or stop the behaviors.
Obsessional jealousy is characterized by
nondelusional preoccupation with a partner’s
perceived infidelity.
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Trauma and Stressor Related
Disorders
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Acute Stress Disorder
• In DSM-5, the stressor criterion (Criterion A) for acute
stress disorder is changed from DSM-IV. The criterion
requires being explicit as to whether qualifying
traumatic events were experienced directly,
witnessed, or experienced indirectly. Also, the DSM-IV
Criterion A2 regarding the subjective reaction to the
traumatic event (e.g., “the person’s response involved
intense fear, helplessness, or horror”) has been
eliminated. Based on evidence that acute
posttraumatic reactions are very heterogeneous and
that DSM-IV’s emphasis on dissociative symptoms is
overly restrictive, individuals may meet diagnostic
criteria in DSM-5 for acute stress disorder if they
exhibit any 9 of 14 listed symptoms in these
categories: intrusion, negative mood, dissociation,
avoidance, and arousal.
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Posttraumatic Stress Disorder
• DSM-5 criteria for posttraumatic stress disorder differ
significantly from those in DSM-IV. The stressor
criterion (Criterion A) is more explicit with regard to
how an individual experienced “traumatic” events.
Also, Criterion A2 (subjective reaction) has been
eliminated.
• Whereas there were three major symptom clusters in
DSM-IV—reexperiencing, avoidance/numbing, and
arousal—there are now four symptom clusters in
DSM-5, because the avoidance/ numbing cluster is
divided into two distinct clusters: avoidance and
persistent negative alterations in cognitions and
mood.
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Posttraumatic Stress Disorder (Cont.)
• This latter category, which retains most of the DSM-IV
numbing symptoms, also includes new or
reconceptualized symptoms, such as persistent
negative emotional states.
• The final cluster—alterations in arousal and
reactivity—retains most of the DSM-IV arousal
symptoms. It also includes irritable or aggressive
behavior and reckless or self-destructive behavior.
• Posttraumatic stress disorder is now developmentally
sensitive in that diagnostic thresholds have been
lowered for children and adolescents. Furthermore,
separate criteria have been added for children age 6
years or younger with this disorder.
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Reactive Attachment Disorder
• The DSM-IV childhood diagnosis reactive attachment
disorder had two subtypes: emotionally withdrawn/inhibited and indiscriminately
social/disinhibited.
• In DSM-5, these subtypes are defined as distinct
disorders: reactive attachment disorder and
disinhibited social engagement disorder.
• Both of these disorders are the result of social
neglect or other situations that limit a young child’s
opportunity to form selective attachments.. The two
disorders differ in other important ways, including
correlates, course, and response to intervention, and
for these reasons are considered separate disorders.
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Dissociative Disorders
• Major changes in dissociative disorders in DSM-5
include the following:
• 1) derealization is included in the name and
symptom structure of what previously was called
depersonalization disorder and is now called
depersonalization/derealization disorder,
• 2) dissociative fugue is now a specifier of
dissociative amnesia rather than a separate
diagnosis, and
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Dissociative Disorders (Cont.)
• 3) the criteria for dissociative identity disorder have
been changed to indicate that symptoms of
disruption of identity may be reported as well as
observed, and that gaps in the recall of events may
occur for everyday and not just traumatic events.
• Also, experiences of pathological possession in some
cultures are included in the description of identity
disruption.
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Dissociative Identity Disorder
• Several changes to the criteria for dissociative
identity disorder have been made in DSM-5.
• Criterion A has been expanded to include
certain possession-form phenomena and
functional neurological symptoms to account
for more diverse presentations of the disorder.
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Dissociative Identity Disorder (Cont.)
• Criterion A now specifically states that
transitions in identity may be observable by
others or self-reported. Third, according to
Criterion B, individuals with dissociative
identity disorder may have recurrent gaps in
recall for everyday events, not just for
traumatic experiences. Other text
modifications clarify the nature and course of
identity disruptions.
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Somatic Symptom and Related Disorders
• Somatic Symptom Disorder
• DSM-5 better recognizes the complexity of the
interface between psychiatry and medicine.
Individuals with somatic symptoms plus abnormal
thoughts, feelings, and behaviors may or may not
have a diagnosed medical condition.
• Individuals previously diagnosed with somatization
disorder will usually meet DSM-5 criteria for somatic
symptom disorder, but only if they have the
maladaptive thoughts, feelings, and behaviors that
define the disorder, in addition to their somatic
symptoms.
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• In DSM-IV, the diagnosis undifferentiated
somatoform disorder had been created in
recognition that somatization disorder would
only describe a small minority of “somatizing”
individuals, but this disorder did not prove to be a
useful clinical diagnosis. Because the distinction
between somatization disorder and
undifferentiated somatoform disorder was
arbitrary, they are merged in DSM-5 under
somatic symptom disorder, and no specific
number of somatic symptoms is required.
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Medically Unexplained Symptoms
• DSM-IV criteria overemphasized the importance of an
absence of a medical explanation for the somatic
symptoms. Unexplained symptoms are present to
various degrees, particularly in conversion disorder,
but somatic symptom disorders can also accompany
diagnosed medical disorders. The reliability of
medically unexplained symptoms is limited, and
grounding a diagnosis on the absence of an
explanation is problematic and reinforces mind -body
dualism.
• The DSM-5 classification defines disorders on the
basis of positive symptoms (i.e., distressing somatic
symptoms plus abnormal thoughts, feelings, and
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behaviors in response
to these symptoms).
Hypochondriasis and Illness Anxiety
Disorder
• Hypochondriasis has been eliminated as a
disorder, in part because the name was
perceived as pejorative and not conducive to
an effective therapeutic relationship. Most
individuals who would previously have been
diagnosed with hypochondriasis have
significant somatic symptoms in addition to
their high health anxiety, and would now
receive a DSM-5 diagnosis of somatic
symptom disorder.
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Hypochondriasis and Illness Anxiety
Disorder (Cont.)
• In DSM-5, individuals with high health anxiety
without somatic symptoms would receive a
diagnosis of illness anxiety disorder (unless
their health anxiety was better explained by a
primary anxiety disorder, such as generalized
anxiety disorder).
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Pain Disorder
• DSM-5 takes a different approach to the
important clinical realm of individuals with pain.
In DSM-IV, the pain disorder diagnoses assume
that some pains are associated solely with
psychological factors, some with medical diseases
or injuries, and some with both. There is a lack of
evidence that such distinctions can be made with
reliability and validity, and a large body of
research has demonstrated that psychological
factors influence all forms of pain. Most
individuals with chronic pain attribute their pain
to a combination of factors, including somatic,
psychological, and environmental influences.
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Pain Disorder (Cont.)
• In DSM-5, some individuals with chronic pain
would be appropriately diagnosed as having
somatic symptom disorder, with predominant
pain. For others, psychological factors
affecting other medical conditions or an
adjustment disorder would be more
appropriate.
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Psychological Factors Affecting Other
Medical Conditions and Factitious Disorder
• Psychological factors affecting other medical
conditions is a new mental disorder in DSM-5, having
formerly been included in the DSM-IV chapter “Other
Conditions That May Be a Focus of Clinical Attention.”
• This disorder and factitious disorder are placed
among the somatic symptom and related disorders
because somatic symptoms are predominant in both
disorders, and both are most often encountered in
medical settings. The variants of psychological factors
affecting other medical conditions are removed in
favor of the stem diagnosis.
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Feeding and Eating Disorders
• In DSM-5, the feeding and eating disorders
include several disorders included in DSM-IV
as feeding and eating disorders of infancy or
early childhood in the chapter “Disorders
Usually First Diagnosed in Infancy, Childhood,
or Adolescence.”
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• Pica and Rumination Disorder
• The DSM-IV criteria for pic (eating clay, paper,
sand, etc.) and for rumination disorder,
(bringing up and re-chews food) have been
revised for clarity and to indicate that the
diagnoses can be made for individuals of any
age.
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Avoidant/Restrictive Food Intake Disorder
• DSM-IV feeding disorder of infancy or early
childhood has been renamed
avoidant/restrictive food intake disorder, and
the criteria have been significantly expanded.
• The DSM-IV disorder was rarely used, and
limited information is available on the
characteristics, course, and outcome of
children with this disorder. Additionally, a
large number of individuals, primarily but not
exclusively children and adolescents,
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Avoidant/Restrictive Food Intake Disorder
(Cont.)
substantially restrict their food intake and
experience significant and experience significant
associated physiological or psychosocial problems
but do not meet criteria for any DSM-IV eating
disorder.
• Avoidant/restrictive food intake disorder is a
broad category intended to capture this range
of presentations.
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Binge-Eating Disorder
• Extensive research followed the promulgation of
preliminary criteria for binge eating disorder in
Appendix B of DSM-IV, and findings supported
the clinical utility and validity of binge-eating
disorder.
• The only significant difference from the
preliminary DSM-IV criteria is that the minimum
average frequency of binge eating required for
diagnosis has been changed from at least twice
weekly for 6 months to at least once weekly over
the last 3 months, which is identical to the DSM-5
frequency criterion for bulimia nervosa.
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Sexual Dysfunctions
• In DSM-IV, sexual dysfunctions referred to sexual
pain or to a disturbance in one or more phases of
the sexual response cycle. Research suggests that
sexual response is not always a linear, uniform
process and that the distinction between certain
phases (e.g., desire and arousal) may be artificial.
In DSM-5, gender-specific sexual dysfunctions
have been added, and, for females, sexual desire
and arousal disorders have been combined into
one disorder: female sexual interest/arousal
disorder.
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Sexual Dysfunctions (Cont.)
• To improve precision regarding duration and
severity criteria and to reduce the likelihood of
overdiagnosis, all of the DSM-5 sexual
dysfunctions (except substance-/medicationinduced sexual dysfunction) now require a
minimum duration of approximately 6 months
and more precise severity criteria. These changes
provide useful thresholds for making a diagnosis
and distinguish transient sexual difficulties from
more persistent sexual dysfunction.
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Subtypes
• DSM-IV included the following subtypes for all
sexual disorders: lifelong versus acquired,
generalized versus situational, and due to
psychological factors versus due to combined
factors.
• DSM-5 includes only lifelong versus acquired and
generalized versus situational subtypes.
