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8/5/2013
Understanding the DSM-5
General Themes and Criteria for
the New Diagnostics
Brandy Hall, MA, LPC
S. David Hall, PsyD, LMFT, LPC
www.narrativeinstitute.org
Who We Are
• S. David Hall, PsyD, LMFT, LPC
• Dr. David Hall the director of the Narrative
Institute and is a licensed marital and family
therapist and a licensed professional
counselor in practice with Ebenezer
Counseling Services in Knoxville, TN.
Who We Are
• Brandy Hall, MA, LPC/MHSP
• Licensed professional counselor in
Tennessee, practicing with Ebenezer
Counseling Services in Knoxville, TN. She
also serves as one of the teaching faculty
with the Narrative Institute. Brandy’s clinical
and teaching interests include anxiety,
addiction, and the clinical diagnostic
process.
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The Narrative Institute
• Is an educational and training group that is
devoted to the study and application of
narrative theory and the craft of story in the
fields of psychotherapy, medicine, spiritual
care, education, entertainment, creative
expression, business, and personal
enrichment.
What we will not be
spending time on
• The history of DSM
• Minor controversies
• We are not going to review all DSM-5
diagnoses, only those with significant changes
between the DSM-IV-TR and the DSM-5
Important Dates
• Now Available: DSM-5 Diagnostic Criteria
Mobile App (came out July 22, 2013 for $70)
• December 31, 2013: Insurance companies are
expected to have transitioned
• April 2014: Examinations given by NBCC will
reflect changes
• October 1, 2014: Everyone is required to start
using the ICD-10-CM codes (the codes in
parentheses)
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The Importance of Language
• Language shapes the world (for good
and ill)
– The language we use to describe our clients
shapes how we think of them
– The language the client uses to describe
themselves shapes how they think of
themselves
– The language the client uses to describe the
problems they face shapes how they think of
their problems
The Importance of Language
• The language others use to describe the
client and their problems affects how they
see the client
• The labels, or diagnoses, we apply,
therefore, will mold how we think of our
clients, how they think of themselves, how
they think of their problems, and how the
world will see them as well.
The Importance of Language
• Potential clients who are afraid of certain diagnoses,
or more correctly, of seeing themselves or being seen
in a certain way, will often avoid seeking help whether
by avoiding coming in altogether or by masking their
true concerns even when they do come in.
• This is one of the main reasons behind many of the
name changes and new diagnostic names.
– Mental Retardation --> Intellectual Disorder
– Hypochondriasis --> Illness Anxiety Disorder
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The Purposes of
the DSM-5
For Clinicians & Researchers
• The idea that diagnosis means to “know
thoroughly”
– To allow professionals to have an agreed upon
basis of knowledge and understanding between
each other
– “Primarily designed to assist clinicians in
conducting clinical assessment, case formulation,
and treatment planning” (pg. 25, DSM-5).
– To help professionals conceptualize the client - to
understand the problem(s) and know how to treat
For Clinicians & Researchers
• Does the DSM help in “knowing thoroughly”
the disorders that we work with?
• The DSM does not provide treatment
guidelines for any disorder, only the
diagnostic criteria.
• The diagnostic guidelines set in the DSM are
also given to provide criteria for improved
research in mental disorders
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Insurance Reimbursement
• The APA expects that the insurance industry
will transition to the DSM-5 by December 31,
2013.
• Insurance utilizes the codes from DSM/ICD to
determine reimbursement
• In the past many insurance companies used
the mutliaxial format, while some did not, and
only used the codes.
Insurance Reimbursement
• The DSM Task Force has to take into consideration
that insurance companies will not reimburse for
conditions not included in the DSM/ICD.
– Discussed dropping Gender Identity Disorder, but there
was outcry from those who seek assistance from
insurance, so instead they changed the criteria some and
renamed it Gender Dysphoria
– The addition of Gambling Disorder under addictions
Judicial Proceedings
• Criminal responsibility - Use of the insanity
plea
• Involuntary commitment
• Competence to stand trial
• For more see page 25 of DSM-5
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Pharmaceutical Implications
• Ability to research, produce meds for classified
disorders only per FDA
• Controversy
– More on this later
Disability
• Workplaces are not allowed to discriminate
• Workplaces and schools have to allow for and provide
for certain accommodations
• The possibility to file for disability pay
– Regarding disability, “additional information is usually
required beyond that contained in the DSM-5 diagnosis,
which might include information about the individual’s
functional impairments and how these impairments affect the
particular abilities in question. It is precisely because
impairments, abilities, and disabilities vary widely within
each diagnostic category that assignment of a particular
diagnosis does not imply a specific level of impairment or
disability” (pg. 25, DSM-5).
Why the Update?
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To Stay Relevant with
Current Research
• Validity and Reliability
• The APA recognizes, “that past science was
not mature enough to yield fully validated
diagnoses - that is, to provide consistent,
strong, and objective scientific validators of
individual DSM disorders” (pg 5, DSM-5).
• This is still a concern. Research continues.
To Stay Relevant with
Current Research
• Even though reliability is generally viewed as
strong, diagnostic disagreement between
clinicians on a given case still is common due
to the overlap in symptoms between various
diagnoses.
• High comorbidity rates & high rates of using
NOS categories are evidence of this.
• More on this later.
To Stay Relevant Socially, Culturally,
and with Age and Gender
• Developmental age versus chronological age,
gender differences, and cultural variabilities of
norms
• Use of social media, online resources, and
mobile apps
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To Stay Relevant Socially, Culturally,
and with Age and Gender
• A variety of assessment measures for various
disorders, as well as the Cultural Formulation
Interview, that were used in the field trials are
available online at www.psychiatry.org/dsm5
• The DSM-5 is available as an online subscription at
www.psychiatryonline.org
• E-book
• DSM-5 Diagnostic Criteria Mobile App
To Make Money
• In order to meet the first point of staying
relevant with research, they really needed
more time. However, it is estimated that the
APA spent $20-$25 million on developing the
DSM-5, and they could not afford to delay any
longer as there are rumors that the APA was
already in debt millions of dollars, and they
needed to start generating more income.
(hence the higher price tag).
To Make Money
• APA intends, “to make future revision processes more
responsive to breakthroughs in research with
incremental updates until a new edition is required.
Since the research base of mental disorders is
evolving at different rates for different disorders,
diagnostic guidelines will not be tied to a static
publication date but rather to scientific advances.
These incremental updates will be identified with
decimals, i.e. DSM-5.1, DSM-5.2, etc., until a new
edition is required”
(http://www.dsm5.org/about/Pages/faq.aspx).
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To Make Money
• It is not clear at this point in what form the updates
will come or how often. It is likely these updates will
be released online, though they will probably also
have hard copies for sale as well as they did for the
previous Text Revisions.
• As you can imagine, this could possibly lead to
much confusion, and possibly more expense to
professionals.
To work better with the ICD System
• The ICD is the official system for the US, and all
World Health Organization Member States (over 100
countries) use it to report mortality and many for
morbidity rates.
• The ICD-9 codes are to be used until September
2014. The ICD-10 codes must be used starting
October 1, 2014.
To work better with the ICD System
• The DSM-5 contains both sets of codes. The
numerical codes we are already familiar with
are the ICD-9-CM codes. The codes in
parentheses, typically starting with an F or G in
Section II of the DSM-5 and typically starting
with a T or Z in Section III, are the ICD-10-CM
codes that we will all be implementing on
October 1, 2014.
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To work better with the ICD System
• The ICD-11 is currently being revised and is set to be
released in 2015. It will be used with electronic health
applications and information systems.
• See www.who.int/classifications/icd/en/ for more
information.
• The ICD and the DSM has sought over time to
become more congruent and use the same codes and
diagnostic criteria. They are currently classified as,
“compatible”, and able to be used as companions to
one another.
