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Being a Good Diagnostician:
Changes in Diagnosis
Rhoda Olkin, Ph.D.
Distinguished Professor
California School of Professional Psychology – SF
[email protected]
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7 Facts
1) DSM 5 (not V) to allow for numbering of
revisions (5.1, 5.2, etc).
2) Was targeted for 2009, then 2011, now
May 22, 2013.
3) Am Psychiatric Assoc mtg in SF.
4) 2-year grace period for implementation.
5) Complete interface with ICD-11; codes in
parentheses.
6) NIMH
7) Cost: $139 – $199
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Pet Peeves?
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History
• Each DSM has tried to resolve problems
in previous versions.
• Problems in DSM-IV-TR
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– Not very user friendly.
– 9 categories for diagnostic uncertainty.
– NOS predominated.
– Insufficient on culture.
– Index not as good.
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Guiding Principles for
Changes to DSM
 Research evidence should support any addition
or substantive modification.
 Continuity with the current manual should be
maintained when possible.
No restraints should limit the degree of change
between DSM-5 and past editions. (Contradiction)
Routine clinical practices must be able to
implement any changes.
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6 Types of Changes
1)
2)
3)
4)
5)
6)
Structural changes.
Shifting criteria.
New diagnoses.
Reclassification of diagnoses.
Deleted diagnoses.
Code #s
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Sections
• Section 1: Intro to updates, how to use.
• Section II: The diagnoses (22 chapters)
• Section III: Conditions requiring further
research; cultural formulations; glossary.
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Overall Structural Changes
 What is the order of chapters (chronology?
Relatedness?).
 No axes  info goes elsewhere.
 Ego syntonic / dystonic (insight) specifiers:
– Good or Fair (dystonic)
– Poor insight (ambivalent)
– Absent insight (syntonic)
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Overall Structural Changes
•
•
•
•
p. 2
Some require direct knowledge over 12 mos.
Severity indicators (replaces Axis V: GAF).
Severity level is “over time & circumstances.”
Some diagnoses go up to severity level 2, some
to 3. Rating scales.
0 = None (>70 GAF)
1 = Mild (>70 GAF)
2 = Severe
3 = Very severe (<31 GAF)
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Changes
• Axis III: Part of diagnosis on Axis I.
• Axis IV: Make notation of psychosocial and
contextual factors.
• What happened to The Big 4 from DSM IV?
– (GMC, substance use, malingering or factitious,
normal)?
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The Big 4
• GMC:
– Not in index.
– But evident throughout.
– Often option of X Disorder Due to Another
Medical Condition (e.g., Depressive Disorder
Due to MS).
– Sometimes not (e.g., Bipolar Dis Due to A.M.C.)
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The Big 4
• Malingering  Factitious Disorder
– In Somatic Symptom & Related Disorders chapter.
– Factitious Disorder Imposed on Self
– Factitious Disorder Imposed on Another (was “by
proxy).
– Single vs Recurrent Episodes
– “Surreptitious actions to misrepresent, simulate, or
cause signs or symptoms of illness or injury in
absence of obvious external rewards.” (p. 325)
– May co-occur with medical condition (e.g.,
manipulating blood sugar in person with diabetes).
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The Big 4
• Substance Abuse: and Suicidality:
– Elevated status.
– Will always note the correlation.
– Some disorders can be:
“Substance/Medication-Induced.
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The Big 4
• Normal:
– Less of a concern?
• Bereavement (V code).
• Disruptive Mood Dysregulation Disorder (new).
• ASD (increased stigma?).
– “Saving normal” (Allen Francis, 2013)
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Overall Structural Changes
p. 3
• NOS  CNEC (conditions not
elsewhere classified):
– Only for 6 months.
– Only for specific reasons:
1) Diagnosis unclear (e.g., psychotic disorder CNEC)
2) Clinician not trained to make the dx.
3) Clinician cannot get info (e.g., client uncooperative;
records not available).
4) You do not have enough info.
5) Clinicians needs or is required to take more time of
direct observation (e.g., 12 months).
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Implications?
• Positives:
– More reliability?
– Better treatment planning?
– Longer therapy authorized?
• More work & time in the diagnostic process.
• Demand for outcome studies; clinicians to
validate their treatments (Dept of Corrections)
• Responsibilities of diagnostician.