• Sexual dysfunction due to a general medical
condition and the subtype due to psychological
versus combined factors have been deleted due
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Subtypes (Cont.)
to findings that the most frequent clinical
presentation is one in which both psychological
and biological factors contribute.
• To indicate the presence and degree of medical
and other nonmedical correlates, the following
associated features are described in the
accompanying text: partner factors, relationship
factors, individual vulnerability factors, cultural or
religious factors, and medical factors.
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Gender Dysphoria
• Gender dysphoria is a new diagnostic class in
DSM-5 and reflects a change in conceptualization
of the disorder’s defining features by emphasizing
the phenomenon of “gender incongruence”
rather than cross-gender identification per se, as
was the case in DSM-IV gender identity disorder.
• In DSM-IV, the chapter “Sexual and Gender
Identity Disorders” included three relatively
disparate diagnostic classes: gender identity
disorders, sexual dysfunctions, and paraphilias.
Gender identity disorder, however, is neither a
sexual dysfunction nor a paraphilia.
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Gender Dysphoria (Cont.)
• Gender dysphoria is a unique condition in that it
is a diagnosis made by mental health care
providers, although a large proportion of the
treatment is endocrinological and surgical (at
least for some adolescents and most adults). In
contrast to the dichotomized DSM-IV gender
identity disorder diagnosis, the type and severity
of gender dysphoria can be inferred from the
number and type of indicators and from the
severity measures.
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Subtypes and Specifiers
• The subtyping on the basis of sexual orientation
has been removed because the distinction is not
considered clinically useful. A posttransition
specifier has been added because many
individuals, after transition, no longer meet
criteria for gender dysphoria; however, they
continue to undergo various treatments to
facilitate life in the desired gender.
• Although the concept of posttransition is
modeled on the concept of full or partial
remission, the term remission has implications in
terms of symptom reduction that do not apply
directly to gender dysphoria.
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Disruptive, Impulse-Control, and
Conduct Disorders
• The chapter on disruptive, impulse-control, and
conduct disorders is new to DSM-5. It brings
together disorders that were previously included
in the chapter “Disorders Usually First Diagnosed
in Infancy, Childhood, or Adolescence” (i.e.,
oppositional defiant disorder; conduct disorder;
and disruptive behavior disorder not otherwise
specified, now categorized as other specified and
unspecified disruptive, impulse-control, and
conduct disorders) and the chapter “ImpulseControl Disorders Not Otherwise Specified” (i.e.,
intermittent explosive disorder, pyromania, and
kleptomania).
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Disruptive, Impulse-Control, and
Conduct Disorders (Cont.)
• These disorders are all characterized by problems
in emotional and behavioral self-control. Because
of its close association with conduct disorder,
antisocial personality disorder has dual listing in
this chapter and in the chapter on personality
disorders. Of note, ADHD is frequently comorbid
with the disorders in this chapter but is listed
with the neurodevelopmental disorders.
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Oppositional Defiant Disorder
• Four refinements have been made to the criteria
for oppositional defiant disorder.
• First, symptoms are now grouped into three
types: angry/irritable mood,
argumentative/defiant behavior, and vindictiveness. This change highlights that the disorder
reflects both emotional and behavioral
symptomatology.
• Second, the exclusion criterion for conduct
disorder has been removed.
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Oppositional Defiant Disorder (Cont.)
• Third, given that many behaviors associated with
symptoms of oppositional defiant disorder occur
commonly in normally developing children and
adolescents, a note has been added to the
criteria to provide guidance on the frequency
typically needed for a behavior to be considered
symptomatic of the disorder.
• Fourth, a severity rating has been added to the
criteria to reflect research showing that the
degree of pervasiveness of symptoms across
settings is an important indicator of severity.
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Conduct Disorder
• The criteria for conduct disorder are largely
unchanged from DSM-IV. A descriptive features
specifier has been added for individuals who
meet full criteria for the disorder but also present
with limited pro-social emotions. This specifier
applies to those with conduct disorder who show
a callous and unemotional interpersonal style
across multiple settings and relationships. The
specifier is based on research showing that
individuals with conduct disorder who meet
criteria for the specifier tend to have a relatively
more severe form of the disorder and a different
treatment response.
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Intermittent Explosive Disorder
• The primary change in DSM-5 intermittent explosive
disorder is the type of aggressive outbursts that
should be considered: physical aggression was
required in DSM-IV, whereas verbal aggression and
non- destructive/noninjurious physical aggression
also meet criteria in DSM-5.
• DSM-5 also provides more specific criteria defining
frequency needed to meet criteria and specifies that
the aggressive outbursts are impulsive and/or anger
based in nature, and must cause marked distress,
cause impairment in occupational or interpersonal
functioning, or be associated with negative financial
or legal consequences.
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Intermittent Explosive Disorder
(Cont.)
• Furthermore, because of the paucity of research on
this disorder in young children and the potential
difficulty of distinguishing these outbursts from
normal temper tantrums in young children, a
minimum age of 6 years (or equivalent
developmental level) is now required.
• Finally, especially for youth, the relationship of this
disorder to other disorders (e.g., ADHD, disruptive
mood dysregulation disorder) has been further
clarified.
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Substance-Related and Addictive Disorders
Gambling Disorder
• An important departure from past diagnostic
manuals is that the substance-related
disorders chapter has been expanded to
include gambling disorder. This change reflects
the increasing and consistent evidence that
some behaviors, such as gambling, activate
the brain reward system with effects similar to
those of drugs of abuse and that gambling
disorder symptoms resemble substance use
disorders to a certain extent.
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Personality Disorders
• The criteria for personality disorders in Section
II of DSM-5 have not changed from those in
DSM-IV.
An alternative approach to the diagnosis of
personality disorders was developed for DSM5 for further study and can be found in Section
III.
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Paraphilic Disorders
Specifiers
• An overarching change from DSM-IV is the addition
of the course specifiers “in a controlled
environment” and “in remission” to the diagnostic
criteria sets for all the paraphilic disorders.
• These specifiers are added to indicate important
changes in an individual’s status. There is no expert
consensus about whether a long-standing paraphilia
can entirely remit, but there is less argument that
consequent psychological distress, psychosocial
impairment, or the propensity to do harm to others
can be reduced to acceptable levels. Therefore, the
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Paraphilic Disorders
Specifiers (Cont.)
specifier has been added to indicate remission from
a paraphilic disorder.
• The specifier is silent with regard to changes in the
presence of the paraphilic interest per se. The other
course specifier, “in a controlled environment,” is
included because the propensity of an individual to
act on paraphilic urges may be more difficult to
assess objectively when the individual has no
opportunity to act on such urges.
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Also Eliminated
– Somatization Disorder (gone)
– Amnestic Disorders (amnesia now a feature
of neurocognitive disorders)
– Dissociative Fugue (now a subtype of
dissociative amnesia)
– Pain Disorder (gone)
– Hypochondriasis (cases now divided
between Somatic Symptom Disorder and
Illness Anxiety Disorder depending on severity
of physical symptoms)
– Asperger’s Disorder (may now be
diagnosed as ASD)
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Also Eliminated (Cont.)
– Childhood Disintegrative Disorder (may
now be diagnosed as ASD)
– Pervasive Developmental Disorder NOS
(may now be diagnosed as ASD)
– Vaginismus and Dyspareunia (now GenitoPelvic Pain/Penetration Disorder)
– Gender Identity Disorder (now Gender
Dysphoria)
– Sexual Aversion Disorder (dropped, most
cases reclassifiable as specific phobia)
– Substance Dependence/Abuse Disorders,
(now SUD with specifiers)
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Notable Mentions
• The proliferation of medical marijuana has led
to a clinical diagnosis of “cannabis
withdrawal,” for example.
• With the significant increase in caffeine
consumption via coffee shops and energy
drinks there is the clinical diagnosis of caffeine
withdrawal
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Notable Mentions
• Removal of bereavement exclusion: the exclusion
criterion in DSM-IV applied to people
experiencing depressive symptoms lasting less
than two months following the death of a loved
one has been removed and replaced by several
notes within the text delineating the differences
between grief and depression. This reflects the
recognition that bereavement is a severe
psychosocial stressor that can precipitate a major
depressive episode beginning soon after the loss
of a loved one.
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Notable Mentions
• Personality disorders: DSM-5 will maintain the
categorical model and criteria for the 10
personality disorders included in DSM-IV and
will include the new trait-specific
methodology in a separate area of Section 3
to encourage further study how this could be
used to diagnose personality disorders in
clinical practice.
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Notable Mentions
• Disruptive mood dysregulation disorder will
be included in DSM-5 to diagnose children
who exhibit persistent irritability and frequent
episodes of behavior outbursts three or more
times a week for more than a year. The
diagnosis is intended to address concerns
about potential over-diagnosis and
overtreatment of bipolar disorder in children.
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Notable Mentions
• Autism spectrum disorder: The criteria will
incorporate several diagnoses from DSM-IV
including autistic disorder, Asperger’s disorder,
childhood disintegrative disorder, and
pervasive developmental disorder (not
otherwise specified), into the diagnosis of
autism spectrum disorder for DSM-5 to help
more accurately and consistently diagnose
children with autism.