Controversies
&
Criticisms
Relationships with pharmaceutical
companies
• To what extent has this impacted the formulation of
the DSM? Does this effect its credibility?
• Much has been made of the ties that some of the
people on the DSM Task Force have with
pharmaceutical companies as 69% of the Task Force
members had direct industry ties. It should be noted
that 57% of DSM-IV Task Force members had ties to
pharmaceutical companies (Cosgrove & Krimsky,
2012).
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Relationships with pharmaceutical
companies
• The first drafts of the DSM-5 under-emphasized
the biopsychosocial model in favor of the “bio-biobio model”, as former APA President Steven
Sharfstein, MD called it, which leads to an
increasing, “pill and an appointment”, mentality.
– (http://psychnews.psychiatryonline.org/newsarticle.asp
x?articleid=109213)
• This over-emphasis has decreased some in the
final product, but notably more evident than in
DSM-IV-TR.
ICD vs DSM
• The difficulty and questionable necessity of
maintaining both classification systems of the
International Classification of Diseases (ICD) and
the DSM.
– The rest of the world uses the ICD system and it is the
officially sanctioned system by the US government as well.
– The DSM has to line up with the ICD codes for insurance
purposes.
– The ICD system contains the codes, but it does not contain
detailed diagnostic descriptions.
– The ICD is available online for free, whereas the DSM-5
costs $199
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ICD vs DSM
• Is it justifiable? Will the DSM be superseded by the
ICD?
• According to Dr. Geoffrey Reed, a WHO psychologist,
“There would still be a role for the DSM, because it
contains a lot of additional information that will never
be a part of the ICD. In the future, it may be viewed
as an important textbook of psychiatric diagnosis
rather than as the diagnostic ‘Bible’”.
(www.apa.org/monitor/2009/10/icd-dsm.aspx)
National Institute of Mental Health
(NIMH)
• Three weeks before the DSM-5 was released,
Thomas Insel, MD, Director of the NIMH, questioned
the DSM’s validity as it continues to focus on
symptomology, and he announced the launching of
the Research Domain Criteria (RDoC) project, “to
transform diagnosis by incorporating genetics,
imaging, cognitive science, and other levels of
information to lay the foundation for a new
classification system”
(http://www.nimh.nih.gov/about/director/2013/transformingdiagnosis.shtml)
National Institute of Mental Health
(NIMH)
• Insel has since confirmed that the NIMH, “has not
changed it’s position on DSM-5”, and states that,
“DSM-5 and RDoC represent complementary, not
competing, frameworks”, and even says that findings
from RDoC’s research may even be incorporated
into future revisions of the DSM.
(http://www.nimh.nih.gov/news/science-news/2013/dsm-5and-rdoc-shared-interests.shtml)
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Other Concerns
• Open Letter to the DSM-5:
– Published in October 2011, after the first draft of the DSM5 was released for public feedback.
– The authors raises numerous concerns over some of the
proposed changes. The concerns focused on adding
disorders with little to no empirical evidence, the
substantial emphasis on biological theory, the lowering of
diagnostic thresholds, and deemphasizing sociocultural
variation. http://www.ipetitions.com/petition/dsm5/
– Many of these critiques have impacted the DSM-5 greatly.
Summary
• Basically, NIMH and others criticizes DSM for not
being neuro-biologically based enough and calls for
more research to be done, while others criticize the
DSM for focusing too much on medico-physiological
theory without enough research to back it up while
decreasing focus on other types of empirical
knowledge such as psychological, social, cultural, etc.
• The DSM-5 Task Force has since sought to find a
balance between these two extremes while not
jumping ahead of validated research.
Changes To
Know About
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Structural Changes to the Layout
(Metastructure)
• The DSM Task Force has attempted to balance
between various critiques, which has lead to both
many of the structural changes that we do see in the
DSM-5 as well as the lack of some of the changes
we expected to see.
The Discontinuation of Using
Multiaxial Diagnosis
• The DSM-5 combines the first three axes into Section
II. All mental disorders, personality disorders,
intellectual disabilities, and other medical diagnoses
are seen as the primary diagnoses. When making
diagnoses, all disorders should be listed together.
• Part of why Axis II existed was to call attention to
disorders that needed more of a clinical and research
focus. However, the APA states that, “there is no
fundamental difference between disorders described
on DSM-IV’s Axis I and Axis II” (APA, Personality
Disorders Fact Sheet).
The Discontinuation of Using
Multiaxial Diagnosis
• Axis IV is replaced with the last chapter in Section II:
Other Conditions That May Be a Focus of Clinical
Attention, which includes an expanded list of V-codes
(and ICD-10, Z-codes) psychosocial and
environmental factors and other conditions or
problems that would affect treatment. These can be
reported to insurance or just noted in the client’s file.
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The Discontinuation of Using
Multiaxial Diagnosis
• Axis V, the Global Assessment of Functioning, or GAF
score was dropped. The GAF score was being used as
a standard to determine the need for treatment, and the
APA believes it does not convey adequate information to
that end.
• Instead of the single score, the APA recommends, “that
clinicians continue to assess the risk of suicidal and
homicidal behavior...and use available standardized
assessments for symptom severity, diagnostic severity,
and disability such as the measures in Section III of
DSM-5”, including the WHO’s Disability Assessment
Schedule (APA, Insurance Implications of DSM-5).
Moving Toward a
Dimensional Approach
• Categorical approach is dichotomous.
• “Because the previous DSM approach considered
each diagnosis as categorically separate from health
and other diagnoses, it did not capture the
widespread sharing of symptoms and risk factors
across many disorders that is apparent in studies of
comorbidity” (pg. 12, DSM-5).
• This led to high comorbidity rates and the heavy
reliance on NOS diagnoses.
Moving Toward a
Dimensional Approach
• The dimensional approach refers to a set of
continuums on which an individual can have various
levels of characteristics.
• All of the diagnoses listed in Section II are still
categorical.
• In Section III, we see how the DSM is headed toward
a dimensional approach in both the dimensional
assessments offered as well as the alternate model
for personality disorders.
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Moving Toward a
Dimensional Approach
• While the diagnoses in Section II are still categorical, “the
revised chapter organization signals how disorders may relate
to each other based on underlying vulnerabilities or symptom
characteristics. It also breaks out some disorders because of
greater understanding of their basic causes. As an example,
the previous single chapter on ‘Anxiety disorders, including
obsessive compulsive disorder and posttraumatic stress
disorder’ now is three sequential chapters detailing Anxiety
Disorders, Obsessive-Compulsive and Related Disorders, and
Trauma- and Stressor-Related Disorders. This move both
emphasizes the distinctiveness of the categories covered while
signaling their interconnectedness.” (www.psychiatry.org/dsm5,
American Psychiatric Association Releases DSM-5)
Moving Toward a
Dimensional Approach
• These chapters are arranged in clusters which
groups disorders together that relate to each other
the most in overlapping symptoms and potential
risk factors but divergent expressions
Clusters
– Neurodevelopmental Disorders
– Internalizing Disorders
– Somatic Disorders
– Externalizing Disorders
– Neurocognitive Disorders
– Personality Disorders
Full List of Clusters
• Neurodevelopmental Cluster
– Neurodevelopmental Disorders
– Schizophrenia Spectrum & Other Psychotic Disorders
• Internalizing Cluster
–
–
–
–
–
–
Bipolar & Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive & Related Disorders
Trauma- & Stressor-Related Disorders
Dissociative Disorders
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Full List of Clusters
• Somatic Cluster
–
–
–
–
–
–
Somatic Symptom & Related Disorders
Feeding & Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
• Externalizing Cluster
– Disruptive, Impulse-Control, & Conduct Disorders
– Substance-Related & Addictive Disorders
Full List of Clusters
• Neurocognitive Cluster
– Neurocognitive Disorders
• Personality Cluster
– Personality Disorders
• Other Cluster
– Paraphilia Disorders
– Other Mental Disorders
– Medication-Induced Movement Disorders and Other
Adverse Effects of Medication
– Other Conditions That May Be a Focus of Clinical Attention
Conditions for Further Study
Lifespan Approach
• The chapter in DSM-IV-TR, Disorders Usually First
Diagnosed in Infancy, Childhood, or Adolescence
has been eliminated in favor of placing these
disorders in the chapters that they relate to most in
symptomology.