– Severity index.
– Symptom scales for some disorders.
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The Chapters
22 chapters.
New order (?).
Some split (e.g., anxiety disorders).
Some renamed (e.g., neurodevelopmental
disorders).
• Some new (e.g., Trauma- & StressorRelated Disorders)
•
•
•
•
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22 Chapters:
1. Neurodevelopmental
Disorders
2. Schizophrenia Spectrum &
Other Psychotic Disorders
3. Bipolar & Related Disorders
4. Depressive Disorders
5. Anxiety Disorders
6. Obs-Compulsive & Related
7. Trauma- & Stressor-Related
8. Dissociative Disorders
9. Somatic Symptom Disorders
10.Feeding & Eating Disorders
11.Elimination Disorders
12.Sleep/Wake Disorders
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13. Sexual Dysfunctions
14. Gender Dysphoria
15. Disruptive, Impulse-Control
& Conduct Disorders
16. Substance Related &
Addictive Disorders
17. Neurocognitive Disorders
18. Personality Disorders
19. Paraphilic Disorders
20. Other Mental Disorders
21. Medication-induced
Movement…Med Effects
22. Other Conditions (v codes)
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Neurodevelopmental
• Not just a rename –
p. 31
– Etiology important;
– Disorders here are considered genetic/biochemical;
– Not responses to environment.
• Eliminated Rett’s Disorder (genetic).
• Includes: ADHD, ID, ASD, Communication
Disorders, Global Developmental Delay,
Motor (Tic) Disorders, Specific LD.
• May include specifier: “associated with known
med/genetic condition or environmental factor.”
• NO: Sensory Processing Disorder (SID)
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Neurodevelopmental
MR  Intellectual Disability (ICD-11: Int Dev Dis.)
– PL 111-256, 2010, “ID.”
– 3 criteria: Deficits in (a) intellectual functions, (b) adaptive
functioning, (c) onset during develop. period.
– Code 319 with severity specifier: Mild (F70), Moderate
(F71), Severe (F72), Profound (F73). (Table for severity)
– Severity is based on adaptive functioning, not IQ scores.
– Functioning in Conceptual Domain, Social Domain,
Practical Domain.
– Usually IQ scores 70 + 5 (Mean = 100; s.d. = 15).
– Requires testing with instruments “normed for individual’s
sociocultural background and native language.” (p. 37)
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Neurodevelopmental
Autism Spectrum Disorder (ASD): (p. 50)
– Now included as ASD: Autism, Aspergers,
PDD NOS, Disintegrative Disorder.
– 2 areas of disturbance:
• Social Communication & Social Interaction;
• Restricted repetitive patterns of behavior.
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– Diagnostic criteria are “illustrative, not
exhaustive.”
– Table for severity level, requiring: 1-support; 2substantial support; 3-very substantial support.
– M:F = 4:1
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Neurodevelopmental
•
•
•
•
•
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Communication Disorders:
Social Communication Disorder (new):
Language Disorders
Speech Disorders
Unspecified Communication Disorder
All of the following DSM IV disorders are
subsumed under above: Language Emergence;
Specific Language Impairment; Social
Communication Disorder; Voice Disorder; SpeechSound Disorder; Motor Speech Disorder; Child
Onset Fluency Disorder.
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Neurodevelopmental
Social Communication Disorder:
• Must have all of A.
• A. Persistent difficulties in social use of verbal and
nonverbal communication:
– Social purposes: (greeting, sharing info).
– Changing communication to match listener or context.
– Difficulties following rules for conversation or
storytelling (taking turns).
– Difficulties understanding what is not explicitly stated,
and nonliteral or ambiguous meanings (idioms, humor,
metaphors).
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DSM-IV-TR
Autism
Overlap
Aspergers
DSM 5
Autism Spectrum Disorder
RO
Social
Communication
Disorder
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Neurodevelopmental
ADHD (p. 59)
RO
• Inattention (>6/9) and/or hyperactivity-impulsivity
(>6/9) that interferes with functioning or
development.
• Prior to age 12 (instead of 7).
• 2 or more settings.
• Specify: Combined (314.01), Predominantly
inattentive presentation (314.00), Predominantly
hyper/impulsive presentation (314.01). (Typo?)