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Conditions for Further Study
• Proposed criterion sets have been described for
the following conditions in which further research
is encouraged:
–
–
–
–
–
Attenuated Psychosis Syndrome
Depressive episodes with short duration hypomania
Persistent complex bereavement disorder
Internet gaming disorder
Neurobehavioral disorder associated with prenatal
alcohol exposure
– Suicidal behavior disorder
– Non-suicidal self injury
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Combined
Language Disorder
(Expressive Language Disorder
& Mixed Receptive Expressive Language Disorder)
Autism Spectrum Disorder
(Autistic Disorder,
Asperger’s Disorder,
Childhood Disintegrative Disorder,
Rhett's disorder
Pervasive Developmental Disorder-NOS)
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Combined
• Specific Learning Disorder
(Reading Disorder,
Math Disorder,
Disorder of Written Expression)
• Delusional Disorder
(Shared Psychotic Disorder, Delusional
Disorder)
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Combined
• Panic Disorder
(Panic Disorder Without Agoraphobia Panic
Disorder With Agoraphobia)
• Dissociative Amnesia
(Dissociative Fugue
Dissociative Amnesia)
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Combined
• Somatic Symptom Disorder (Somatization
Disorder
Undifferentiated Somatoform Disorder
Pain Disorder)
• Insomnia Disorder
(Primary Insomnia
Insomnia Related to Another Mental Disorder)
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Combined
• Hypersomnolence Disorder
(Primary Hypersomnia
Hypersomnia Related to Another Mental Disorder)
• Non-Rapid Eye Movement Sleep Arousal
Disorders
(Sleepwalking Disorder
Sleep Terror Disorder)
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Combined
• Genito‐Pelvic Pain/Penetration Disorder
(Vaginismus Dyspareunia)
• Alcohol Use Disorder
(Alcohol Abuse
Alcohol Dependence)
• Cannabis Use Disorder
(Cannabis Abuse
Cannabis Dependence)
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Combined
• Phencyclidine Use Disorder (Phencyclidine Abuse
Phencyclidine Dependence)
• Other Hallucinogen Use Disorder (Hallucinogen
Abuse Hallucinogen Dependence)
• Inhalant Use Disorder
(Inhalant Abuse Inhalant Dependence)
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Combined
• Opioid Use Disorder
(Opioid Abuse
Opioid Dependence)
• Sedative, Hypnotic, or Anxiolytic Use Disorder (Sedative,
Hypnotic Anxiolytic Abuse
Sedative, Hypnotic, or Anxiolytic Dependence)
• Stimulant Use Disorder
(Amphetamine Abuse
Amphetamine Dependence;
Cocaine Abuse
Cocaine Dependence)
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Combined
• Stimulant Intoxication
(Amphetamine Intoxication
Cocaine Intoxication)
• Stimulant Withdrawal
(Amphetamine Withdrawal
Cocaine Withdrawal)
• Substance/Medication-Induced Disorders
(aggregated categories:
Mood , Anxiety ,and Neurocognitive )
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• NOS DSM IV = 41
• Other/Unspecified DSM-5 =65
(To match ICD-10)
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15 New Diagnosis
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Social (Pragmatic) Communication
Disorder
• With this addition to the manual, psychiatrists can
now more precisely diagnose speech and written
language problems that are unrelated to autism or
diminished cognitive ability, according to an
American Psychiatric Association fact sheet about
the disorder. Indeed, while symptoms of this
disorder, which must date back to childhood, include
“inappropriate responses in conversation” and
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Social (Pragmatic) Communication
Disorder (Cont.)
difficulty communicating, the diagnosis can only be
made after autism spectrum disorders have been
ruled out, according to the APA. These problems
often hamper people’s social lives, academic careers
and job performance, and the diagnosis, known as
SCD for short, is intended to bring their issues “out
of the shadows” and help them get appropriate
treatment, according to the fact sheet.
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Disruptive Mood Dysregulation
Disorder
• While this diagnosis, limited to children under 18,
could be interpreted by some parents as applicable
"anytime you have a temper tantrum,” says McHugh,
the tendency to dismiss kids’ outbursts often leads to
misdiagnoses, at the expense of the children and
their families, when the disorder goes untreated. The
new diagnosis is designed to help families and
children who “have never been successfully treated
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Disruptive Mood Dysregulation
Disorder (Cont.)
for extreme, explosive rages,” says David Kupfer,
chairman of the DSM-5 task force and a professor of
psychiatry at the University of Pittsburgh “Too many
severely impaired children like this have fallen
through the cracks because they suffer from a
disorder that had not yet been defined.”
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Premenstrual Dysphoric Disorder
• In classifying symptoms preceding women’s
monthly cycle as a mental disorder, the DSM-5
has provoked outrage from those who worry that
people will use the official illness to discriminate
against women, like they have with PMS, the
milder sister to PMDD. (The new disorder was
mentioned in an appendix of the DSM-4 as a
condition needing further study.) Other critics
worry that the diagnosis could allow people to
use common and mundane problems like minor
menstrual cramps as medical excuses. But
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Premenstrual Dysphoric Disorder
(Cont.)
researchers for the DSM-5 found justification for
listing the disorder, which affects 2% to 5% of
premenopausal women, according to an article
published in the American Journal of Psychiatry
in May 2012. Symptoms include depression,
“feelings of hopelessness” and bloating
sensations at specific times during a woman’s
menstrual cycle—severe enough to interfere with
people’s ability to function at work or school.
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Hoarding Disorder
• The television remedy for hoarding on shows such as
A&E”s “Hoarders” usually involves a heavy-duty
house cleaning by a team of professionals and many
garbage bags or dumpsters. But thanks to the DSM5’s inclusion of “hoarding disorder” as a standalone
diagnosis, doctors may be able to treat the condition
with a pill. There is now adequate evidence to
confirm the “diagnostic validity” of hoarding, which is
characterized by “persistent difficulty discarding or
parting with possessions due to a perceived need to
save the items and distress associated with discarding
them,” according to an APA guide to the changes in
DSM-5. The newly added diagnosis is listed under
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Hoarding Disorder (Cont.)
obsessive-compulsive disorders, though the APA
admits that that there is not enough data to say
whether hoarding is truly related to OCD or another
mental illness. Still, hoarding may have underlying
neurobiological causes, which may mean that it can
be treated with medication. Indeed, some DSM critics
believe the creation of hoarding disorder could be
driven by pharmaceutical interests: “All they are
saying is, we think hoarding should be made an
illness that we can get paid for,” says McHugh, who
believes psychiatrists should investigate the root
causes of the hoarding in order to formulate a
treatment plan that could involve behavior therapy
instead of drugs. www.rolandwilliamsconsulting.com
Caffeine Withdrawal
• People who are grumpy before they’ve had their
morning coffee may welcome caffeine withdrawal to
the DSM-5 as a legitimate mental affliction. A
controversial addition, the new diagnosis directly
reflects our increasing dependence on caffeine, from
the proliferation of Starbucks outlets to the growing
array of non-coffee energy drinks and caffeineinjected alcoholic beverages: “Caffeine is invading our
society more and more,” Alan Budney, a psychiatrist
who helped develop the DSM-5, said at a 2011
industry symposium, according to reports. (Caffeine
withdrawal was included in an appendix of the DSM-4
as a condition needing
further study.)
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Caffeine Withdrawal (Cont.)
But some psychiatrists worry that caffeine
withdrawal may be an easy way to clinically label
symptoms such as headaches, sleep disturbances
and moodiness, at the cost of missing a serious
pathological disorder. “The real problem for
[psychiatrists] is, Will they be able to have time with
the patient to distinguish between caffeine
withdrawal and the kind of uneasiness and
headaches that come from an encounter they might
have had in life experiences?” says McHugh.
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Cannabis Withdrawal
• Included in the DSM-5 in tandem with caffeine
withdrawal, experts say the increasing prevalence of
another substance besides coffee merited the new
“cannabis withdrawal” diagnosis. As marijuana has
become available to buy legally and for medical
purposes in more states, psychiatrists have also
noted withdrawal symptoms in people who
frequently smoke marijuana and then quit. A study
of 384 lifetime cannabis smokers, conducted in
partnership with the National Institutes of Health
and published in 2012, found that more than 40% of
participants met the withdrawal criteria in the
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Cannabis Withdrawal (Cont.)
DSM-5. Only in recent years have medical experts
recognized that marijuana can be associated with
drug withdrawal, so the DSM until now excluded the
condition “due to debate about the clinical
significance of the cannabis withdrawal syndrome,”
according to researchers who helped develop the
DSM-5. But the researchers identified several
cannabis withdrawal symptoms that interfered with
people’s ability to function normally, including loss
of appetite, nightmares and “imagining being stoned
(cravings).”
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Excoriation (Skin-Picking) Disorder
• Under the awning of obsessive-compulsive
disorders, this condition is characterized by
chronic picking and scratching of the skin that can
cause wounds and scabs, and diagnosed when
the behaviors are not associated with another
disorder. The disorder can be triggered by other
skin irregularities like acne or bug bites, according
to a 2011 paper from the University of Cincinnati
College of Medicine that proposed including the
disorder in the DSM. The condition can be
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Excoriation (Skin-Picking) Disorder
(Cont.)
associated with other disorders involving
compulsive eating, buying and stealing, the
researchers wrote. The DSM-5 added
“excoriation disorder” in light of “strong evidence
for its diagnostic validity and clinical utility,”
according to the APA, and the problem is often
treated with antidepressants, anti-anxiety drugs
or other medications.
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Binge Eating Disorder
• In the context of an increasing national obesity
epidemic, psychiatrists made a statement by
adding this diagnosis: “This change is intended to
increase awareness of the substantial differences
between binge eating disorder and the common
phenomenon of overeating,” according to an APA
fact sheet. With nearly 70% of Americans
overweight or obese according to the Centers for
Disease Control and Prevention, the manual
distinguishes between problems with weight
versus mental health, noting that “while
overeating is a challenge for many Americans,
recurrent binge eating is much less common, far
more severe, and is associated with significant
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Binge Eating Disorder (Cont.)
physical and psychological problems.” (The new
disorder was included in an appendix of the DSM-4 as
a condition needing further study.) People with this
disorder frequently eat a large amount of food very
quickly, even when they’re not hungry, and often when
they are alone to avoid embarrassment, according to
the APA.
• Binge Eating Disorder is not to be confused with
bulimia nervosa, which involves, in addition to binge
eating, purging behaviors like vomiting. The revised
manual stipulates that binging or purging just once a
week qualifies for the diagnosis, rather than biweekly.
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Rapid Eye Movement Sleep Behavior
Disorder
• In his 2012 autobiographical film “Sleepwalk With
Me,” the comedian Mike Birbiglia brought
attention to this disorder, often called REM
behavior disorder, which causes him to act out his
dreams in real life. The phenomenon became
particularly problematic for Birbiglia after he
jumped through a second-story hotel window in a
dream about escaping a missile, landing him in
the emergency room with glass wounds. (The
disorder differs from typical sleepwalking in that
people with REM behavior disorder usually
remember what they were doing in the dream.)
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Rapid Eye Movement Sleep Behavior
Disorder (Cont.)
• Now, the disorder, which the DSM previously
included ambiguously under parasomnia, gains
official recognition by the clinical psychiatry
community in addition to Hollywood. The
diagnosis, which the APA says is fully supported
by research evidence, is often preceded by dream
enactment episodes resulting in injury to the
person or the partner with whom they share a
bed. In treating the condition, doctors may
recommend removing sharp and dangerous
objects from the bedroom and cushioning the
area around the bed.
