Download Making Sense of the DSM-5: Changes and Changing Perspectives

Making Sense of the DSM-5: Changes and
Changing Perspectives
Chasity S. Norris, MLT, MA, FDEX, NCC
Making Sense of the DSM-5

This workshop is designed to cover the basic changes and
practical implications of the DSM-5 regarding mental health
assessment treatment planning, and evidence-based
practice strategy.

Particular emphasis is placed on understanding the
rationale for the changes and the implications these
changes can have on developing best practices.

An overview of selected diagnostic categories will be
reviewed stressing assessment as it is linked to behaviorbased practice strategy.
Copyright 2013 Chasity Norris
Who is Your Speaker?

Chasity S. Norris, MLT, FDEX, MA, NCC, has a love for therapy
and teaching, and has found ways to combine those passions, in
ways she hopes will be as meaningful to others as they are to
her. She delivers practical information in an entertaining, fastpaced style that is often filled with examples from her
experiences both in the classroom, and in mental health. She
attended East Tennessee State University from 2002-2013,
receiving degrees in the areas of medical laboratory technology,
epidemiology, forensic document examination, criminology, and
counseling. She has published research and education training
manuals including: Psychopathy and Gender: A Comparison
Using the PCL-R, and Ethics in Policing: Instructor’s Manual 6th
ed. Her research includes investigations of psychopathy,
personality disorders, deviant behaviors, stress and coping, and
dialectical behavior therapy. Chasity Norris is currently an adjunct
professor of criminology at East Tennessee State University, and
primary therapist at the Crisis Stabilization Unit in Johnson City,
Tennessee.
Copyright 2013 Chasity Norris
What Is The DSM Used For?


–“Primarily designed to assist clinicians in
conducting clinical assessment, case
formulation, and treatment planning”
(pg. 25, DSM-5)

To help professionals understand the
problem(s) and know how to treat the client.

Diagnostic guidelines also provide some
criteria for future mental disorder research.
Copyright 2013 Chasity Norris
Why a New Edition?

We have begun to be more mindful of the language we use to
describe our clients in order to help influence the way we think
about our clients, the way society thinks about our clients, and
ultimately, the way our clients view themselves.

The diagnosis we apply, often become “labels’ that can help mold
perceptions in positive ways, or negative ways, depending on
their intention and delivery.
Copyright 2013 Chasity Norris
Why a New Edition?

This can influence a client’s willingness to
seek help.

If a client is fearful of certain diagnoses, or
more appropriately, of being “labeled” with a
certain disorder, they can be much less likely
to seek help when needed.
Copyright 2013 Chasity Norris
Why a New Edition?

This issue is one of the driving forces behind the
movement for a new edition.

The DSM-5 now includes many updated diagnostic
names that are more sensitive and less stigmatic
than previous editions.

Ex. (“Mental Retardation” is now titled (“Intellectual
Disorder”)
Copyright 2013 Chasity Norris
Why a New Edition?

There has been widely inconsistent use of the
multiaxial system previously used in the DSM-IV-TR.

The DSM must consider as many conditions as
possible because insurance companies will not
reimburse for conditions not listed in the DSM’s ICD.

This factor was a huge influence on the task forces
decision to include some previously omitted
disorders such as:

Gender Dysphoria (previously Gender Identity
Disorder)
Gambling DisorderCopyright 2013 Chasity Norris

Why a New Edition?

More effective and thorough in judicial proceedings to determine
insanity, and competence to stand trial.

Aid in determining disabilities for protection against discrimination
in the workplace, or for accessing accommodations in work or
school settings.

Ability to aid in research for medications geared toward specific
disorders.
Copyright 2013 Chasity Norris
Brief History

28 member task force created in 2007, and worked
in working groups for 6 years.

Guided by the ideas that the new edition had to be
useful for routine clinical practice, and any new
changes had to be guided by research evidence.

APA developed website in 2010 to gather input from
the public and other professionals.

Final approval for publication in December 2012
Copyright 2013 Chasity Norris
Cultural Concerns Addressed

Section III now contains tools for extensive
cultural assessment.

Topic of Culture Bound Syndromes
addressed

Describes three types of culture-bound
syndromes:
Copyright 2013 Chasity Norris
1.
Cultural Syndrome- group of symptoms
found in specific cultural groups that are not
recognized as illness within the culture, but
is recognizable to outside observers.
2.
Cultural Idiom of Distress- way of talking
about suffering among individuals within a
group . (“I’ve got nerves”)
3.
Cultural Explanations or Perceived
Cause- model that provides a culturally
determined etiology.
Copyright 2013 Chasity Norris
Why a New Edition?