• Research showed that some of these disorders last
into adulthood, but were being missed due to the
assumption that they were childhood disorders. (e.g.,
ADHD, Pica)
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Lifespan Approach
• Some disorders can be precursors for other
related disorders.
– e.g., Individuals with Separation Anxiety Disorder
tend to develop other anxiety disorders later in life if
left untreated
• Many of the chapters are internally, “arranged
developmentally, with disorders sequenced
according to the typical age of onset.” (DSM-5,
pg. 189)
Diagnostic
Changes
Definition of Mental Disorder: DSM-IV
• DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR all used the same
definition: “A clinically significant behavioral or psychological
syndrome or pattern that occurs in an individual and that is
associated with present distress (e.g., a painful symptom) or
disability (i.e., impairment in one or more areas of functioning) or
with a significantly increased risk of suffering death, pain,
disability, or an important loss of freedom. In addition, this
syndrome or pattern must not be merely an expectable and
culturally sanctioned response to a particular event, for example,
the death of a loved one. Whatever the original cause, it must
currently be considered a manifestation of a behavioral,
psychological, or biological dysfunction. Neither deviant behavior
(e.g. political, religious, or sexual) and conflicts that are primarily
between the individual and society are mental disorders unless the
deviance or conflict results from a dysfunction in the individual, as
described above.”
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Definition of Mental Disorder: DSM-5
• DSM-5: “A syndrome characterized by clinically significant
disturbance in an individual’s cognition, emotional
regulation, or behavior that reflects a dysfunction in the
psychological, biological, or developmental processes
underlying mental functioning. Mental disorders are
usually associated with significant distress or disability in
social, occupational, or other important activities. An
expectable or culturally approved response to a common
stressor or loss, such as the death of a loved one, is not a
mental disorder. Socially deviant behaviors (e.g., political,
religious, or sexual) and conflicts that are primarily
between the individual and society are not mental
disorders unless the deviance or conflict results from a
dysfunction in the individual, as described above.”
General Changes
• The DSM-5 replaces the NOS categories with
two options: other specified disorder and
unspecified disorder to enhance diagnostic
specificity to the clinician.
• 799.9 Diagnosis or Condition Deferred has
been dropped, though the provisional specifier
is still available.
General Changes
• Some cultural concepts have been integrated into various
“Other Specified” diagnoses.
– e.g.,- Shubo-kyofu, Koro, & Jikoshu-kyofo are some of the options
listed under Other Specified Obsessive-Compulsive and Related
Disorder.
• Some of the disorders and subtypes share the same
diagnostic code because DSM codes are now completely
compatible with ICD codes, and therefore new codes could
not be created for billing purposes.
– e.g., Hoarding Disorder and Obsessive-Compulsive Disorder share
300.3 (F42). However, the name of the diagnosis should always be
recorded in the medical record, not only the code.
• Some of the names of DSM-5 disorders are different than
names used in the ICD system. Again, this is due to the
necessity of lining up the codes with the ICD system.
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DSM-5 Disorder
DSM5/ICD-9CM Code
ICD-9-CM Title
DSM5/ICD-10CM Code
ICD-10-CM Title
Social (pragmatic)
communication disorder
315.39
Other developmental
speech or language
disorder
F80.89
Other developmental
disorders of speech and
language
Disruptive mood
dysregulation disorder
296.99
Other specified episodic
mood disorder
F34.8
Other persistent mood
[affective] disorders
Premenstrual dysphoric
disorder
625.4
Premenstrual tension
syndromes
N94.3
Premenstrual tension
syndrome
Hoarding disorder
300.3
Obsessive- compulsive
disorders
F42
Obsessive- compulsive
disorder
Other specified obsessive 300.3
compulsive and related
disorder
Obsessive- compulsive
disorders
F42
Obsessive- compulsive
disorder
Unspecified obsessive
compulsive and related
disorder
Obsessive- compulsive
disorders
F42
Obsessive- compulsive
disorder
Excoriation (skin picking) 698.4
disorder
Dermatitis factitia
[artefacta]
L98.1
Factitial dermatitis
Binge eating disorder
Bulimia nervosa
F50.8
Other eating disorders
300.3
307.51
Coding Mistakes in DSM-5
• In their rush in getting the DSM-5
released, the APA had several coding
mistakes. Code mistakes and corrections
can be found at
http://www.dsm5.org/Documents/IMPORTANT%20CODI
NG%20CORRECTIONS%20FOR%20DSM-5%207-1513.pdf
Coding Corrections for DSM-5 and DSM-5 Desk Reference
– Updated 6/20/13
Name of
Disorder
Incorrectly
Listed As
Corrected Code
IN DSM-5:
Corrections
should be made
on the following
pages:
IN DSM-5 DESK
REFERENCE:
Corrections
should be made
on the following
pages:
Intellectual Disability
(Intellectual
Developmental
Disorder)
319 (70) Mild
319 (71) Moderate
319 (72) Severe
319 (73) Profound
317 (70) Mild
318.0 (71) Moderate
318.1 (72) Severe
318.2 (73) Profound
xiii, 33, 848, 872
(also delete coding
note on page 33)
ix, 18
(also delete coding
note on page 18)
Selective Mutism
312.23 (F94.0)
313.23 (F94.0)
xviii, 195, 859, 871
xvii, 116
Trichotillomania
(Hair-Pulling
Disorder)
312.39 (F63.2)
312.39 (F63.3)
xix, 251, 861, 890
xviii, 133
Conduct Disorder,
Adolescent Onset
Type
312.32 (F91.2)
312.82 (F91.2)
xxiv, 846, 871
xxv
Kleptomania
312.32 (F63.3)
312.32 (F63.2)
xxiv, 478, 848, 890
xxvi, 225
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DSM-5 Disorders
Clusters/Groups
• Neurodevelopmental Cluster
– Neurodevelopmental Disorders
– Schizophrenia Spectrum & Other Psychotic Disorders
•
•
•
•
•
•
Internalizing Cluster
Somatic Cluster
Externalizing Cluster
Neurocognitive Cluster
Personality Cluster
Other Cluster
Neurodevelopmental Disorders
• Intellectual Disabilities
–Intellectual Disability (Intellectual
Developmental Disorder)
–Global Developmental Delay
–Unspecified Intellectual Disability
(Intellectual Developmental Disorder)
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Neurodevelopmental Disorders
• Intellectual Disability (Intellectual
Developmental Disorder)
• A federal statute (Public Law 111-256, Rosa’s
Law) replaces the term “mental retardation” with
“intellectual disability”, which is reflected in the
DSM-5.
• The term Intellectual Developmental Disorder
will be used in the ICD-11
Neurodevelopmental Disorders
• Intellectual Disability (Intellectual
Developmental Disorder)
– Emphasis is placed in the wording on intellectual
and adaptive functioning deficits, and changes the
severity specifiers to the basis of adaptive
functioning rather than IQ scores since adaptive
functioning determines the level of support required.
See pages 34-36 for information to determine
severity level.
– The ICD-9 coding is inaccurate in both the DSM-5
and the Desk Reference. Coding is done by
specifier: 317 Mild, 318.0 Moderate, 318.1 Severe,
318.2 Profound
Neurodevelopmental Disorders
• Communication Disorders
– Language Disorder
• A combination of DSM-IV’s Expressive and Mixed
Receptive-Expressive Language Disorders
– Speech Sound Disorder
• Previously Phonological Disorder, changed to reflect the
understanding that the etiology of the disorder may be
from difficulty with phonological knowledge or with the
ability to coordinate movements for speech.