• Specify: Mild, moderate, Severe.
• Prevalence: About 5% of children, 2.5% of adults.
• M:F 2:1
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Neurodevelopmental
Specific Learning Disorder: (p. 66)
– Difficulties despite “provision of interventions” in:
– A. 6 areas (no specified # to be met).
– Specify and code: Reading; Written expression;
Mathematics.
– Specify: Mild, Moderate, Severe.
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Neurodevelopmental
Motor Disorders (p. 74)
– Developmental Coordination Disorder.
– Stereotypic Movement Disorder.
– Tic Disorders (specify: Tourette’s; Persistent
Motor or Vocal Tic disorder; Provisional Tic
Disorder.)
Other childhood disorders:
– See other chapters.
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Anxiety Disorders
Split into 3 chapters:
– Anxiety Disorders:
• Fight or flight system (Amygdala).
– Trauma- & Stressor-Related Disorders.
• Greater focus on affective response to external stressors.
– OCD & Related Disorders.
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• Based on imaging and genetic studies, and treatment
response.
• Basal ganglia – movement circuit – focus on urge and
behavior, less on anxiety.
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Anxiety Disorders
• Fear (fight or flight) + Anxiety (hyper-vigilance) +
Behavior (avoidance).
• Separation Anxiety.
• Selective Mutism.
• Specific Phobias (more specifiers).
• Social Anxiety Dis. (in chldrn, not just w adults).
• Panic Disorder (4/12 symptoms + worry + behav.).
• Agoraphobia.
• GAD (3/6 sxs for adults, 1/6 for children).
• Substance/medication induced; Anxiety due to AMC
• Also Panic Attack Specifier (p. 214)
p. 189
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Obsessive-Compulsive
& Related Disorders
 OCD.
 Hoarding Disorder.
 Excoriation (Skin
Picking Disorder).
 Hair Pulling Disorder.
 Substance/Medication Induced.
 Due to Another Medical Condition.
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p. 235
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Obsessions vs
Compulsions
Obsessions: Recurrent & persistent
thoughts, urges, or images that are
experiences as intrusive and unwanted.
Compulsions: Repetitive behaviors or
mental acts that an individual feels driven
to perform in response to an obsession or
according to rules that must be rigidly
applied.
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Trauma- & Stressor-Related
p. 265
Exposure to traumatic or stressful event.
New grouping of disorders from various places in DSM
 Adjustment Disorder.
 Acute Stress Disorder.
 PTSD.
– 4 clusters of symptoms: Intrusion, Avoidance, Negative
mood/cognitions, Arousal & reactivity.
– Children: expanded definition; section for < 6 yo.
– Specifiers: (a) dissociative sxs (depersonalization
or derealization); (b) delayed expression.
 Attachment disorders (next slide).
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Trauma- & Stressor-Related
Attachment related disorders:
 Common etiology: Absence of adequate caregiving
during childhood.
 Reactive Attachment Disorder:
 Internalizing disorder: depression, withdrawal.
 New criteria (4/5 sxs; onset between 9 mos. & 5
yrs.)
 Disinhibited Social Engagement: (NEW).
 Externalizing disorder: disinhibition, externalizing
behavior.
 2/4 sxs; onset > 9 mos.
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5 Pathogenic Realms
Some disorders are considered to arise from one or
more of five pathogenic realms. This distinguishes
them from disorders that are thought to be
biochemical (e.g., bipolar disorder).
Persistent disregard of child’s emotional needs; &/or
Persistent disregard of child’s physical needs; &/or
Repeated changes in primary caregivers; &/or
Raised in settings with limited opportunities for
stable attachments; &/or
5. Persistent harsh punishment or other types of
grossly inept parenting.
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1.
2.
3.
4.
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Bipolar Disorders
• 1974: Increased focus on distinguishing BP
from schizophrenia.
• Mid-1980s: Broadening the “BP spectrum”
– Avoid antidepressant-induced mania
– Treat the spectrum properly
• Mid-1990s: Pediatric BD
– Catch it early, avoid kindling
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p. 123
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Bipolar Disorders
• Late 1990s: Increased use of 2nd
generation antipsychotics for BD.
• Now: Narrowing the gate on Pediatric
BD.