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Restless Legs Syndrome
• Given its solid neurological basis, some
psychiatrists, including McHugh at Johns Hopkins,
wonder why the disease, characterized by
uncomfortable urges to move the legs when lying
down, wasn’t given full DSM status long ago. But
scientific and genetic research have advanced the
medical knowledge of the disorder, which is now
also identified as Willis-Ekbom disease, since the
previous version of the DSM.
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Restless Legs Syndrome (Cont.)
While about 2% to 3% of adults are severely
affected by it, up to 10% of people in the U.S.
may have it, according to the Willis-Ekbom
Disease Foundation (formerly the Restless Legs
Syndrome Foundation). By giving official
diagnostic status to the disorder, which was
previously classified as a “not otherwise
specified” form of dyssomnia, the DSM-5 may
promote more precise diagnoses and treatment
of restless legs syndrome, psychiatrists say.
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Major Neurocognitive Disorder and
Mild Neurocognitive Disorder
• With these additions, the DSM-5 expands the category of dementia, the
memory and cognitive impairment increasingly afflicting the aged: About
14% of Americans age 71 and older have dementia, and the number is
expected to double by 2050 because of the wave of baby boomers hitting
65, according to a new report by the Alzheimer’s Association. The new
diagnoses also allow psychiatrists to distinguish between different levels
of dementia’s severity. “The psychiatry group is waking up to what the
neurologists have been classifying and recognizing for a long time,” says
McHugh, the Johns Hopkins psychiatrist. Still, the “threshold” between
mild and major neurocognitive disorder “is inherently arbitrary,” the APA
admits. (The newly added mild version was mentioned in an appendix of
the DSM-4 for conditions needing further study.) But by differentiating
between them, the DSM-5 could pave the way for the diagnosis and
treatment of “less disabling” cognitive impairment that could be
nonetheless problematic for people and their families, according to the
APA.
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Disinhibited Social Engagement Disorder
• This disorder can often be mistaken for ADHD,
attention deficit/hyperactivity disorder, but the
DSM-5 may reduce the confusion by adding it to
the list of official diagnoses. While children with
disinhibited social engagement disorder can be
inattentive and impulsive, the disorder may stem
from inadequate caregiving and neglect. This
disorder was previously grouped with reactive
attachment disorder, children who have it may
not actually lack attachments, according to the
APA. The separate classification allows for
different clinical interventions and treatment
plans.
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Central Sleep Apnea and
Sleep-Related Hypoventilation
• The DSM has long struggled to classify sleep
disorders, especially those that related to
problems with breathing while sleeping. The
growing share of the population with diabetes
and cardiovascular disease, which studies have
shown to increase the risk of central sleep
apnea and other breathing-related sleep
disorders, may make it more important to
precisely identify the problems. But the
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Central Sleep Apnea and
Sleep-Related Hypoventilation (Cont.)
medical community has also learned much
more about these conditions since the
previous DSM edition, enabling the new
diagnoses: “This change reflects the growing
understanding of pathophysiology in the
genesis of these disorders and, furthermore,
has relevance to treatment planning,”
according to the APA’s guide to the changes in
the DSM-5.
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Other Conditions that may be a
Focus of Clinical Attention
Commonly referred to as “the V codes”
Child Maltreatment and Neglect
Adult Maltreatment and Neglect
Relational Problems
Educational Problems
Occupational Problems
Housing Problems
Economic Problems
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Z Codes in ICD 10
• Z00-Z13 Persons encountering health services for
examinations
• Z14-Z15 Genetic carrier and genetic susceptibility
to disease
• Z16-Z16 Resistance to antimicrobial drugs
• Z17-Z17 Estrogen receptor status
• Z18-Z18 Retained foreign body fragments
• Z20-Z28 Persons with potential health hazards
related to communicable diseases
• Z30-Z39 Persons encountering health services in
circumstances related to reproduction
• Z40-Z53 Encounters for other specific health care
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Z Codes in ICD 10 (Cont.)
• Z40-Z53 Encounters for other specific health care
• Z55-Z65 Persons with potential health hazards
related to socioeconomic and psychosocial
circumstances
• Z66-Z66 Do not resuscitate status
• Z67-Z67 Blood type
• Z68-Z68 Body mass index (BMI)
• Z69-Z76 Persons encountering health services in
other circumstances
• Z77-Z99 Persons with potential health hazards
related to family and personal history and certain
conditions influencing health status
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Mental Health Issues Expanded
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No More Axis I-V
• With the advent of the DSM-5 in 2013, the APA
eliminated the longstanding multiaxial system for
mental disorders.
• Previously, the DSM-IV organized each psychiatric
diagnosis into five dimensions (axes) relating to
different aspects of disorder or disability:
• Axis I = clinical psychiatric disorders (ex.
depression, schizophrenia)
• Axis II = Personality disorders (ex. bipolar,
conduct disorder, borderline)
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No More Axis I-V (Cont.)
• Axis III= General medical conditions (ex. Diabetes,
Hypertension, Stroke)
• Axis IV= Psychosocial and environmental
problems (ex. Death of loved one, Divorce, Jobloss, Bankruptcy)
• Axis V= Global assessment function (ex. scale of
1-100) 1 is low level of function and 100 being
superior function.
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This is Not New
• What many professionals do not realize is that
this new coding system presented in DSM-5 is not
completely new. Both DSM-IV and DSM-IV-TR
offered two ways of coding: the multiaxial system
and simply listing the diagnosis, similar to what is
now required in DSM-5. In DSM-5, listing the
mental disorders and the relevant medical
conditions are combined, thereby avoiding the
artificial distinction suggested by listing them on
separate axes. The diagnostic assessment starts
with identifying either the principal or the
provisional diagnosis
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Making and Reporting Diagnosis
•
•
•
•
How to order the diagnoses;
The use of subtypes, specifiers, and severity;
Making a provisional diagnosis
Use of “other specified” or “unspecified”
disorders.
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The Diagnostic Impression
• With the elimination of Axis I, II, and III that
were used in earlier versions of the DSM, the
replacement requires all three of these axis to
be combined by simply listing the relevant
diagnosis as either the principal diagnosis or
in some cases adding a provisional diagnosis.
Listing the principal diagnosis eliminates the
need for Axes I and II.
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The Diagnostic Impression (Cont.)
• Also, combining any medical conditions and
listing them with the principal diagnosis
eliminates the need for Axis III, which included
any related medical conditions. Eliminating
Axis I, II, and III helped to clarify that Axis II
specifically was never meant to be a separate
set of diagnoses, nor was it the intent of the
multiaxial system to separate medical and
mental health conditions in assessment or
treatment.
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The Diagnostic Assessment
• Biomedical Factors
– medical conditions, perceived overall health
status, maintenance and continued health and
wellness.
• Psychological Factors
– Mental functioning, cognitive functioning,
assessment of danger to self/others
• Social and Environmental Factors
– social societal help seeking, occupational
participation, social support, family support,
ethnic or religious affiliation
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Ordering the Diagnosis
• Individuals will often have more than one diagnosis,
so it is important to consider their ordering. The first
diagnosis is called the principal diagnosis. In an
inpatient setting, this would be the most salient
factor that resulted in the admission.
• In an outpatient environment, this would be the
reason for the visit or the main focus of treatment.
The secondary and tertiary diagnosis should be listed
in order of need for clinical attention.
• If a mental health diagnosis is due to a general
medical condition, the ICD coding rules require listing
the medical condition first, followed by the psychiatric
diagnosis, due to the general medical condition.
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Principal and Provisional Diagnosis
• The Practitioner can Use Either of These Terms
When the Diagnostic Criteria are Met:
– Principal diagnosis:
• Symptoms related to the disorder are the
primary reason for the diagnostic assessment
and often denotes the request for treatment/
intervention. When the principal diagnosis is
listed according to DSM-5, it is listed first, but
there can be more than one diagnosis as long
as each meets the criteria. If there is more than
one diagnosis, they should be listed in terms of
severity.
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– Provisional diagnosis:
• Many times when a client is interviewed and the
initial diagnostic assessment is completed, a
principal diagnosis cannot be determined. In these
cases, a provisional diagnosis can be assigned. A
provisional diagnosis (often referred to in the field
as the best-educated clinical guess) is based on
clinical judgment and reflects a strong suspicion
that an individual suffers from a type of disorder
that, for some reason or another, either the actual
criteria are not met or the practitioner does not
have information available to make a more
informed diagnostic.
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Subtypes and Specifiers
• Subtypes “Specify whether”
– Mutually exclusive and exhaustive
– Homogeneous subgroupings within a diagnosis
• Specifiers:
–
–
–
–
–
course, ( in partial remission)
severity, ( mild, moderate, severe)
frequency, ( two times per week)
duration, ( minimum duration of six months)
descriptive features, ( with poor insight)
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Subtypes
• Subtypes for a diagnosis can be used to help
communicate greater clarity. They can be
identified in the DSM-5 by the instruction
“Specify whether” and represent mutually
exclusive groupings of symptoms (i.e., the
clinician can only pick one). For example, the
ADHD has three different subtypes to choose
from:
• predominantly inattentive,
• predominantly hyperactive/impulsive, or
• a combined presentation.
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Specifiers
• Specifiers, on the other hand, are not mutually
exclusive, so more than one can be used. The
clinician chooses which specifiers apply, if any, and
they are listed in the manual as “Specify if.” Some
diagnoses will offer an opportunity to rate the
severity of the symptoms. These are identified in
the DSM as “Specify current severity.” Referencing
the ADHD diagnosis, there are three options of
severity: mild, moderate, or severe.
• Severity levels of autism spectrum disorder”,
which classifies autism on three levels of severity
“requiring support,” “requiring substantial
support,” and “requiring very substantial support.”
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• Subtype: “Specify whether”—only choose one,
• Specifier: “Specify if”—pick as many as apply,
and
• Severity: “Specify current severity”—choose
the most accurate level of symptomology.
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Informal Diagnostic Labels
• Rule-out—the client meets many of the
symptoms but not enough to make a diagnosis
at this time; it should be considered further
(e.g., rule-out major depressive disorder).
• Traits—this person does not meet criteria,
however, he or she presents with many of the
features of the diagnosis (e.g., borderline
traits or cluster B traits).
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Informal Diagnostic Labels (Cont.)
• By history—previous records (another
provider or hospital) indicate this diagnosis;
records can be inaccurate or outdated (e.g.,
alcohol dependence by history).