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Neurodevelopmental Disorders
• Communication Disorders
• Childhood-Onset Fluency Disorder
(Stuttering)
– Criteria are mostly unchanged except:
• Criteria A deletes interjections as an option
• Criteria B adds anxiety about the disturbance as an
option if other limitations are not present
• There is an additional criteria that the onset be in
childhood as Adult-Onset Fluency Disorder has a
separate diagnosis code.
Neurodevelopmental Disorders
• Social (Pragmatic) Communication Disorder
• New diagnosis
• SCD is characterized by a persistent difficulty in
the social use of verbal and nonverbal
communication that cannot be explained by low
cognitive ability.
• Symptoms include difficulty in the acquisition
and use of spoken and written language as well
as problems with inappropriate responses in
conversation that result in functional limitations.
Neurodevelopmental Disorders
• Autism Spectrum Disorder
– Research supports the combination of four separate
disorders from the DSM-IV, Autistic Disorder
(Autism), Asperger’s Disorder, Childhood
Disintegrative Disorder, and Pervasive
Developmental Disorder NOS, into a continuum of
symptom severity.
– ASD requires both deficits in social communication
and social interaction and restricted repetitive
behaviors, interests, and activities (RRBs)
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Neurodevelopmental Disorders
• Autism Spectrum Disorder
– 3 Levels of Severity: (see table on pg. 52)
• Level 1: Requiring support
• Level 2: Requiring substantial support
• Level 3: Requiring very substantial support
– Note: Anyone with an established DSM-IV
diagnosis of Autism, Asperger’s, or PDD NOS
should be given the diagnosis of ASD for
continuity of care.
• Rett’s Disorder has been dropped as it is now
understood to be a neurogenetic disorder with
specific etiology.
Neurodevelopmental Disorders
• Attention Deficit Hyperactivity Disorder (ADHD)
– Research has shown that ADHD symptoms can
often hold steady through adulthood, and so DSM-5
seeks to enable adults to receive care.
– The symptoms have not changed, but they have
included examples to help clinicians identify the
symptoms in clients of all ages.
– Children still need to exhibit at least 6 symptoms,
but older adolescents and adults only need 5.
– Also, several symptoms must have been present
before age 12, which was changed from age 7 in
DSM-IV.
Neurodevelopmental Disorders
• Specific Learning Disorder
• Because various learning deficits commonly cooccur, the DSM-5 has combined Reading
Disorder, Disorder of Written Expression, and
Mathematics Disorder, though they still have
separate diagnosis codes.
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Neurodevelopmental Disorders
• Motor Disorders
• No substantial changes in this category, though
criteria in stereotypic movement disorder
differentiates from body-focused repetitive
behavior disorders in the chapter on obsessivecompulsive and related disorders.
Schizophrenia Spectrum & Other Psychotic Disorders
• Schizophrenia
– Regarding symptomatic changes to schizophrenia, the
special attribution of bizarre delusions and Schneiderian
first-rank auditory hallucinations (multiple voices
conversing with one another) was eliminated. The
special attribution of these two symptoms in the DSM-IV
meant that the manifestation of only one of the
symptoms was sufficient in and diagnosis of
schizophrenia.
– The symptom threshold has been raised from 1 to 2
specific symptoms exhibited to qualify for diagnosis,
including the requirement of the symptom of delusions,
hallucinations, or disorganized speech
Schizophrenia Spectrum & Other Psychotic Disorders
• Schizophrenia
– The DSM-5 has also done away with the subtypes
of schizophrenia as research showed that these
were too labile and/or too commonly overlapped
with other subtypes. Certain subtypes are now
descriptive specifiers and can be applied to other
disorders such as schizoaffective disorder, major
depressive disorder, and bipolar disorder.
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Schizophrenia Spectrum & Other Psychotic Disorders
• Schizoaffective Disorder
• The changes regarding schizoaffective disorder
involve a more stringent criterion that a major
mood episode needs to be present for the
majority of the time that schizophrenic
symptoms are also being exhibited.
• The desire was to make schizoaffective
disorder more of a longitudinal diagnosis rather
than an episodic one.
Schizophrenia Spectrum & Other Psychotic Disorders
• Delusional Disorder
• The criterion that delusions be “non-bizarre” has
been removed with the updates to the DSM-5, with
an added specifier for bizarre type delusions.
• Explicit demarcation has also been added to
exclude overlap with psychotic variants of
obsessive-compulsive disorder and/or body
dysmorphic disorder. If symptoms are better
explained by either OCD or BDD then those
diagnoses are to be used.
Schizophrenia Spectrum & Other Psychotic Disorders
• Delusional Disorder
• Shared delusional disorder is no longer
separated from delusional disorder in DSM-5, if
shared delusions are present but the criteria for
delusional disorder is not, the diagnosis should
be “other specified schizophrenia spectrum and
other psychotic disorder.”
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Schizophrenia Spectrum & Other Psychotic Disorders
• Catatonia
• Criteria for this diagnosis is standardized across
all disorders; whether it be depressive, bipolar,
psychotic, medical, or unidentified. All contexts
require three symptoms (up from the one or two
symptoms) out of 12 in order to meet diagnosis
for catatonia.
• Catatonia may be used as a separate diagnosis
or as a specifier within psychotic, bipolar, or
depressive disorders.
Clusters/Groups
• Neurodevelopmental Cluster
• Internalizing Cluster
•
•
•
•
•
– Bipolar & Related Disorders
– Depressive Disorders
– Anxiety Disorders
– Obsessive-Compulsive & Related Disorders
– Trauma- & Stressor-Related Disorders
– Dissociative Disorders
Somatic Cluster
Externalizing Cluster
Neurocognitive Cluster
Personality Cluster
Other Cluster
Bipolar & Related Disorders
• Bipolar Disorders
– The criteria for bipolar episodes, whether manic or
hypomanic, now focus on changes in both activity
and energy level as opposed to just mood.
– The diagnosis of bipolar I disorder, mixed episode,
has been removed from the DSM-5 and replaced
with the specifier “with mixed features.” This new
specifier may be used with either bipolar I or bipolar
II.
– A new specifier of “anxiety distress” has been
added to delineate anxiety symptoms manifested
along with the bipolar symptoms.
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Depressive Disorders
• New depressive disorders such as “disruptive mood
dysregulation disorder” and “premenstrual dysphoric
disorder” have been added to the DSM-5. Disruptive
mood dysregulation disorder is intended for children
up to the age of 18 years who exhibit many symptoms
that were previously categorized as bipolar disorder.
The results of significant research has led to
“premenstrual dysphoric disorder” being classified in
the main body of the DSM-5 (whereas in the DSM-IV it
was included in appendix B as a diagnosis for “further
study”)
Depressive Disorders
• Major Depressive Disorder
– The main diagnostic criterion for major depressive disorder
remains unchanged in the DSM-5. The cooccurrence of
manic symptoms which are insufficient for a diagnosis of a
manic episode now fall under the specifier of “with mixed
features.”
– The exclusion of bereavement has been removed from the
DSM-5. This was done as research showed that the loss of
a loved one often precipitated a major depressive episode
and because bereavement related depression symptoms
responded the same to medication and psychological
treatments which are shown to be efficacious in the
treatment of non-bereavement related depression.
– See section 3 for persistent complex bereavement disorder
Depressive Disorders
• Persistent Depressive Disorder
• This is disorder is a merger of both chronic major
depressive disorder and dysthymic disorder.
• The merger came out of the lack of scientifically
significant findings regarding differences between the
two previously separate diagnoses.