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Bipolar Disorders
• Bipolar I: no change (> 1 episode mania).
(NB: suicide risk 15 x’s greater)
• Bipolar II: no change (hypomania & MDD)
(Lethality of suicide methods greater than
Bipolar I)
• Cyclothymia: (hypomanic episodes below
criteria for hypomania + depression below
threshold for MD); (minimum of 2 years for
adults, 1 year in children/adolescents).
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Bipolar Disorders
Specifiers:
o Anxious distress (mild,
moderate, moderate-severe,
severe).
o Mixed features.
o Rapid cycling (4 mood
episodes in 12/ months.
o With melancholic features.
o With atypical features.
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What about Pediatric Bipolar?
• Increasing diagnosis, over-diagnosis, wrong medication
interventions, inaccurate prediction, heterogenous disorder.
• There may be two types of currently diagnosed PBD:
– a narrow definition that looks like adult BD > still BD.
– a different form that includes explosive emotional outbursts that don’t look
like mania (no grandiosity, delusions) and are not so cyclical.
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• Looks a little like ADHD, but there may be more aggression.
Looks like disruptive behavior disorder, but more emotional
lability.
• Believed that they will not grow up with BD and should perhaps
be treated with antidepressants and/or Ritalin.
• Many will now be diagnosed with Disruptive Mood
Dysregulation Disorder (under Depression).
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p. 155
Depressive Disorders
Disruptive Mood Dysregulation Disorder:
RO
– New disorder.
– Older than 5 yrs;
– Persistent irritability;
– Frequent episodes of behavior outbursts > 3 a
week for more than 1 year;
– Intended to address concerns about potential overdx & over-trmnt of bipolar disorder in children;
– First diagnosis between ages 6-18;onset <10.
– Cannot coexist with ODD or bipolar disorder.
– Children with this dx typically develop unipolar
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depression or anxiety, not bipolar disorder.
Depression Disorders
Major Depressive Episode –
– Need 5/9 symptoms.
– In children/adol mood may be irritable.
– Table of codes for severity and single vs recurrent
Dysthymia  Persistent Depressive Disorder
– Still 2 years (adults); 1 yr children/adol
– Five specifiers. (p. 169)
o Nixed Mixed Anxiety Depression  Section 3.
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Depression Disorders
Premenstrual Dysphoric Disorder
• 5 sxs in week before menses.
• Improvement few days after onset of
menses.
• A: 1/4 mood symptoms + B: 1/7 behavior
symptoms = combined to equal 5 sxs.
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Bereavement
“Responses to a significant loss (e.g., bereavement…) may
include the feelings of intense sadness, rumination about
the loss, insomnia, poor appetite, and weight loss noted in
the Criterion A [for MDE], which may resemble a depressive
episode. Although such symptoms may be understandable
or considered appropriate to the loss, the presence of a
MDE in addition to the normal response to a significant loss
should also be carefully considered. This decision inevitably
requires the exercise of clinical judgment based on the
individual’s history and cultural norms for the expression of
distress in the context of loss.” (p. 125-126) {V Code}
• See footnote p. 126; same footnote p. 161
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Schizophrenia & Other
Psychotic Disorders
p. 87
• Schizophrenia:
– Eliminated subtypes (paranoid, hebephrenic,
disorganized, residual, catatonic).
– 2/5 sxs (a. delusions, b. hallucinations, c.
disorganized speech, d. disorganized or catatonic
behavior, e. negative symptoms); 1 sx must be a, b,
or c; 1 month.
– What are negative sxs? “diminished emotional
expression or avolition”).
– Functional impairment.
– Disturbance persist for > 6 months.
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Schizophrenia & Other
Psychotic Disorders
Delusional Disorders: Few changes.
• Subtypes: erotomanic, grandiose, jealous,
persecutory, somatic, mixed, unspecified.
• Specifier: w. bizarre content (implausible, not
within ordinary experience).
Brief Psychotic Disorder:
– 1 day to 1 month.
– Specifiers: w./w-o stressors; postpartum; with
catatonia, severity (0-4 for each symptom).
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Schizophrenia & Other
Psychotic Disorders
• Schizophreniform Disorder.
– 1 to 6 months.