To be more culturally aware and considerate

Stay current with research

Ability to integrate information with social
networking

DSM-5 online subscription:
www.psychiatryonline.org

*Also have E-Book and Mobile App
Copyright 2013 Chasity Norris
Changes from DSM-IV-TR To DSM-5
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
Major Structural Changes: Discontinuation of
Multiaxial System

Axis I: Clinical Disorders

Other Conditions that May Be a Focus of Clinical Attention

Axis II: Personality Disorders

Mental Retardation

Axis III: General Medical Conditions

Axis IV: Psychosocial & Environmental Problems

Axis V: Global Assessment of Functioning
Copyright 2013 Chasity Norris
Discontinuation of Multiaxial System

Instead of using the prior system of
organization, the DSM-5 actually combines
the first three axes (mental disorders,
intellectual disabilities, and personality
disorders) into section II.

They are now all regarded as equally
important in achieving a correct diagnosis, so
they are listed together, in the particular order
the clinician feels they are affecting the client.
Copyright 2013 Chasity Norris
Discontinuation of Multiaxial System

The axis system was originally used to
separate out the disorders that had been
heavily researched and confirmed (organic
disorders) from those needing more research
to be acknowledged (personality disorders),
however, the APA now agrees there is no
fundamental difference between the
disorders on Axis I and Axis II.
Copyright 2013 Chasity Norris
Discontinuation of Multiaxial System

Section II also contains much of the information
formerly listed under Axis IV.

Any of the environmental factors or other conditions
in life that could hinder treatment are now listed at
the end of this section, instead of being separated.

The rational for this change is that all of these
factors are equally important when making and
treating a specific diagnosis, so they should all be
listed and considered together, forming a more
holistic picture of the presenting issues.
Copyright 2013 Chasity Norris
Discontinuation of Multiaxial System

Global Assessment Functioning Score (GAF) dropped completely
from DSM-5

Physicians and Clinicians are still encouraged to assess suicidal
and homicidal behavior with standard assessments for severity,
according to symptoms.

Disability now measured using the World Health Organization’s
Disability Assessment Schedule (WHODAS). Can also use other
information under section III of DSM-5
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
Integrational Approach to Diagnosis

Rather than the prior Axis system, the new
chapter order is organized in “Clusters”.

This allows for disorders that are relatable or
share similar symptoms and characteristics to
be looked at together.
Copyright 2013 Chasity Norris
Neurodevelopmental Cluster
This includes all Neurodevelopmental
Disorders and Schizophrenia Spectrum &
Psychotic Disorders
Copyright 2013 Chasity Norris
Internalizing Cluster







Includes:
Bipolar Disorder
Depressive Disorder
Obsessive-Compulsive and Related
Disorders
Anxiety Disorder
Trauma & Stressor Disorders
Dissociative Disorder
Copyright 2013 Chasity Norris
Somatic Cluster

Includes:

Somatic Symptom Disorders
Feeding & Eating Disorders
Gender Dysphoria
Sexual Dysfunctions
Elimination Disorders
Sleep Disorders





Copyright 2013 Chasity Norris
Externalizing Cluster

Disruption, Conduct, and Impulse-Control
Disorders

Substance and Addictive Disorders
Copyright 2013 Chasity Norris
Neurocognitive Disorders

Neurocognitive Disorders
Copyright 2013 Chasity Norris
Personality Cluster

Personality Disorders
Copyright 2013 Chasity Norris
Other

Paraphilias

Medication-Induced Movement Disorders

Conditions for Further Study
Copyright 2013 Chasity Norris
Sensitivity to Stability of Disorders

Chapter in DSM-IV-TR describing “Disorders Usually
Diagnosed During Infancy, Childhood, and
Adolescence has been eliminated and the
subsequent disorders have been divided up into the
chapters they relate to by symptomology.

This is due to research showing most of these
disorders are stable into adulthood, and can also
present during adulthood, not just childhood. (Pica,
ADHD).
Copyright 2013 Chasity Norris
No More NOS!

The NOS (not otherwise specified) category
has been eliminated all together.

Options now include:

Other Specified Disorder

Unspecified Disorder

*Condition deferred still available, but is not
listed.
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
DSM-5 Specific Disorders

Neurodevelopmental Disorders including:

Internalizing Cluster
Somatic Cluster
Externalizing Cluster
Neurocognitive Cluster
Personality Cluster
Other Cluster





Copyright 2013 Chasity Norris
Neurodevelopmental Disorders

Intellectual Disability (formerly “Intellectual
Development Disorder”)

Global Developmental Delay
Unspecified Intellectual Disability
(formerly “Intellectual Development Disorder)

Copyright 2013 Chasity Norris

A federal state statute “Rosa’s Law” (public
Law 111-256), determined “mental
retardation” was now to be termed
“intellectual disability”
Copyright 2013 Chasity Norris
Neurodevelopmental cont.