• You would not give a the diagnoses of major
depressive disorder and persistent depressive
disorder at the same time.
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Anxiety Disorders
• Changes to the anxiety disorders chapter of the
DSM-5 include the removal of obsessivecompulsive disorder, posttraumatic stress
disorder, and acute stress disorder; which of all
been placed in different chapters related
specifically to obsessive-compulsive and
trauma-stressor disorders.
Anxiety Disorders
• Agoraphobia, Specific Phobia, Social Anxiety
Disorder
• Changes to the phobic disorders include the removal
of the requirement that an individual over 18
recognizes that their anxiety is excessive or
unreasonable, and instead simply qualifies that the
anxiety is out of proportion to the actual threat or
danger of the situation. Also, the requirement that the
phobic features be present for six months duration
now applied to individuals all ages as opposed to
simply individuals under the age of 18
Anxiety Disorders
• Panic attack
• The main diagnostic structure of panic attacks remains
the same. However, the descriptions of the different
types of panic attacks have been simplified to
“unexpected” or “expected” panic attacks. As panic
attacks were seen as an indicator for the severity of
many diagnoses, “with panic attacks” can be listed as
a specifier with all DSM-5 diagnosis.
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Anxiety Disorders
• Panic Disorder and Agoraphobia
• The previous connection of panic disorder and
agoraphobia from the DSM-IV is done away with in the
DSM-5, with panic disorder and agoraphobia being
two completely separate diagnoses.
• In instances where there is cooccurrence of panic
disorder and agoraphobia they are coded as two
separate diagnoses.
• Agoraphobia now requires the presence of two or
more situations causing fear, this to help distinguish
agoraphobia from other specific phobias.
Anxiety Disorders
• Specific Phobias
• The only change to the diagnostic criteria for specific
phobias is that insight and/or belief in the
excessiveness or unreasonableness of the phobic fear
is no longer required for individuals over 18 years old
to receive the diagnosis.
Anxiety Disorders
• Social anxiety disorder (social phobia)
• Like specific phobias, individuals over the age of 18
are not now required to recognize the excessiveness
or unreasonableness of their fear in order to be
diagnosed. 2 diagnostic specifiers added to social
anxiety disorder are “generalized” and “performance
only.” This change was done as research had shown
that those who experience social anxiety only in the
context of performance situations, such as public
speaking, represented a distinct subgroup in terms of
both etiology and treatment.
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Anxiety Disorders
• Separation Anxiety Disorder
• This disorder has been moved from the section of
“disorders usually first diagnosed in infancy,
childhood, or adolescence” and is now classified in the
“anxiety disorder” section.
• The disorder may now be diagnosed even if the onset
has been shown after the age of 18.
• An addition to the criterion is that the anxiety must be
present for 6 months or more.
Anxiety Disorders
• Selective Mutism
• Like separation anxiety disorder, this disorder has
been moved from the section of “disorders usually first
diagnosed in infancy, childhood, or adolescence” and
is now classified in the “anxiety disorder” section as
research has shown that anxiety is a major feature of
individuals with selective mutism.
Obsessive-Compulsive
& Related Disorders
• This chapter on obsessive-compulsive and related disorders is
new to the DSM-5. “Because recent studies have shown that
obsessive-compulsive disorder involves distinct neurocircuits, it
and several related disorders constitute their own chapter
instead of being addressed in the chapter on anxiety disorders”
(The Organization of DSM-5).
• Disorders in this section include the DSM-IV diagnoses of
obsessive-compulsive disorder, body dysmorphic disorder, and
trichotillomania (hair-pulling disorder); as well as new disorders
including excoriation (skin-picking) disorder, hoarding disorder,
substance-/medication-induced obsessive-compulsive and
related disorder and obsessive-compulsive and related disorder
due to another medical condition.
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Obsessive-Compulsive & Related Disorders
• New specifiers for obsessive-compulsive and related
disorders
• The three specifiers of “good or fair insight,” “poor insight, “ and
“absent insight/delusional” are given for use in obsessivecompulsive disorder with analogous specifiers also added to
body dysmorphic disorder and hoarding disorder. The “absent
insight/delusional” specifier now allows individuals who meet
the criteria to be diagnosed with a obsessive-compulsive or
related disorder rather than a schizophrenia spectrum disorder.
• An added “tic-related” specifier for obsessive-compulsive
disorder has also been added due to growing research showing
the comorbidity between obsessive-compulsive disorder and a
tic disorder and how this might have relevance in the clinical
situation.
Obsessive-Compulsive & Related Disorders
• Body Dysmorphic Disorder
• Relevant to the reclassification of body dysmorphic disorder
from a somatic disorder into the new section of obsessivecompulsive and related disorders, the new criterion for body
dysmorphic disorder involves the patient engaging in repetitive
behaviors or mental acts in response to their preoccupation
with perceived defects or flaws in their physical appearance.
• A new specifier of “with muscle dysmorphia” has also been
added to reflect growing research regarding the particulars of
those whose fixation is related to their muscles.
• The specifier of “absent insight/delusional” with body
dysmorphic disorder is now to be utilize with those presenting
with the delusional variant of body dysmorphic disorder as
opposed to the DSM-IV duel-diagnosis of delusional disorder,
somatic type, and body dysmorphic disorder.
Obsessive-Compulsive & Related Disorders
• Hoarding Disorder
• This represents a new diagnosis for the DSM-5 that is seen as
related to obsessive-compulsive disorder but has been shown
by the available data not to be a variant of OCD or any other
mental disorder.
• This diagnosis involves the patient presenting with persistent
difficulty discarding or parting with possessions and noted
distress associated in discarding them.
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Obsessive-Compulsive & Related Disorders
• Trichotillomania (hair-pulling disorder)
• The parenthetical “hair-pulling disorder” is the only noted
change to trichotillomania beyond the categorization shift from
the DSM-IV to the DSM-5.
• Excoriation (skin-picking) Disorder
• Excoriation represents a new disorder in the DSM-5. It is
characterized by the recurrent urge to pick at one's own skin,
often to the point of causing dermatological damage.
Obsessive-Compulsive & Related Disorders
• Substance/medication-induced obsessive-compulsive and
related disorder and obsessive-compulsive and related
disorder due to another medical condition
• This new diagnosis replaces the DSM-IV diagnosis of “anxiety
disorder due to a general medical condition with obsessivecompulsive symptoms.” The diagnosis also replaces the DSMIV diagnosis of “substance-induced anxiety disorder” with the
“obsessive-compulsive symptoms” specifier.
Obsessive-Compulsive & Related Disorders
• Other specified and unspecified obsessive-compulsive and
related disorders
• Conditions under this category include “body-focused repetitive
behavior disorder,” “obsessional jealousy,” and “unspecified
obsessive-compulsive and related disorder.”
• Body-focused repetitive behavior disorder involves recurrent
body focused behaviors, other than hair pulling and skin
picking, (i.e., nail biting, etc.).
• Obsessional jealousy involves a preoccupation with perceived
infidelity of one's partner that does not qualify as delusional.
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Trauma- & Stressor-Related Disorders
• This new category allows for broader
qualification in traumatic experience in many of
the trauma-based diagnoses, with vicarious
experiences of stress and trauma now seen as
legitimate underlying causes for many of the
Trauma-& Stressor-Related Disorders.
Trauma- & Stressor-Related Disorders
• Posttraumatic Stress Disorder
• “Compared to DSM-IV, the diagnostic criteria for DSM-5 draw a
clearer line when detailing what constitutes a traumatic event.