• By self-report—the client claims this as a
diagnosis; it is currently unsubstantiated;
these can be inaccurate (e.g., bipolar by selfreport).
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Other/Unspecified Disorders
• The DSM-IV had a diagnosis of not otherwise
specified (NOS) to capture symptomology that
did not fit well into a structured category. In lieu
of the NOS diagnosis, the DSM-5 offers two
options when these situations arise. The other
specified and unspecified disorders should be
used when a provider believes an individual’s
impairment to functioning or distress is clinically
significant, however, it does not meet the specific
diagnostic criteria in that category.
• The “other specified” should be used when the
clinician wants to communicate specifically why
the criteria do not fit.
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Other/Unspecified Disorders (Cont.)
• The “unspecified disorder” should be used when
he or she does not wish, or is unable to,
communicate specifics.
• For example, if someone appeared to have
significant panic attacks but only had three of the
four required criteria, the diagnosis could be
“Other Specified Panic Disorder—due to
insufficient symptoms.” Otherwise, the clinician
would report “Unspecified Panic Disorder.”
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WHODAS 2.0 Replaces GAF
• World Health Organization Disability
Assessment Schedule
• This 36-item, self-administered questionnaire
assesses a client’s functioning in six domains:
understanding and communicating, getting
around, self-care, getting along with people,
life activities, and participation in society
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WHODAS 2.0
• Generic assessment instrument for health and
disability
• Used across all diseases, including mental,
neurological and addictive disorders
• short, simple and easy to administer ( 5 to 20 minutes)
• applicable in both clinical and general populations
settings
• a tool to produce standardized disability levels and
profiles
• applicable across cultures, and all adult populations
• directly linked at the level of concepts to the
international classification of functioning, disability
and health, (ICF)
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• The WHODAS 2.0 looks at functioning across
six specific domains:
• Functioning is not assumed to be static, rather
it is expected to change, and therefore it can
be measured. The WHODAS will not tell you
“why” someone is having problems
functioning, but it will tell you which areas, if
any, pose problems for the client.
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WHODAS Covers 6 Domains of
Functioning
• Cognition – understanding and communicating
• Mobility – moving and getting around
• Self-care – hygiene, dressing, eating and staying
alone
• Getting along – interacting with other people
• Life activities – domestic responsibilities, leisure,
work and school
• Participation – joining in community activities
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• Cognition comprises questions about
communication and thinking activities. Specific
areas assessed include concentrating,
remembering, problem solving, learning and
communication.
• Mobility questions explore the client’s ability to
stand, move around inside the home, get out of
the home and walk a long distance. The latter
uses the term “kilometer”, since the rest of the
world uses the metric system.
• Self-care looks at the client’s ability to manage
bathing, dressing, eating, and staying alone.
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Treatment Planning
using the WHODAS 2.0
• Writing a treatment plan using WHODAS 2.0
results is fairly straightforward. You can
incorporate the results domain by domain,
and/ or you can summarize the results giving a
general disability score. This is a far more
psychometrically sound method of evaluating
global assessment of functioning than the
GAF.
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• These first three areas are typically considered
by most clinicians in evaluating how well a
client functions. The addition of three other
domains makes the WHODAS especially useful
in assessing individuals with behavioral health
issues.
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• Getting along assesses the client’s ability to relate
to other people, and explores difficulties that
might be encountered with this due to a health
condition. This may include intimates (e.g. spouse
or partner, family members or close friends), or
strangers.
• Life activities includes activities that people do on
most days such as household tasks, and
attendance at work and school. The questions
explore the client’s difficulty in engaging in these
activities on a day-to-day basis. Definitions for
what each of these activities include are provided
on a flashcard.
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• Participation asks clients to consider how other
people and the world around them make it
difficult for them to take part in society. The focus
of these questions is on how the environment
(external factors) as opposed to their own
difficulties (internal factors) impacts their ability
to function. This domain also includes questions
about the impact of their health condition. “Here,
they are reporting not on their activity limitations
but rather on the restrictions they experience
from people, laws and other features of the
world in which they find themselves.
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PLEASE"NOTE:"When"scoring"WHODAS,"the"following"numbers"are"assigned"to"responses:
0"="No"Difficulty
1"="Mild"Difficulty
2"="Moderate"Difficulty
3"="Severe"Difficulty
4"="Extreme"Difficulty"or"Cannot"Do
Score
Understanding and communicating
D1.1
Concentrating on doing something for ten minutes?
0
D1.2
Remembering to do important things?
0
D1.3
Analysing and finding solutions to problems in day-to-day life?
0
D1.4
Learning a new task, for example, learning how to get to a new place?
0
D1.5
Generally understanding what people say?
0
D1.6
Starting and maintaining a conversation?
0
Getting around
D2.1
Standing for long periods such as 30 minutes?
0
D2.2
Standing up from sitting down?
0
D2.3
Moving around inside your home?
0
D2.4
Getting out of your home?
0
D2.5
Walking a long distance such as a kilometre [or equivalent]?
0
Self-care
D3.1
Washing your whole body?
0
D3.2
Getting dressed?
0
D3.3
Eating?
0
D3.4
Staying by yourself for a few days?
0
Getting along with people
D4.1
Dealing with people you do not know?
0
D4.2
Maintaining a friendship?
0
D4.3
Getting along with people who are close to you?
0
D4.4
Making new friends?
0
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WHODAS Client Results
Understanding
and
Communicatin
g
Getting
Around
Self-Care
Getting
Along
w/Others
Extreme
5.00
Severe
4.00
Moderate
3.00
Mild
2.00
None
1.00
Domain Averages
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Life
Activities,
School/Work
Life
Activities,
Household
Participation
in Society
Cultural Formulation
• One of the improved elements of the DSM-5 is
the updating of the Cultural Formulation
Interview. In addition to acknowledging the
impact culture has on behavior, this edition of the
DSM calls for systematic assessment of the
cultural identity of the individual, how that
individual and his/ her family conceptualizes
distress, the key stressors experienced, the
cultural features of vulnerability and resilience for
the individual, how culture informs or interferes
with the therapeutic relationship, and an overall
cultural assessment (APA, 2013).
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Identifying Cultural Aspects
• Practitioners Need to Help the Client:
– Identify and discuss the impact of current life
circumstances that can affect daily functioning.
– Self-report race and ethnicity, respecting the selfidentification of multiracial individuals, in a
manner consistent with how the client thinks of
himself or herself.
– Identify and acknowledge any psychological
problems stemming from adaptation to a new
environment.
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Identifying Cultural Aspects (Cont.)
– Identify and explore the degree to which the client
has positive and supportive peer relationships
contributing to or reducing feelings of isolation
and facilitating transition.
– Identify social variables for which race or ethnicity
serves as a proxy (e.g., social status, neighborhood
context, perceived discrimination, social cohesion,
social capital, social support, types of occupation,
employment, emotional well-being, and perceived
life opportunities.
– Identify willingness to explore new coping skills to
help negotiate his or her environment.
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Cultural Formulation Interview
• The Cultural Formulation Interview (CFI) is a brief (16question), semi-structured interview used to elicit the
individual’s experience, as well as inviting informants
from that individual’s social and cultural networks to
contribute their observations. Four areas are explored
using person-centered and problem-centered
language. A script is provided to guide the interviewer
in eliciting the client’s cultural definition of the
problem, his or her cultural perceptions as to the
cause and context of the problem, as well as what
support exists, what cultural factors affect the client’s
self-coping abilities and past help-seeking strategies,
and what problems exist in terms of current helpwww.rolandwilliamsconsulting.com
seeking.
The CFI
• Semi-structured interviews
• No right or wrong answers
• Gather demographic information first as it can
help to select questions
• Can use entire instrument or just what is needed
to supplement the interview
• Supplementary modules are available online for
children and adolescents, elderly individuals,
immigrants, and
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CFI Examines Four Domains
• Cultural Definition of the Problem
• Cultural Perceptions Cause, Contexts, and
Support
• Cultural Factors Affecting Self Coping, and
Pass Help Seeking
• Cultural Factors Affecting Current Help
Seeking
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Selected Cultural Concepts of Distress
• Ataque de nervios (anxiety often related to a
trauma [Latino])
• Nervios (similar to ataque de nervios but chronic
in nature [Latino]) Dhat syndrome (discharge and
impotence [Southeast Asia])
• Khyai cap (windlike attacks [Cambodian])
• Kufungisisa (similar to brain fog [Nigeria] anxiety
attacks, brain-tiredness [Zimbabwean])
• Maladi moun (humanly caused illness, sent
sickness, jealous [Haitian])
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Selected Cultural Concepts of Distress
(Cont.)
• Shenjing shuairuo (stress related, imbalances
[Chinese])
• Susto (stress-related frightening traumatic event
[Latino, Mexico, Central or South America)
• Taijin kyofusho (unrealistic fears, body odor
[Japan])
• Source: Abbreviated definitions summarized from
the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. Copyright 2013 by the
American Psychiatric Association.
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Supplemental Modules
•
•
•
•
•
•
•
•
•
•
•
•
Explanatory Model
Level of Functioning
Social Network
Psychosocial Stressors
Spirituality, Religion And Moral Traditions
Cultural Identity
Coping and Help Seeking
Client Patient Relationship
School-Age Children and Adolescents
Older Adults
Immigrants and Refugees
Caregivers
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Assessment Measures
• For further clinical evaluation and research, the
APA is offering a number of “emerging measures”
in Section III of DSM-5. These patient assessment
measures were developed to be administered at
the initial patient interview and to monitor
treatment progress, thus serving to advance the
use of initial symptomatic status and patient
reported outcome (PRO) information, as well as
the use of “anchored” severity assessment
instruments. Instructions, scoring information,
and interpretation guidelines are included.
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• These measures should be used to enhance
clinical decision-making and not as the sole
basis for making a clinical diagnosis. Further
information on these measures can be found
in DSM-5.
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Cross-Cutting
• Cross-cutting symptom measures may aid in a
comprehensive mental status assessment by
drawing attention to symptoms that are
important across diagnoses. They are intended to
help identify additional areas of inquiry that may
guide treatment and prognosis. The cross-cutting
measures have two levels: Level 1 questions are a
brief survey of 13 domains for adult patients and
12 domains for child and adolescent patients, and
Level 2 questions provide a more in-depth
assessment of certain domains.