– Specifiers: good/w-o good prognostic features,
with catatonia, each sxs severity 0-4
• Schizoaffective Disorder:
• Major Mood Episode + Criterion A of
schizophrenia.
• >2 weeks of delusions or hallucinations w-o mood.
• Some discussion of Schizotypal PD here.
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Substance-Related &
Addictive Disorders
• No “abuse” or “dependence”; now “use.”
• Chapter reorganized by substance.
– 10 classes of drugs:
Alcohol; Caffeine; Cannabis; Hallucinogens;
Inhalants; Opioids; Sedatives, hypnotics &
anxiolytics; Stimulants; Tobacco; Other.
• Two groups of disorders: (a) Substance use
disorders, (b) Substance-induced disorders.
p. 481
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Substance-Related &
Addictive Disorders
• Substance use disorder: continued use of
substance despite significant substancerelated problems. 4 sets of criteria:
– Impaired control (4 criteria).
– Social impairment (3 criteria).
– Risky use (2 criteria).
– Pharmacological criteria (2 criteria:
tolerance & withdrawal).
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Substance-Related &
Addictive Disorders
• Severity levels:
– Mild (2-3 symptoms)
– Moderate (4-5 symptoms)
– Severe (> 6 symptoms)
• Remission:
– Early vs Sustained;
– Maintenance therapy
– Controlled environment
Example:
Moderate
Valium use
disorder; Mild
alcohol use
disorder;
Secobarbital
withdrawal.
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Substance-Related &
Addictive Disorders
• New language:
“All drugs that are taken in excess have in common
direct activation of the brain reward system….
Individuals with lower levels of self-control, which
may reflect impairments of brain inhibitory
mechanisms, may be particularly predisposed to
develop substance use disorders, suggesting that the
roots of substance use disorders for some persons can
be seen in behaviors long before the onset of actual
substance use itself.” (p. 481)
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Substance-Related &
Addictive Disorders
• “This chapter also includes gambling
disorder, reflecting evidence that gambling
behaviors activate reward systems similar
to those activated by drugs of abuse, and
produce some behavioral symptoms that
appear comparable to those produced by the
substance use disorders.” (p. 481)
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Substance-Related &
Addictive Disorders
• Controversy about other behavioral
“addictions” to be included here/elsewhere.
– Gambling is here.
– Other behavioral patterns are not: Internet
gaming, shopping, sex, exercise addiction.
52
Disruptive, Impulse Control,
& Conduct Disorders
• Some childhood disorders went here.
• These disorders share symptom of problems of
self-control of emotions and behaviors.
• Unique in that they violate the rights of others
or brings person into conflict with authority.
• Typical onset is in childhood or adolescence.
p. 461
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Disruptive, Impulse Control,
& Conduct Disorders
•
•
•
•
•
•
•
RO
Oppositional defiant disorder.
Intermittent explosive disorder.
Conduct disorder.
Antisocial PD (see PD chapter)
Pyromania.
Kleptomania.
Other.
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Disruptive, Impulse Control,
& Conduct Disorders
Conceptualizing the relationship across
ODD, CD, & Antisocial PD:
CD
APD
ANXIETY
DEPRESSION
ODD
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Disruptive, Impulse Control,
& Conduct Disorders
Oppositional Defiant Disorder:
o 4/7 symptoms
• Angry/Irritable Mood (3)
• Argumentative/Defiant Behavior (4)
o Plus has been spiteful or vindictive > x2 in past 6
months.
o 6 months; not just with sibling.
o Mild (1 setting); Moderate (2 settings); Severe (>3
settings)
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Disruptive, Impulse Control,
& Conduct Disorders
Intermittent Explosive Disorder
– Either verbal aggression 2/week for 3 mos., or
behavioral outbursts resulting in damage of
property or assault on animals or person, 3 xs
in 12 mos.
– Minimum age of 6. (For ages 6-18 is not part
of Adjustment Disorder.)
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Disruptive, Impulse Control,
& Conduct Disorders
Conduct Disorder (minor wording changes)
o 3/15 criteria in 12 mos, from any category:
•
•
•
•
Aggression to people and animals (7)
Destruction of property (2)
Deceitfulness or theft (3)
Serious violation of rules (3)
o Subtypes: Age of onset (<10, >10, unspecified)
o Specifier: With limited prosocial emotions (use
multiple sources of information). (see p. 470)
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Disruptive, Impulse Control,
& Conduct Disorders
• Pyromania and Kleptomania remained.