Sexual assault is specifically included, for example, as is a
recurring exposure that could apply to police officers or first
responders. Language stipulating an individual’s response to
the event—intense fear, helplessness or horror, according to
DSM-IV—has been deleted because that criterion proved to
have no utility in predicting the onset of PTSD”
(http://www.dsm5.org/Documents/PTSD%20Fact%20Sheet.pdf)
• The DSM-5 attempts take into account behavioral symptoms
that manifest with PTSD. To this end, 4 diagnostic clusters of
re-experiencing, avoidance, negative cognitions and mood, and
arousal.
Trauma- & Stressor-Related Disorders
• Acute Stress Disorder
• An explicit qualification of the traumatic event experienced is
now required for the diagnosis of acute stress disorder; with the
qualifiers being that the event was experienced directly, was
witnessed, or was experienced indirectly.
• The DSM-IV criteria that “the person’s response involved
intense fear, helplessness, or horror” has been removed due to
the lack of supporting research in the diagnostic validity of that
requirement.
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Trauma- & Stressor-Related Disorders
• Adjustment Disorders
• The DSM-5 reclassified as just disorders in the context of
stress-response conditions occurring in reaction to distressing
events. This is a reconceptualization of the adjustment
disorders, which in the DSM-IV were used to diagnose
individuals exhibiting clinically significant symptoms without
meeting the criteria for a range of other disorders. The DSM-IV
subtypes of “depressed mood,” “anxiety,” and “disturbance in
conduct” have been retained in the DSM-5 without changes.
Trauma- & Stressor-Related Disorders
• Reactive attachment disorder
• The two subtypes of reactive attachment disorder, “emotionally
withdrawn/inhibited” and “indiscriminately social/disinhibited,”
that were found in the DSM-IV have been redefined as distinct
disorders in the DSM-5.
• Reactive attachment disorder now entails only the “emotionally
withdrawn/inhibited” subtype whereas the “indiscriminately
social/disinhibited” subtype fits into the new diagnosis of
“Disinhibited Social Engagement Disorder.”
• Both disorders are seeing as an outcome of social neglect and
healthy attachment.
• Yet reactive attachment disorder is seen as more closely
related to internalizing disorders, while disinhibited social
engagement disorder is more closely linked with ADHD and the
Neurodevelopmental cluster.
Dissociative Disorders
• Dissociative Identity Disorder
• The criteria for diagnosis of dissociative identity
disorder now allows for self-report, as well as
observance by others, as meeting criterion A for
diagnosis.
• Criterion B now allows for recurrent gaps in recall for
events that are not necessarily consider traumatic.
• There is also now a greater willingness to consider
certain possession-form phenomenon and
neurological symptoms in accounting for the diversity
of presentation in this disorder.
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Clusters/Groups
•
•
Neurodevelopmental Cluster
Internalizing Cluster
• Somatic Cluster
– Somatic Symptom & Related Disorders
– Feeding & Eating Disorders
– Elimination Disorders
– Sleep-Wake Disorders
– Sexual Dysfunctions
– Gender Dysphoria
•
•
•
•
Externalizing Cluster
Neurocognitive Cluster
Personality Cluster
Other Cluster
Somatic Symptom & Related Disorders
• What was known in the DSM-IV as somatoform
disorders are now called “somatic symptom and
related disorders” in the DSM-5. There is a reduction
of number and subcategories of these disorders in the
DSM-5 in order to decrease diagnostic overlap.
Somatic Symptom & Related Disorders
• Somatic Symptom Disorder
• This new disorder is designed to replace the DSM-IV
diagnosis of somatization disorder and
undifferentiated somatoform disorder, which is
problematic due to its high symptom count required for
diagnosis and its preclusion against the diagnosis of
another medical condition. The new diagnosis of
somatic symptom disorder is designed to diagnose
individuals maladaptive thoughts, feelings, and
behaviors with somatic symptoms that may or may not
be related to a known medical condition.
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Somatic Symptom & Related Disorders
• Somatic Symptom Disorder
• The significance placed on the requirement of
medically unexplained symptoms for many of the
somatoform disorders in the DSM-IV has been
lessened in the DSM-5 with the recognition that the
establishment of a diagnosis because of the absence
of an explanation was problematic and did not
recognize the reciprocal affects between psychological
and physiological stress that current research has
validated.
Somatic Symptom & Related Disorders
• Somatic Symptom Disorder
• The DSM-5 therefore focuses on diagnosis on the
basis of positive symptoms, whether somatic or
psychological in nature, and diminishes the
importance of positively proving the absence of a
medical explanation for the symptoms. The exception
to this is in conversion disorder or pseydocyesis
(phantom pregnancy) because in these cases it is
possible to demonstrate the lack of medical causation.
Somatic Symptom & Related Disorders
• Hypochondriasis and illness anxiety disorder
• The DSM-5 has removed hypochondriasis from its list
of disorders as connotation of the diagnosis was
perceived as pejorative. For individuals who would
have previously met diagnostic criteria for
hypochondriasis who experience both high health
anxiety and significant somatic symptoms, the
diagnosis should be somatic symptom disorder.
• For those individuals with high health anxiety without
somatic symptoms, the new diagnosis of “illness
anxiety disorder” is most appropriate when a primary
anxiety disorder does not provide better explanation.
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Somatic Symptom & Related Disorders
• Pain Disorder
• The growing body of research which has
demonstrated major psychological factors in all
experienced forms of pain has influenced the
restructuring of pain disorder in the DSM-5. The DSMIV subcategories of pain associated solely with
psychological factors, pain associated with medical
diseases or injuries, and pain associated with both has
been eliminated due to the poor reliability and validity
between these subcategories.
Somatic Symptom & Related Disorders
• Psychological Factors Affecting Other Medical
Conditions
• This was included in the DSM-IV under Other
Conditions That May Be a Focus of Clinical Attention,
but was made a mental disorder in the DSM-5 in part
because of its common utilization in insurance billing
Somatic Symptom & Related Disorders
• Factitious Disorder & Factitious Disorder Imposed
on Another
• Previously had their own chapter, but subsumed under
this chapter as they commonly occur in medical
settings.
• Factitious Disorder Imposed on Another has been
taken out of the NOS shadow, and the name clarified
(from Factitious Disorder By Proxy).
• Criteria for both are slightly altered (see pgs. 324325).
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Somatic Symptom & Related Disorders
• Conversion Disorder (functional neurological
symptom disorder)
• Criteria for conversion disorder has changed to
emphasize the lack of evidence of psychologically
causal factors at the time of diagnosis and reemphasizes the importance of neurological
examination in excluding diagnosable neurological
impairment as causal for the dysfunction.
Feeding & Eating Disorders
• Pica and Rumination Disorder
• the age restrictions found in the DSM-IV for both Pica
and Rumination disorder have been removed so now
the diagnosis may be made for individuals regardless
of age.
• Avoidant/Restrictive Food Intake Disorder
• The diagnosis was previously known as feeding
disorder of infancy or early childhood. Along with the
name change, the DSM-5 expands the diagnostic field
for this disorder to include adult individuals as well as
children and adolescents.
Feeding & Eating Disorders
• Anorexia Nervosa
• Most of the diagnostic criteria for anorexia nervosa
remains unchanged, though the requirement of
amenorrhea (absence of menstrual period) has been
completely eliminated as a requirement for the
disorder.
• Criterion B of the diagnosis is been expanded to
include persistent behavior that interferes with weight
gain as opposed to only overtly expressed fear of
weight gain.
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Feeding & Eating Disorders
• Bulimia Nervosa
• DSM-5 criteria for bulimia nervosa reduces the
required minimum of frequency of binge eating and
inappropriate compensatory behavior from the DSMIV requirement twice a week to only once a week.
Feeding & Eating Disorders
• Binge Eating Disorder
• As with bulimia nervosa, the diagnostic threshold for
binge eating disorder has been lowered from the
DSM-IV standard of binge eating twice weekly for 6
months to the new standard of once weekly over the
last 3 months. The major diagnostic difference
between bulimia nervosa and binge eating is that
binge eating does not involve the inappropriate
compensatory behavior in response to the binge
eating.