Communication Disorders
Language Disorder- a combo of DSM-IV’s
expressive and mixed-receptive expressive
language disorders.
Speech Sound Disorder- Previously
Phonological Disorder.
Copyright 2013 Chasity Norris
Neurodevelopmental cont.

A new diagnosis of Social Communication
Disorder has been added.

SCD- is persistent difficulty in the social use
of verbal and nonverbal communication that
is not caused by low cognitive ability.
Copyright 2013 Chasity Norris
Neurodevelopmental cont.

Autism Spectrum Disorder
Combines:
 Autistic Disorder
 Asperger's
 Childhood Disintegrative Disorder
 Pervasive Developmental Disorder
**Requires both social communication and social
interaction, and restricted repetitive behaviors,
interests, and activities.
Copyright 2013 Chasity Norris
Neurodevelopmental cont.

Attention Deficit Hyperactivity Disorder

Now has symptoms added to help diagnose in
adults

Children still need to have at least 6 symptoms, but
older adolescents and adults need 5

Symptoms must have presented before age 12, not
age 7 as previously held in DSM-IV
Copyright 2013 Chasity Norris
Schizophrenia

Schneiderian first-rank auditory hallucinations
eliminated.

Symptom threshold raised form 1 to 2 specific
symptoms to qualify for diagnosis

Includes requirements for symptoms of delusions,
hallucinations, or disorganized speech.

Also eliminated subtypes (paranoid, disorganized,
catatonic, undifferentiated, etc. )
Copyright 2013 Chasity Norris
Schizoaffective Disorder

Now must have presence of a mood
dysregulation for the majority of time the
schizophrenic symptoms present.

Makes it more longitudinal DX.
Copyright 2013 Chasity Norris
Delusional Disorder

Criteria for delusions to be “non-bizarre”
eliminated.

Shared Delusional Disorder no longer
separated from delusional disorder

Now is “other specified schizophrenia
spectrum and other psychotic disorder”
Copyright 2013 Chasity Norris
Bipolar and Related Disorders

Now includes changes in activity level or energy
level, not just mood.

BP I, mixed episode has been removed

Replaced with ‘With Mixed Features”

Qualifier can be used in either BP I or II

“with anxious distress” also new qualifier for those
exhibiting anxiety along with BP symptoms.
Copyright 2013 Chasity Norris
Depressive Disorders

New diagnoses added:

Disruptive Mood Dysregulation Disorder – violent
temper outbursts manifested verbally

Premenstrual Dysphoric Disorder
Copyright 2013 Chasity Norris
Persistent Depressive Disorder

Combines Chronic Major Depressive
Disorder and Dysthymic Disorder.
Copyright 2013 Chasity Norris
Anxiety Disorders

Disorders no longer included in this section include:

Obsessive-Compulsive Disorder

Post Traumatic Stress Disorder

Acute Stress Disorder

Now listed under new chapter (obsessivecompulsive and trauma-stressor disorders)
Copyright 2013 Chasity Norris

Panic Disorder and Agoraphobia are now
tow-separate disorders under the DSM-5.

If there is a co-occurrence of panic and
agoraphobia, they are coded as two separate
diagnoses.
Copyright 2013 Chasity Norris
Social Anxiety Disorder (social phobia)

Now has “generalized” and “performance
only” qualifiers.
Copyright 2013 Chasity Norris
Separation Anxiety Disorder

Now moved out of section describing
childhood or adolescent disorders, and is
now in with the anxiety disorders

This is due to research showing it can occur
after age 18

Must still be present for >6 months

Selective Mutism also moved to anxiety
disorders for same reason.
Copyright 2013 Chasity Norris
Obsessive-Compulsive & Related Disorders

New chapter to the DSM

includes:

Obsessive-Compulsive Disorder
Body Dysmorphic Disorder
Trichotillomania (hair-pulling)
Excoriation (skin-picking)
Hoarding Disorder
Substance-Medication Induced OCD
OCD related to other medical conditions






Copyright 2013 Chasity Norris
Body Dysmorphic Disorder

Somatic disorder with repetitive behaviors
and mental acts responding to their
preoccupation with their perceived physical
defects or flaws.

Now has “with muscle dysmorphia” and
“absent insight/ delusional” specifiers.
Copyright 2013 Chasity Norris
Hoarding Disorder

NEW!!