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Crosscutting of Symptoms
• Acknowledging the diagnostic criteria, while
documenting the crosscutting or overlapping
symptoms, allows explication of the relationship
between symptoms characteristic of more than
one disorder to be documented without the
creation or addition of a second disorder.
• For example, how many times have you worked
with a depressed client who did not have sleep
difficulties that could be confused with the
diagnosis of insomnia?
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Crosscutting of Symptoms (Cont.)
Documenting with the dimensional assessment
and taking into account the crosscutting of
symptoms, while clearly noting those related to
depression and disturbed sleep, can make a
stronger diagnostic assessment while avoiding an
unnecessary label indicative of a second
diagnosis.
• Cross Cutting of Symptoms Measurement Scale
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Disorder Specific Severity Measures
• Severity measures are disorder-specific,
corresponding closely to criteria that
constitute the disorder definition. They may
be administered to individuals who have
received a diagnosis or who have a clinically
significant syndrome that falls short of
meeting full criteria. Some of the assessments
are self-completed, whereas others require a
clinician to complete.
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WHODAS 2.0
• The World Health Organization Disability
Assessment Schedule, Version 2.0 (WHODAS 2.0)
assesses a patient’s ability to perform activities in
six areas: understanding and communicating;
getting around; self-care; getting along with
people; life activities (e.g., household,
work/school); and participation in society. The
scale is self- or informant-administered and
corresponds to concepts contained in the WHO
International Classification of Functioning,
Disability and Health.
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Personality Inventories
• The Personality Inventories for DSM-5
measure maladaptive personality traits in five
domains: negative affect, detachment,
antagonism, disinhibition, and psychoticism.
For adults and children ages 11 and older,
there are brief forms with 25 items and full
versions with 220 items.
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Alternative Model for Diagnosing
Personality Disorders
• The DSM-5 alternative model suggests that two
determinations must be met when diagnosing a
personality disorder: level of impairment and
evaluation of which personality traits are
pathological in nature. Disturbances in “self” and
“interpersonal functioning” are hallmarks of
personality disorders. The alternative model
suggests that these disturbances are best
evaluated on a continuum, rather than on a
dichotomous, “present/ not present”
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• “Self” is further divided into elements of identity
and self-direction. The DSM-5 provides
definitions of both these. “Identity” consists of
the individual’s experience of self and other,
including self-esteem and capacity for and ability
to regulate emotions. “Self-direction” includes
the ability to have and pursue life goals, to have
internalized standards of behavior that are
constructive and pro-social, and to be able to be
self-reflective.
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• Interpersonal functioning is also divided,
specifically identifying empathy and intimacy as
measurable elements. “Empathy” is defined as
having both comprehension and appreciation of
the experiences and motivations of others, as
well as understanding the effects of behavior on
others. “Intimacy” consists of connection,
closeness, and regard, as evidenced by depth and
duration of the connection, desire and capacity
for closeness, and mutuality reflected in
interpersonal behavior.
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Levels of Pathology
• Drawing from the Five-Factor Model (FFM) of
personality, the DSM-5 alternative model
identifies the following pathological
personality traits: detachment, antagonism,
disinhibition, and psychoticism. Within these
domains they identify 25 specific trait facets
shown in the table below.
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Negative
Affectivity
Detachment
Antagonism
Dis-inhibition
Pscychoticism
Emotional
Lability
Withdrawal
Manipulative
Responsibility
Unusual
Beliefs and
Experiences
Anxiousness
Intimacy
Avoidance
Deceitfulness
Impulsivity
Eccentricity
Separation
Insecurity
Anhedonia
Grandiosity
Distractivity
Cognitive and
Perceptual
Dysregulation
Depressivity
Attention
Seeking
Risk-Taking
Hostility
Restricted
Affectivity
Callousness
Rigid
Perfectionism
Perseveration
Suspiciousness Hostility
Submissiveness
Suspiciousness
Restricted
Affectivity
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Psychotic Disorders
• When preparing for the diagnostic assessment
and the appropriate diagnosis, the practitioner
must first be aware of the key features prevalent
in the psychotic disorders that are used to
constitute the diagnosis. Starting this process
requires familiarity with applying the five primary
characteristics of each of the following disorders:
delusions, hallucinations, disorganized thinking
and speech, grossly disorganized or abnormal
motor behavior (including catatonia), and
negative symptoms.
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Diagnostic Criteria
• Diagnostic criteria for the specific personality
disorders consists of seven items:
• 1) moderate or greater impairment in personality
functioning,
• 2) identification of the specific personality traits
that are pathologic,
• 3) demonstration that the impairments are
relatively inflexible and pervasive across a broad
range of personal and social situations,
• 4) these impairments and trait expression are
“relatively stable” and have an onset at least at
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Diagnostic Criteria (Cont.)
adolescence or early adulthood,
• 5) these impairments and traits can’t be
explained by something else (e.g., culture,
circumstance, illness),
• 6) these can’t be attributed to the physiological
effects of a substance or medical condition (e.g.,
head trauma), and
• 7) these are not better understood as “normal”
for the developmental stage or sociocultural
environment.
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Categorical vs Dimensional Approach
• Whereas a categorical approach to diagnosis
classifies a diagnosis as either present or
absent, a dimensional approach to diagnosis
entails using measures to evaluate the extent
to which symptoms exist. Hence, the
dimensional approach provides a continuum
to evaluate symptoms, whereas a categorical
system does not.
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Yes/No Categorical Approach
• The Categorical Approach is the approach to
classifying mental disorders involving assessment
of whether an individual has a disorder on the
basis of symptoms and characteristics that is
described as typical of the disorder. This
approach also uses 2 classification strategies DSM
and ICD. The DSM names the disorders and
describes them in specific terms. The ICD
identifies symptoms that indicate the presence of
a disorder. Categorical approaches are based on a
number of underlying principles and assumptions
including:
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Score Based Dimensional Approach
• The Dimensional approach is the approach to
classifying mental disorders that quantifies a
person’s symptoms or other characteristics of
interest and represents them with numerical
values on one or more scales or continuums,
rather than assigning them to a mental disorder
category.
• Diagnosis then becomes not a process of deciding
the presence of a symptom or disorder but rather
the degree to which a particular characteristic is
present. Instead of making judgements, the
dimensional approach asks the question “how
much?” Lower scores equate to lower impairment
and higher scores equate to higher impairment.
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The End to NOS
• To be replaced with:
– Other Specified Disorder
• this category enables the clinician to identify
presentations in which the symptoms are
clinically significant, but did not meet the full
criteria for disorder, and to state the specific
reason why the diagnostic criteria for any given
disorder has not been met. (When this
diagnosis is used documenting the reason for
selecting it is required.)
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The End to NOS (Cont.)
– Unspecified Disorder
• If the presentation is clinically significant and
does not meet the full criteria for disorder,” and
the clinician chooses not to specify the reason
the criteria have not been met, (e.g. insufficient
information, emergency room setting, etc. ),
that “unspecified diagnosis” would be given.
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Basic Definitions
• Neurodevelopmental: Examines diagnoses
across the life span. Disorders most frequently
diagnosed in childhood.
• Neurocognitive: Disorders most frequently
diagnosed in adulthood
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• The DSM-5 has 20 chapters that are dedicated to
each category of disorders listed. At the
beginning of each chapter is an overview of the
disorders outlined in that particular chapter,
listing what they are and what they have in
common.
• For example, in the chapter on schizophrenia
spectrum and other psychotic disorders, key
features that define all of the psychotic disorders
in the chapter are outlined, highlighting what
they share, with each listed and organized along a
gradient of psychopathology.
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Presentation of Disorders
• Diagnostic Features (outlines specific criteria)
• Associated Features Supporting the Diagnosis
(characteristics)
• Prevalence (adults, males, females, etc.)
• Development and Course (signs and how long it
lasts)
• Risk and Prognostic Factors (temperamental,
environmental, genetic, and physiological)
• Course Modifiers
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Presentation of Disorders (Cont.)
• Culture-Related Diagnostic Issues
• Gender-Related Diagnostic Issues
• Diagnostic Markers (sleep history and a sleep
diary)
• Suicide Risk
• Functional Consequences
• Differential Diagnosis
• Comorbidity
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Bipolar Disorders:
Episodes and Specifies
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Bipolar and Related Disorders
• The diagnostic assessment of an individual
suffering from any type of bipolar disorder shows
the presence of two primary symptoms:
• a depressed mood and
• an elevated mood.
• Displaying both symptoms can confuse both
families and practitioners. When clients report
the symptoms of depression, it may lack clarity,
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Bipolar and Related Disorders (Cont.)
and there may be problems in semantics related
to defining what is experienced. When they
experience a bipolar episode and the energy
returns, optimism may rise, only to have it
extinguished as the lift in mood becomes
uncontrollable and destructive to the expected
purpose.
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Manic episode:
• Present mood is persistently elevated, irritable,
and expansive, with severe mood disturbance,
and leading to impaired functioning. There must
be at least three of these symptoms: pressured
speech, increased psychomotor agitation, flight
of ideas, decreased need for sleep, increased
involvement in goal-oriented activities,
distractibility, and inflated self-esteem or
grandiosity. There is also excessive involvement in
pleasurable activities, which have the potential
for high risk and negative consequences. The
time frame for the episode is at least 1 week. If
hospitalization to control or address behaviors
occurs, the 1-week time frame is not needed.
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Hypomanic episode:
• Similar to manic, but all features and symptoms are
less severe, although they still interfere with
functioning. Criteria for hypomanic include a distinct
period of persistently expansive, irritable, elevated
mood that lasts at least 4 days but less than 1 week.
There must be present at least three symptoms
(whereas four symptoms are required if there is
predominantly an irritable mood): pressured speech,
increased involvement in goal-oriented activities,
psychomotor agitation, distractibility, decreased need
for sleep, and inflated self-esteem or grandiosity.
There is also excessive involvement in pleasurable
activities, which have the potential for high risk and
negative consequences.
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Major depressive episode:
• Depressed mood for at least 2 weeks or a loss of
interest or pleasure in nearly all activities, plus at
least five additional symptoms experienced by
the client almost daily for the same 2-week
period. Associated features include sleeping and
appetite disturbances (very common symptoms);
fatigue or decreased energy; changes in sleep;
changes in psychomotor activity; reduced ability
to think, concentrate, or make decisions; feelings
of worthlessness or guilt; morbid ideation or
suicidal ideation, plans, or attempts; and irritable
mood.