Elimination Disorders
• No major changes have been made to elimination
disorders in the DSM-5, except for their
reclassification into their own chapter instead of being
classified under disorders usually first diagnosed in
infancy, childhood, or adolescence as was the case in
the DSM-IV.
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Sleep-Wake Disorders
• Due to the research which has demonstrated the
interactive, and not necessarily causal, effects between
sleep disorders and comorbid medical and mental
disorders, the DSM-5 has removed the previous
diagnoses of “sleep disorders related to another mental
disorder” and “sleep disorder related to general medical
condition.”
• The differentiation between primary and secondary
insomnia is also reduced with both DSM-IV disorders now
falling under the new diagnosis of “insomnia disorder.”
• Hypersomnolence is now distinguished from narcolepsy,
as narcolepsy has been shown to be associated with
hypocretin deficiency.
Sexual Dysfunctions
• Genito-Pelvic Pain/Penetration Disorder
• This new disorder replaces the previous DSM-IV
diagnoses of vaginismus and dyspareunia, which had
high symptom overlap and comorbidity.
• Sexual Aversion Disorder
• This diagnosis is been removed from the DSM-5 due
to the lack of supporting research and underuse
diagnostically by clinicians.
Gender Dysphoria
• Gender dysphoria represents a new section in the
DSM-5 and reflects the different conceptualization of
“gender congruence” as not helpfully related to sexual
dysfunctions and paraphilias, which was were the
DSM-IV’s diagnosis of gender identity disorder was
categorized.
• The new diagnostic conceptualization focuses more
on the wording of “gender incongruence” rather than
cross-gender identification. This is an
acknowledgment of the wide variety of gender
incongruent variances individuals may have.
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Gender Dysphoria
• In children, the criteria of a “strong desire to be the
other gender” replaces “repeatedly stated desire to be
the other gender” which recognizes that in certain
environments children may not verbalize their desire
to be a different gender.
• A specifier of “posttransition” has been added to
gender dysphoria those individuals who are still
pursuing various treatments related to living as their
desired gender, though they may not still need the
initial diagnostic criteria for gender dysphoria.
Clusters/Groups
• Neurodevelopmental Cluster
• Internalizing Cluster
• Somatic Cluster
• Externalizing Cluster
– Disruptive, Impulse-Control, & Conduct
Disorders
– Substance-Related & Addictive Disorders
• Neurocognitive Cluster
• Personality Cluster
• Other Cluster
Disruptive, Impulse-Control,
& Conduct Disorders
• This is a new chapter in the DSM-5 incorporates
disorders that were previously found in the chapter
“disorders usually first diagnosed in infancy,
childhood, or adolescence.” The main distinction of
these disorders is that they are characterized by
difficulties in behavioral and emotional self-control.
Because of its comorbidity with some of these
disorders in later development, antisocial personality
disorder is listed both in this chapter as well as in the
chapter on personality disorders.
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Disruptive, Impulse-Control,
& Conduct Disorders
• Oppositional Defiant Disorder
• 4 modifications of note have been made to oppositional defiant
disorder. Firstly, symptoms are now grouped around the three
types of “angry/irritable mood,” “argumentative/defiant
behavior,” and “vindictiveness.” This refinement has been done
to better encapsulate what is seen as both the emotional and
behavioral elements of this disorder. Secondly, the exclusion
criterion related to conduct disorder has been eliminated.
Thirdly, a guide regarding frequency has been added in order to
avoid overdiagnosis for defiant behavior that is considered
developmentally normative in children and adolescents. And
finally a severity rating has been added related to the
pervasiveness of the contexts of symptoms.
Disruptive, Impulse-Control,
& Conduct Disorders
• Conduct Disorder
• Mostly unchanged from the DSM-IV, though the
specifier has been added for individuals who also
display with “limited pro-social emotions” as this has
been shown as an indicator of severity in the disorder.
Disruptive, Impulse-Control,
& Conduct Disorders
• Intermittent Explosive Disorder
• The DSM-5 has expanded to include verbal and
nondestructive aggression as meeting diagnostic
criteria, whereas the DSM-IV required physical
aggression. In order to avoid overdiagnosis for temper
tantrums immune children which are considered
developmentally normative, a minimum of six years of
age, or the developmental equivalent, is now required.
The outbursts also have to be deemed to be driven by
impulsivity and/or anger, and cause marked distress
and impairment, in order to qualify for diagnosis.
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Substance-Related
& Addictive Disorders
• Gambling Disorder
• In including gambling disorder, the DSM-5
incorporated, for the first time, a process/behavioral
addiction which is not directly related to substance
use. Though other process/behavioral addictions were
considered for inclusion in the DSM-5 (notably sex
addiction), gambling disorder was the only nonsubstance addiction considered to be empirically
supported enough for inclusion at this point.
Substance-Related
& Addictive Disorders
• Substance Use Disorder
– The previously independent diagnoses of substance abuse
and substance dependence have been merged in the DSM5 into substance use disorder. Previous DSM-IV diagnostic
requirements for recurrent legal problems have been
eliminated out of the DSM-5 requirements. Added have been
criterion for “creating or a strong desire were urged to use
the substance.” The combination of the two previous
disorders the diagnostic threshold has been increased to
meeting two or more criteria rather than one or more as was
the case in the DSM-IV.
• Cannabis Withdrawal and Caffeine Withdrawal are
new diagnoses in the DSM-5.
Clusters/Groups
•
•
•
•
Neurodevelopmental Cluster
Internalizing Cluster
Somatic Cluster
Externalizing Cluster
• Neurocognitive Cluster
• Neurocognitive Disorders
• Personality Cluster
• Other Cluster
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Neurocognitive Disorders (NCDs)
• The disorders listed in this chapter were previously
under the DSM-IV chapter “Delirium, Dementia, and
Amnestic and Other Cognitive Disorders”
• Delirium
• Previously Delirium was broken into 5 different
diagnoses, but in the DSM-5 all of them are listed
together with clarified criteria along with different
specifiers and coding notes to identify the etiology of
the condition.
Neurocognitive Disorders (NCDs)
• Major and Mild Neurocognitive Disorders
– Combines DSM-IV diagnoses of Dementia and
Amnestic Disorder.
– The term “dementia” may still be used when appropriate
and necessary, but not all Major and Mild NCDs will
apply.
– Mild NCDs are included to allow for early detection and
treatment of the cognitive issues that go beyond normal
aging in order to hopefully slow and possibly even halt
progression.
– Note: severity specifiers in Major NCD address
difficulties with activities of daily living (ADL), not the
level of cognitive deficits.
Neurocognitive Disorders (NCDs)
• Major and Mild Neurocognitive Disorders
– A table is available on page 593 with updated
cognitive domains with examples of symptoms,
observations, and assessments.
– In addition to the already established criteria sets
for the etiological subtypes of alzheimer’s, vascular
disease, and substance/medication use; there are
new criteria sets for frontotemporal lobar
degeneration, lewy body disease, traumatic brain
injury, HIV infection, prion disease, parkinson’s
disease, huntington’s disease. NCDs due to
another medical condition, multiple etiologies, and
unspecified are also included.
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Clusters/Groups
•
•
•
•
•
Neurodevelopmental Cluster
Internalizing Cluster
Somatic Cluster
Externalizing Cluster
Neurocognitive Cluster
• Personality Cluster
• Personality Disorders
• Other Cluster
Personality Disorders
• Section II
– They have retained the categorical approach with the same
personality disorders with no change to criteria. (The reports
of its demise have been greatly exaggerated).