Related to OCD, but not a variant of

Patient presents with persistent difficulty
discarding or parting with possessions and
noted distress associated with discarding
them.
Copyright 2013 Chasity Norris
Excoriation Disorder

NEW!!

Skin Picking causing dermatological
damage
Copyright 2013 Chasity Norris
Trauma & Stressor Related Disorders

New Category!

PTSD now has a list of traumatic event
qualifiers and “second-hand exposure”
allowance (first-responders collecting human
remains)
Copyright 2013 Chasity Norris

Includes:

Reactive Attachment Disorder as a distinct disorder

Also includes Disinhibited Social Engagement
Disorder

Both outcome of social neglect and denial of healthy
attachment
Copyright 2013 Chasity Norris
Somatic Symptom and Related Disorders

Previously called “Somatoform Disorders”

Reduced subcategories
Copyright 2013 Chasity Norris
Somatic Symptom Disorder

Combines previous “somatization disorder’ and
“undifferentiated somatoform disorder”.

Designed to diagnose those with maladaptive
thoughts, feelings, and behaviors with somatic
symptoms that may or may not be related to medical
conditions.

Requirement that medically unexplained symptoms
be present removed. Psychological stress more
important.
Copyright 2013 Chasity Norris
Hypochondriasis and Illness Anxiety Disorder

Hypochondriasis removed from DSM-5
Copyright 2013 Chasity Norris
Sexual Dysfunctions

Genito-Pelvic Pain/ Penetration Disorder-

NEW!!

Replaces Vaginismus and Dyspareunia

Sexual Aversion Disorder Removed
Copyright 2013 Chasity Norris
Gender Dysphoria

NEW!!

No longer associated with sexual dysfunction.

“strong desire to be the other gender”
replaces “repeatedly stated desire to be the
other gender” in children.
Copyright 2013 Chasity Norris
Disruptive, Impulse-Control, & Conduct
Disorders

NEW CHAPTER!!

Characterized by difficulties in behavioral and
emotional self-control.

Due to high co-morbidity, antisocial
personality disorder is listed here and in
personality disorder chapter.
Copyright 2013 Chasity Norris

Includes:

Oppositional Defiant Disorder

Conduct Disorder (limited pro-social
emotions”)

Intermittent Explosive Disorder
Copyright 2013 Chasity Norris
Substance-Related & Addictive Disorders

NEW Disorder!!

Gambling Disorder

Substance Abuse and Substance Dependence
Disorders now combined into “Substance Use
Disorder”

Cannabis Withdrawal & Caffeine Withdrawal also
added!
Copyright 2013 Chasity Norris
Neurocognitive Disorders

Delirium now all listed together instead of
being 5 different diagnoses.

Dementia and Amnestic Disorders now
combined into “Major and Mild
Neurocognitive Disorders”
Copyright 2013 Chasity Norris
Personality Disorders (Section II)

Updates in terminology

Added “Personality Change Due to
Another Medical Condition”

Now listed alongside other mental disorders
rather than separately
Copyright 2013 Chasity Norris
PD (Section III)

Replaces NOS with Personality DisorderTrait Specified (PD-TS)

Provides more specific, individual diagnosis
Copyright 2013 Chasity Norris


Criterion A
-Level of personality functioning

Shows disturbances of self (identity), and interpersonal functioning (empathy &
intimacy)

Criterion B
-one or more pathological personality traits











Criterion C
-inflexibility and pervasiveness of impairment and traits.
Criterion D:
-Stability of impairment and traits
Criterion E:
-not better accounted for by another mental disorder
Criterion F:
-Not due to the effects of a substance
Criterion G:
- not normal for their developmental
stage or socioculurall environment.
Copyright 2013 Chasity Norris
Paraphilias and Paraphilic Disorders

Distinction made between the two

Paraphilic Disorders causing “marked
distress and impairment”.
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris
Controversy
Copyright 2013 Chasity Norris
What Should You Know if You’re a Social
Worker?

No social workers were formally invited to
participate in the Task Force or Work
Groups for the fifth edition of the DSM!!

This is not a recent occurrence

There was only one social worker on the
Task Force for the DSM-IV-TR.
Copyright 2013 Chasity Norris
Bibliography

Diagnostic and statistical manual of mental
disorders: DSM-5. (5th ed.). (2013).
Washington, D.C.: American Psychiatric
Association.

Diagnostic and statistical manual of mental
disorders: DSM-IV-TR. (4th ed.). (2000).
Washington, DC: American Psychiatric
Association.
Copyright 2013 Chasity Norris
Copyright 2013 Chasity Norris