• All disorders in this chapter:
Are correlated with substance abuse.
Prognosis guarded.
• Not included: Nonsuicidal self-injury (see
proposed criteria in Section 3).
RO
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p. 451
Gender Dysphoria
• Different criteria for children, & adoles. & adults.
• 6/8 symptoms over 6 mos (must include strong desire
to be other gender)
• Language:
– Sex = biology; Gender = social role/identity;
– Transgender = identify with other gender;
– Transexual = seeks/has undergone social transition to other
gender.
– Gender dysphoria = distress that may accompany the
incongruience between assigned and expressed gender.
– Thus dysphoria, not identity, is key to this diagnosis.
• Specifier: With disorder of sex development (for children & adults);
post-transition (adolescents & adults).
60
Gender Dysphoria
• Less pathologizing term than Disorder.
• Balancing Needs:
– Not a Mental Disorder per se.
– How to get insurance coverage?
•
•
•
•
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Imperfect compromise.
Other dysphorias?
Keeping pathology in gender identity?
No “Discrimination Disorder”  A new V
code?
61
Other Disorders:
V codes!









RO
p. 715
Relational problems (7) [uncomplicated bereavement]
Abuse & Neglect (approximately 48)
Educational Problems (1)
Occupational Problems (2)
Housing & Economic Problems (9)
Other problems related to social environment (6) [discrimination]
Problems related to crime or interaction w legal system (5)
Other health srvc encounters for counseling & medical advice (2)
Problems related to other psychosocial, personal, &
environmental circumstances (7)
 Other circumstances of personal history (7)
 Problems related to access to medical & other health care (2)
 Nonadherence to medical treatment (5) [malingering]
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Re Suicidal Behaviors
• Kapusta, N. (2012). Non-suicidal selfinjury and suicide risk assessment, quo
vadis DSM-V? Suicidology Online, 3, 1-3.
63
Diagnosing Personality Disorders
What is a “personality” and
how can it be “disordered”?
RO
64
Where Are We?
Where were we?
Where did we go wrong?
Where should we go?
RO
65
Personality Traits
Previously:
Gordon Allport: 4,000 personality traits
Unmanageable.
Raymond Cattell: 16 personality factors
Still too complex.
Hans Eysenck: 3-factor theory
Too simplistic.
Then:
D. W. Fiske (1949); Norman (1967); Smith
(1967); Goldberg (1981); and McCrae & Costa
(1987): THE BIG FIVE
– Studied in over 50 cultures; remarkably consistent.
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66
The Big Five
(OCEAN)
 Openness: This trait features characteristics such as imagination
and insight, and those high in this trait also tend to have a broad
range of interests.
 Conscientiousness: Common features of this dimension include
high levels of thoughtfulness, with good impulse control and goaldirected behaviors. Those high in conscientiousness tend to be
organized and mindful of details.
 Extraversion: This trait includes characteristics such as
excitability, sociability, talkativeness, assertiveness and high
amounts of emotional expressiveness.
 Agreeableness: This personality dimension includes attributes such
as trust, altruism, kindness, affection, & other pro-social behaviors.
 Neuroticism: Individuals high in this trait tend to experience
emotional instability, anxiety, moodiness, irritability, and sadness.
•
RO
67
Dimensional Scale
Based on Big Five
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68
Big 5 vs DSM-IV
The five personality dimensions were not
the building blocks for the personality
disorders in DSM-IV.
Instead, 10 PD were put into three clusters.
The characterization of the clusters did not
coincide with the Big 5.
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69
DSM-IV-TR Clusters
• Cluster A
: Odd or eccentric
– Schizoid, Paranoid, Schizotypal
• Cluster B
erratic
: Dramatic, emotional or
– Antisocial, Borderline, Narcissistic, Histrionic
• Cluster C
: Anxious, fearful
– Avoidant, Dependent, Obsessive-Compulsive
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70
The Categorical System
71
Personality Disorders
Study on clients diagnosed with PD who were in
treatment, conducted by DSM TF, 1999-2007:
– Rediagnosed using RDC on 5,000 clients  75%
false positives.