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Description of Bipolar Mood Disorders
• Bipolar I Disorder: This disorder is considered the
most severe and is characterized by at least one
manic episode and a history of hypomanic or a
depressive episode. Specific criteria for the number
of symptoms required for each manic, hypomanic, or
depressive episode must be met.
• Bipolar II Disorder: This disorder is characterized by
one or more depressive episodes with at least one
hypomanic episode: a period of elevated or irritable
mood with increased activity, lasting at least 4
consecutive days and present throughout each day
most of the time.
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• Cyclothymic Disorder: This disorder is
characterized by a persistent mood disturbance
lasting at least 2 years (1 year in children and
adolescents), and the individual must not be
without the symptoms for 2 months. This
disorder, although considered more chronic
because of the duration of the symptoms, is less
severe because the symptoms experienced do
not meet the criteria for either the full
hypomanic or depressive episodes.
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• Substance/ Medication-Induced Bipolar and Related
Disorder: This disorder is characterized by a disturbance
in mood that clinically predominates and includes
symptoms of elevated or irritable mood, with or without
depressed mood, or diminished interest or pleasure in all
or most activities. A physical exam and laboratory tests
are needed to confirm that the symptoms developed
during or soon after substance intoxication or withdrawal
or after taking a medication as evidence that the
substance/ medication produces the mood symptoms.
The disorder is not better explained by a bipolar or
related disorder that is not induced by substances/
medications, does not occur only during a delirium, and
causes significant impairment in social, occupational, or
other areas of functioning. Categories of the substances
include alcohol, phencyclidine, other hallucinogen,
sedative, hypnotic or anxiolytic, amphetamine or other
stimulant, cocaine, other, or unknown substance.
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• Bipolar and Related Disorder Due to Another Medical
Condition: This disorder is characterized by a period
of elevated or irritable mood with abnormally
increased activity or energy that is presented
clinically. Results from laboratory tests and physical
exams show evidence of another medical disorder.
The disturbance is not explained by another mental
disorder and does not occur exclusively during a
delirium. The disorder must cause significant
impairment in social, occupational, or other areas of
functioning to meet this diagnosis. It is indicated to
specify with manic features, with manic or
hypomanic features, or with mixed features.
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• Other Specified Bipolar and Related Disorder: This
disorder is characterized by impairment in social,
occupational, or other significant areas of
functioning but does not meet full criteria for any of
the other categories of bipolar and related disorders.
This diagnostic category can apply to the following
four clinical presentations: short-duration hypomanic
episodes (2– 3 days) and major episodes, hypomanic
episodes with insufficient symptoms and major
depressive episodes, hypomanic episode without
prior major depressive episode, and short-duration
cyclothymia (less than 24 months).
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• Unspecified Bipolar and Related Disorder: This
disorder presents with symptoms
characteristic of bipolar and related disorder
but does not meet the full criteria for any of
the bipolar and related disorder category. The
unspecified bipolar disorder category used
when there is insufficient information to place
a more formal diagnosis and may be used in
settings such as emergency rooms.
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Specifies for Bipolar and Related
Disorders
•
•
•
•
•
•
•
•
•
•
With anxious distress
With mixed features
With rapid cycling
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia
With peripartum onset
With seasonal pattern
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Overview of Depressive Disorders
• Somatic, cognitive, and emotional concerns
identified in the DSM-5 are the predominant
features linking the disorders. In addition, these
disorders all share depressed mood with
subsequent changes in eating, sleeping, and
energy levels; impairments in executive function
and attention; and changes in self-awareness and
perception. When depressed clients experience a
loss of interest or pleasure in activities and
difficulty concentrating, these symptoms can lead
to problems with performing activities of daily
living (ADLs) and making decisions.
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• Although some types of mixed presentations in
depression exist, the DSM-5 focuses primarily on
the depressive ones. For a diagnosis, however,
these problems must be severe enough to affect
occupational and social functioning.
• When suffering from depressive disorders, all
individuals experience some degree of depressive
symptoms, although the duration, time frame,
and etiology may vary.
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Disruptive Mood Dysregulation
Disorder (DMDD)
• DMDD has 11 specific criteria (ranging from A to
K) that must be met. The core feature is
irritability that is persistent for at least a year and
maintains a severe and continuous course that is
not related to a developmental phase. The
behaviors are not consistent with the
precipitating event and involve either verbal or
behavioral manifestations toward people or
property. Temper outbursts must be continuous,
occurring at least three or more times over a 7day period. Other criteria are documented in this
text.
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Major Depressive Disorder
• There are nine primary symptoms, and the
individual must have at least five of them. In
addition, the symptoms must all occur during the
same 2-week period, and the individual who
suffers from major depressive disorder must have
either a depressed mood or a loss of interest or
pleasure in daily activities consistently for the 2week period. Of the nine symptoms, at least one
must be depressed mood or loss of interest or
pleasure.
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Persistent Depressive Disorder
(Dysthymia)
• This is a milder yet more chronic form of the
disorder, requiring a 2-year history of
depressed mood. The individual suffering
from this disorder is not without the
symptoms for more than 2 months at a time.
The disorder is considered less severe than
major depressive disorder but is constant for a
period of 2 years, during which the individual
experiences some symptoms related to the
disorder almost every day.
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Premenstrual Dysphoric Disorder
(PMDD)
• This new condition to the DSM-5 occurs in
women who have severe depressive
symptoms, irritability, and tension that occur
before menstruation.
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Substance/ Medication-Induced
Depressive Disorder
• Meet the criteria for major depressive
disorder and document the substance/
medication taken, confirmed by history,
physical exam, or lab result. The individual
needs to experience the symptoms soon after
ingestion or with resultant intoxication or
withdrawal from the substance. In addition,
that the substance taken is capable of
displaying the side effects that resulted has to
be confirmed.
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Depressive Disorder Due to Another
Medical Condition
• Similar to the criteria for substance/
medication-induced disorder, the individual is
expected to suffer from a persistent depressed
mood, accompanied by diminished interest
and pleasure in activities that once were
pleasurable. There also needs to be direct
evidence from an adequate history, physical
exam, or lab result that makes the connection
to the medical condition causing it.
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Other Specified Depressive Disorder or
Unspecified Depressive Disorder
• The diagnosis of either of these disorders
requires the symptoms characteristic of the
depressive disorders. The three specifiers are
recurrent brief depression, short-duration
depressive episode, and depressive episode with
insufficient symptoms. The primary difference
between the specified and the unspecified
disorder is that in the specified disorder, the
practitioner documents the reason that it does
not meet the criteria.
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Presentation of Anxiety
• Clients who are anxious often do not seek the help of
a primary care physician unless urged by family
members or support system influences, such as
emergency responders.
• Clients often cannot control the signs and symptoms
experienced and try to address them with repetitive
behaviors.
• Clients present with both physical and mental
symptoms (e.g., tremors, dyspnea, dizziness,
sweating, irritability, restlessness, hyperventilation,
pain, heartburn) and when confronted, may back
away from help or attention to their concerns.
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Understanding OCD and Related
Disorders
• Obsessive-compulsive disorder (OCD) and the
related disorders are characterized by
“recurrent obsessions or compulsions that are
severe enough to be time consuming or cause
marked distress or significant impairment”.
The significant impairment occurs in the
person's normal routine, occupational
functioning, academic functioning, social
activities, or relationships. Obsessions can be
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Understanding OCD and Related
Disorders (Cont.)
defined as recurring and distressing thoughts,
images, and urges. These factors are beyond the
control of the individual and are perceived as
inappropriate and anxiety provoking. Some of the
most common obsessions are a fear of
contamination, a fear of being harmed or harming
others, disturbing visions of a sexual or aggressive
content, doubting, and unacceptable impulses.
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• Obsessive-compulsive disorder (OCD):
– OCD has four specific criteria (ranging from A to D)
that must be met. The core criterion is the
presence of obsessions and/ or compulsions.
• Body dysmorphic disorder (BDD):
– BDD has four specific criteria (ranging from A to D)
that must be met. Individuals with this disorder
exhibit a “preoccupation with one or more
perceived defects or flaws in physical appearance”
that may or may not be visible to others.
• Hoarding disorder (HD):
– HD has six specific criteria (ranging from A to F)
that must be met. Individuals with hoarding
disorder suffer from an inability to discard
possessions that may have significant financial
value, emotional value, or no value at all.
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• Trichotillomania (hair pulling disorder):
– Five specific criteria (ranging from A to E) must be
met. This disorder consists of hair loss associated
with recurrent hair pulling when the individual has
tried unsuccessfully to decrease or stop the hair
pulling.
• Excoriation (skin picking) disorder:
– Five specific criteria (ranging from A to E) must be
met. The recurrent skin picking results in skin
lesions and/or skin infections; there are
unsuccessful attempts to stop or decrease the skin
picking.
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• Substance/medication induced obsessivecompulsive and related disorder:
– Five specific criteria (ranging from A to E) must be
met, along with two components that can be
documented based on history and medical
examinations (physical exams and laboratory finds).
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Overview of the 9 Disorders
• Obsessive-compulsive and related disorder due to
another medical condition:
– Five specific criteria (ranging from A to E) must be
met. The behaviors related to the disorder
dominate the individual's situation. There is
evidence based on history and medical tests that
the disorder results from another medical
condition.
• Other specified obsessive-compulsive and related
disorder:
– The designation of this category requires that the
symptoms are characteristic of an obsessivecompulsive and related disorder. This category can
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Overview of the 9 Disorders (Cont.)
be used when there is not enough information to
make a full diagnosis or when the symptoms do not
fully reach the criteria of the obsessive-compulsive
and related disorder.
• Unspecified obsessive-compulsive and related
disorder:
– This diagnosis is used when the symptoms do not
fully meet the obsessive-compulsive and related
disorder categories and the cause for not meeting
the disorder is not listed.
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Obsessions and Compulsions
• Obsessions: Persistent, recurring, and distressing
intrusive thoughts, images, and urges
inappropriate, anxiety provoking, and contrary to
the individual's free will.
• Compulsions: Persistent repetitive behaviors
(e.g., checking and rechecking, collecting, skin
picking) or mental acts (e.g., counting) in
response to an obsession or to applied rigid rules,
and not performed for pleasure or gratification.
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Trauma and Stressor Related Disorders
• Trauma can be defined as the occurrence of
emotionally traumatic events that overwhelm an
individual. All of the disorders presented in this
chapter require identification of a triggering
event. This triggering event does not have to be
isolated; it can be a multitude of events that are
repeated and ongoing. Although much of the
current research has focused on major
catastrophes and people's reactions to them,
each individual may respond to trauma
differently.
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Trauma and Stressor Related Disorders
(Cont.)
• For some, the event teaches resilience and to
push forward beyond what is generally expected.
In normative stress reactions the aftermath of the
trauma may last two to three days. Yet, when the
reaction becomes too extensive and the
individual cannot function or regroup, a disorder
may result. What all of the disorders listed in this
chapter of the DSM share is exposure to a
traumatic event. For reactive attachment disorder
and disinhibited social engagement disorder, this
early trauma can include social neglect.
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• Trauma and stress can affect people differently.
When most people experience anxiety, they have
an adequate set of background capacities and can
attribute meaning, motivation, and intention.
Extreme circumstances, especially over a period
of time or in the formative years, including
repeated social and emotional neglect or
situational factors such as acts of betrayal,
malevolence, and deceit (e.g., war, torture), can
be especially difficult to process.
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DSM-5 Categorizes the Following under
Trauma and Stressor Related Disorders
•
•
•
•
•
•
Reactive attachment disorder (RAD)
Disinhibited social engagement disorder (DSED)
Posttraumatic stress disorder (PTSD)
Acute stress disorder (ASD)
Adjustment disorders
Other specified trauma- and stressor-related
disorders
• Unspecified trauma- and stressor-related
disorder.
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Primary Spectrums of Mental Illness
• The Depression Spectrum: Sadness versus Despair
• The Mania Spectrum: Moody versus Bipolar
• The Anxiety Spectrum: Carelessness versus
Anxiousness
• The Psychosis Spectrum: Eccentric versus Psychotic
• The Focusing Spectrum: Attentive versus Obsessive
Compulsive Disorders
• The Substance Abuse Spectrum: Social Use versus
Addicted
• The Autism Spectrum: Withdrawn versus Autistic
• The Personality Spectrum: Obnoxious versus
Neurotic
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Substance Use Disorders Expanded
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• Changes in Substance Related Disorders from
the DSM-IV
– Removal of Substance Abuse and Dependence
– Severity of disorder (mild to severe) based on
the number of symptom criteria met:
• Mild:
• Moderate:
• Severe:
2-3 symptoms
4-5 symptoms
6 or more symptoms
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• DSM-IV-TR
– 305.00 Alcohol
Abuse
– 303.90 Alcohol
Dependence
• DSM-5
– (F10.10) Mild Alcohol
Use Disorder
– (F10.20) Moderate
Alcohol Use Disorder
– (F10.20) Severe
Alcohol Use Disorder
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• The word “addiction” is omitted due to it’s
uncertain definition and it’s potentially
negative connotation
• Craving or strong desire replaces
preoccupation
• Items deleted: “recurrent legal problems” and
the polysubstance category
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10 Separate Classes of Drug
•
•
•
•
•
•
•
•
•
•
Alcohol
Caffeine
Cannabis
Hallucinogens
Inhalants
Opioids
Sedatives, hypnotics and anxiolytics
Stimulants
Tobacco
Other (or unknown) substances
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Addictive Disorders
• Includes Gambling Disorder
• Other potential behavioral addictions,
(internet addiction, sex addiction, exercise
addiction, shopping addiction, etc.) not
included due to, “insufficient peer-reviewed
evidence to establish the diagnostic criteria
and course description”
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Substance Use Disorders
• The Essential Feature – continued use despite
significant substance-related problems
• Changes in brain circuits may persist,
exhibited in repeated relapses & intense drug
cravings
• Criteria include impaired control, social
impairment, risky use, and pharmacological
symptoms (withdrawal/tolerance)
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Substance Use Disorders
• 11 diagnostic criteria (some classes of
substances have 10 criteria)
• 2 or more within a 12-month period
• Must include a pattern of use leading to
clinically significant impairment or distress
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Substance Use Disorders: Diagnostic
Criteria
1. Substance often taken in larger amounts or over
a longer period of time than intended (impaired
control)
2. A persistent desire or unsuccessful efforts to cut
down or control use (impaired control)
3. A great deal of time spent in activities necessary
to obtain the substance, use it, or recover from
its effects (impaired control)
4. Craving, or strong desire or urge to use
(impaired control) (New criteria)
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Substance Use Disorders: Diagnostic
Criteria
5. Recurrent use resulting in failure to fulfill
major role obligations at work, school, or home
(social impairment)
6. Continued use despite having persistent or
recurrent social/interpersonal problems caused
or exacerbated by use (social impairment)
7. Important social, occupational, or recreational
activities given up or reduced because of use
(social impairment)
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Substance Use Disorders: Diagnostic
Criteria
8. Recurrent use in situations which is physically
hazardous (risky use)
9. Use is continued despite knowledge of having
a persistent or recurrent physical/psychological
problem likely to have been caused or
exacerbated by use (risky use)
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Substance Use Disorders: Diagnostic
Criteria
10. Tolerance: the need for markedly increased
amounts of substance to achieve intoxication or
desired effect, or a markedly diminished effect
with continued use of same amount
(pharmacological)
11. Withdrawal: a characteristic syndrome, or
use to relieve or avoid withdrawal
(pharmacological)
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• Criteria 1-4 relate to use
• Criteria 5-8 relate to behavioral issues
associated with use
• Criteria 9-11 relate to physical/emotional
issues
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The Big Five
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•
•
•
•
Criteria 2: Wanting to cut down/setting rules
Criteria 4: Craving and/or compulsion to use
Criteria 5: Failure at role fulfillment due to use
Criteria 7: Sacrifice activities to use
Criteria 11: Withdrawal symptoms
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Sustained Remission
• No positive diagnostic findings (other than
craving) for 12 consecutive months
• Substance use is NOT part of the remission
definition
• This remission definition is appropriate for both
misuse and chronic addiction
• Possible levels of outcome: 1) abstinence without
problems; 2) some use without problems; 3) use
with sub-diagnostic problems; 4) meets current
diagnosis
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ICD-10 Diagnostic Criteria for Alcohol
Dependence
• A craving or feeling of compulsion to use the
alcohol.
• Evident impairment of the ability to control use
of alcohol. This can be related to difficulties in
avoiding initial use, difficulties in discontinuing
use, difficulties in controlling the level of use.
• Withdrawal state, or use of the substance to
mitigate or avoid withdrawal symptoms, and
subjective awareness of the efficacy of this
behavior.
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ICD-10 Diagnostic Criteria for Alcohol
Dependence (Cont.)
• Presence of tolerance to the alcohol’s effects.
• Progressive neglect of pleasures, behaviors or
interests in favor of using alcohol.
• Persistent use of alcohol despite evident
presence of harmful consequences.
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Compatibility DSM5-ICD-10
• Use any positive finding on the DSM-5 criteria to
match on the basis of where each criterion loads
on the ICD-10
• Likely to over diagnosis as some components of
the DSM-5 category are not part of ICD-10
• Example: Job problems (DSM Criterion 5) or
interpersonal conflicts (DSM Criterion 6) due to
use do not neglect of interests for the
dependence criteria nor necessarily a
“dysfunctional behavior” for harmful use
• Global match based on DSM-5 criteria most likely
to produce a good fit.
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Recording Procedures for Substance
Related Disorders
• New recording procedures to occur by 10/14
• Use the code for the class of substances, but
record the specific substance
• Severity determined by # of symptom criteria
• Mild (2-3); Moderate (4-5); Severe (6 or more)
• Severity can change over the course of time by
reductions or increases
• Record for each individual substance disorder
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Recording Procedures for Substance
Related Disorders
Course Specifies
• “in early remission” (3-11 months)
• “in sustained remission” (12 mos. or longer)
• None of the criteria met for that duration with
exception of craving
• “on maintenance therapy” (for opioids, tobacco)
• “in a controlled environment” (access to
substance is restricted)
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Substance Related Disorders
• Divided into two groups:
– Substance induced disorders: includes conditions
of intoxication or withdrawal and other induced
mental disorders
– Substance use disorders: relates to pathological
patterns of behaviors related to the use of a
substance
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Tobacco Use Disorder
• Problematic pattern of use leading to
significant impairment or distress as
manifested by 2 or more of the 11 symptom
criteria
• Includes the specifier “on maintenance
therapy” for those taking a nicotine
replacement aid or a tobacco cessation
medication
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Gambling Disorder
• Previously known as “Pathological Gambling”
and was in category of Impulse Control
Disorders
• Problematic gambling leading to significant
impairment or distress
• Leading to four or more of the following
symptoms over a 12-month period
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Gambling Disorder Diagnostic Criteria
1. Needs to gamble with increasing amounts of
money for desired excitement
2. Is restless or irritable when attempting to cut
down or stop gambling
3. Repeated unsuccessful efforts to control, cut
back, or stop gambling
4. Often preoccupied with gambling
5. Gambles when feeling distressed (helpless,
guilty, anxious, depressed)
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Gambling Disorder Diagnostic Criteria
6. After losing money gambling, often returns
another day to get even
7. Lies to conceal the extent of involvement with
gambling
8. Jeopardized or lost a significant relationship,
job, or career opportunity due to gambling
9. Relies on others to provide money to relieve
financial situations caused by gambling
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Gambling Disorder Diagnostic Criteria
• Removal of the criteria “has committed acts of
forgery, fraud, theft, or embezzlement to
finance gambling”
• Can be specified as either “Episodic” or
“Persistent” and “In early remission” or “In
sustained remission”
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Gambling Disorder Severity Rating
• Mild: 4-5 criteria
• Moderate: 6-7 criteria
• Severe: 8-9 criteria
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Gambling Disorder
• About 0.2%-0.3% of general population
• 3x more likely in males
• Highest in African Americans (0.9%), whites
(0.4%), Hispanics (0.3%)
• For females, the progression is more rapid
• About 17% commit suicide
• Often associated with SUDs and impulse –control
disorders (males) & mood/ anxiety D/O (females)
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Closure
• Sources:
– American Psychiatric Association (APA)
www.DSM5.org.
– www.APA,org
– DSM-5 Essentials, Wiley
– DSM-5 in Action, Wiley
www.rolandwilliamsconsulting.com