– Those with “BPD”  85% false positives.
– After 1 yr most no longer meet criteria.
Therefore, workgroup considered:
– Eliminating some PD.
– Elevating criteria for PD.
– Making process of dx more daunting.
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72
From DSM-IV to DSM 5
• Erase all PD?
• Recluster?
• Redefine?
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73
Could Redefine “Personality”
• DSM-IV: A pervasive pattern of thinking/
behaving/emotionality.
• Perhaps? A personality disorder reflects
"adaptive failure" involving:
– "Impaired sense of self-identity" or
– "Failure to develop effective interpersonal
functioning."
RO
74
Personality Disorders –
The way it almost was
• Personality types defined by personality
domains and facets:
– Negative affect (facets: lability,anxiety/
insecurity, hostility)
– Detachment (facets: withdrawal/depression,
suspicion)
– Antagonism (facets: difficult to get along with:
manipulative, deceitful, hostile)
– Disinhibition (facets: impulsive/irresponsible)
– Psychoticism (facets: unusual/bizarre
experiences, eccentric)
RO
75
Personality Disorders –
The way it almost was
More emphasis on process of PD diagnosis:
1. Does person have a personality problem (self,
interpersonal)
2. Determine if it matches 1 of the 6 personality types
(former PD’s)
3. If it does, describe using domains and their facets
4. If it doesn’t PD-trait specified (PDTS) category: you
can describe people even if they don’t have a trait
diagnosis.
5. Would require knowing more about a client, increase
involvement of psychotherapist in diagnosis, reduce
use of PD diagnosis.
6. Sequestered to Section 3 as of December 2012
76
Personality Disorders
Suggested process of diagnosis:
1. Documented observations over 12 months
of impairments in core functioning (self,
interpersonal, empathy, intimacy).
2. Personally observed pathological traits
over 12 months.
3. Recognized overall severity level of 3 over
12 months.
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Personality Disorders
Pathological traits seen in 5 realms, as seen in
relationship with therapist over 12 months:
1. Negative affectivity:
Lability, anxiety, separation insecurity, hostility,
perseveration, submissiveness, suspiciousness,
dysphoric attitudes, emotional dysregulation.
2.
Detachment:
Emotional constriction, anhedonia, withdrawal,
intimacy avoidance.
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Personality Disorders
3.
Antagonism:
Manipulative, deceitful, attention seeking, grandiose,
callous.
4.
Disinhibition or compulsivity:
Perfectionism, controlling, impulsive, risk taking,
distancing, emotionally inaccessible.
5.
Psychoticism:
Unusual beliefs, eccentric, cognitive dysregulation.
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Personality Disorders
• Considered eliminating:
– Schizotypal (to be moved to Schiz.)
– Schizoid (to be moved to Schiz.)
– Histrionic PD
– Dependent PD
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Personality Disorders
Instead, retained:
All 10 PDs
The cluster system
What did they change?
Removed lower age limit (except
Antisocial PD).
 See also Section 3
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Culture
DSM-IV: Culture bound syndromes.
APA Multicultural Guidelines: How
social, cultural, political, and historical
contexts manifest in clinical presentations.
DSM 5: More in text; Cultural
formulation chapter (p. 749-759) w CF
Interview (16 Qs).
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Good Article re Culture:
Dadlani, Overtree, & Perry-Jenkins
(2012). Culture at the center: A
reformulation of diagnostic
assessment. Professional Psychology:
Research & Practice, 43(3), 175-182.
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Good Books re Diagnosis
 Beach, Wamboldt, Kaslow, Heyman, First, Underwood,
& Reiss (Eds.) (2006). Relational processes and DSM-V:
Neuroscience, assessment, prevention, and treatment.
Arlington, VA: American Psychiatric Association.
 Garcia, B., & Petrovich, A. (2011). Strengthening the
DSM: Incorporating resilience and cultural competence.
NY: Springer Publishing Co.
 Frances, A. (2013). Saving normal: An insider’s revolt
against out-of-control psychiatric diagnosis, DSM 5, big
pharma, & the medicalization of ordinary life. NY:
William Morrow.
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Questions?
Answers?
Thank you!
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