– The only changes are updates in terminology that reflects
changes to other diagnoses. (e.g., Schizoid PD includes an
exclusion that symptoms do not occur exclusively during
Autism Spectrum Disorder, as opposed to Pervasive
Developmental Disorder)
– There is the addition of Personality Change Due to Another
Medical Condition, and as it is throughout the DSM-5,
Personality Disorder NOS has been broken apart into Other
Specified and Unspecified Personality Disorder.
Personality Disorders
• Section II
– Since the multi-axial format has been eliminated, these
personality disorders are now to be listed alongside other
mental disorder rather than listed separately.
– There was much discussion about significantly changing the
methodology of how we conceptualize and diagnose
personality disorder, however, based on feedback, the APA
decided it was premature to overhaul this section at this
point.
– There is an alternate model available for use in Section III
which offers a hybrid methodology that incorporates both the
categorical and dimensional approaches.
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Personality Disorders
• Section III
– The APA wanted to introduce the model they had
developed in earlier drafts in order to allow
professionals the ability to start using the model now
with the hopes that they would become more familiar
with the model (so there would be less push-back in the
future), and also so clinicians and researchers can give
feedback on its utility.
– The hybrid model incorporates six of the familiar
personality disorders (antisocial, avoidant, borderline,
narcissistic, obsessive-compulsive, and schizotypal),
though the criteria for there have been redesigned in a
dimensional/trait approach.
Personality Disorders
• Section III
• The hybrid model replaces the NOS
designation with Personality Disorder-Trait
Specified (PD-TS) which will provide a more
informative diagnosis as it allows the clinician to
identify trait domains and facets that are
specific to the individual.
Criteria for a Personality Disorder in
the Hybrid Model- Section III
• Criterion A: Level of personality functioning
– Disturbances in self (identity and self-direction) and
interpersonal (empathy and intimacy) functioning
– Moderate or greater impairment
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Criteria for a Personality Disorder in
the Hybrid Model- Section III
• Criterion B: One or more pathological
personality traits
– Five broad domains (based on the Five Factor
Model)
1. Negative Affectivity (vs. Emotional Stability): emotional
lability, anxiousness, separation insecurity,
submissiveness, hostility, perseveration, depressivity,
suspiciousness, and restricted affectivity
2. Detachment (vs. Extraversion): withdrawal, intimacy
avoidance, anhedonia, depressivity, suspiciousness,
and restricted affectivity
Criteria for a Personality Disorder in
the Hybrid Model- Section III
• Criterion B: One or more pathological
personality traits
– Five broad domains (based on the Five Factor
Model)
3. Antagonism (vs. Agreeableness): manipulativeness,
deceitfulness, grandiosity, attention seeking,
callousness, and hostility
4. Disinhibition (vs. Conscientiousness): irresponsibility,
impulsivity, distractibility, risk taking, and rigid
perfectionism
5. Psychoticism (vs. Lucidity): unusual beliefs and
experiences, eccentricity, cognitive and perceptual
dysregulation.
Criteria for a Personality Disorder in
the Hybrid Model- Section III
• Criteria C:
– Inflexibility and pervasiveness of impairment and traits
• Criteria D:
– Stability of impairment and traits
• Criteria E:
– Not better accounted for by another mental disorder
• Criteria F:
– Not due to the effects of a substance or another medical
condition
• Criteria G:
– Not normal for their developmental stage or
sociocultural environment
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Level of Personality
Functioning Scale (see pg. 775-778)
• 0-4: 0 - Little or No Impairment, 1 - Some Impairment, 2 Moderate Impairment, 3 - Severe Impairment, 4 - Extreme
Impairment
• Must exhibit Moderate Impairment (Level 2) or above to
qualify for a Personality Disorder.
• This helps clinicians to be able to think about personality
traits in a continuum, which not only prevents overdiagnosis, but also aids case conceptualization for clients
who do not have a personality disorder.
An example of proposed diagnostic
criteria for Narcissistic PD
A. Moderate or greater impairment in personality
functioning, manifested by characteristic
difficulties in two or more of the following areas:
1. Identity: Excessive reference to others for self-definition
and self-esteem regulation; exaggerated self-appraisal
inflated or deflated, or vacillating between extremes;
emotional regulation mirrors fluctuations in self-esteem.
2. Self-direction: Goal setting based on gaining approval
from others; personal standards unreasonably high in order
to see oneself as exceptional, or too low based on a sense
of entitlement; often unaware of own motivations.
An example of proposed diagnostic
criteria for Narcissistic PD
A. Moderate or greater impairment in personality
functioning, manifested by characteristic
difficulties in two or more of the following areas:
3. Empathy: Impaired ability to recognize or identify with the
feelings and needs of others; excessively attuned to
reactions of others, but only if perceived as relevant to self;
over- or underestimate of own effect on others.
4. Intimacy: Relationships largely superficial and exist to
serve self-esteem regulation; mutually constrained by little
genuine interest in others’ experiences and predominance
of a need for personal gain.
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An example of proposed diagnostic
criteria for Narcissistic PD
B. Both of the following pathological personality
traits
1. Grandiosity (an aspect of Antagonism): Feelings of
entitlement, either overt or covert; self-centeredness; firmly
holding to the belief that one is better than others;
condescension toward others.
2. Attention seeking (an aspect of Antagonism): Excessive
attempts to attract and be the focus of the attention of
others; admiration seeking.
Criteria C - G are also met.
An example of proposed diagnostic
criteria for Narcissistic PD
• Specifiers: Other traits and personality functioning
specifiers may be used. For example, other traits of
Antagonism can be specified when more pervasive
antagonistic features (“malignant narcissism”) are present.
Other traits of Negative Affectivity can be specified to
record more “vulnerable” presentations. The level of
personality functioning (Level 2-4) can also be specified.
• Assessments for both adolescents and adults, as well as
an informant version, are available online that help
clinicians to identify specific traits in their clients. There
are also brief versions that identify problems in the five
domains.
Clusters/Groups
•
•
•
•
•
•
Neurodevelopmental Cluster
Internalizing Cluster
Somatic Cluster
Externalizing Cluster
Neurocognitive Cluster
Personality Cluster
• Other Cluster
– Paraphilia Disorders
– Other Mental Disorders
– Medication-Induced Movement Disorders and Other
Adverse Effects of Medication
– Other Conditions That May Be a Focus of Clinical
Attention Conditions for Further Study
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Paraphilia Disorders
• A distinction is drawn in the DSM-5 between
paraphilias and paraphilic disorders, with the
requirement for paraphilic disorders being that the
paraphilia causes “marked distress or impairment” or
entails harm to self or others. These changes were
done in order to avoid pathologizing consensual and
non-distressing sexual activity which meets the criteria
of paraphilia.
Other Mental Disorders
• This is the catch-all chapter that lists four
diagnoses:
– Other Specified Mental Disorder Due to Another
Medical Condition
– Unspecified Mental Disorder Due to Another
Medical Condition
– Other Specified Mental Disorder
– Unspecified Mental Disorder
Medication-Induced Movement
Disorders and Other Adverse Effects of
Medication
• These disorders were previously included in the
chapter for Other Conditions that May Be a
Focus of Clinical Attention
• Antidepressant Discontinuation Syndrome is a
notable addition
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Other Conditions That May Be a
Focus of Clinical Attention
• These are not mental disorders.
• These are conditions or problems that either are a
reason for the visit or otherwise affect the diagnosis,
course, prognosis, or treatment of the individual’s
mental disorder.
• These include codes from the ICD-9 (typically V
codes) and ICD-10 (usually Z codes).
• Some examples include Parent-Child Relational
Problem, Child Sexual Abuse, Homelessness,
Religious or Spiritual Problem, and Malingering.
DSM-5: Section III
A review what has not been
looked at already
Assessment Measures
• Cross-Cutting Symptom Measures
– “These 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.”
– Only Level 1 is included in the DSM-5. Level 2 and disorderspecific severity measures are only available online.
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Assessment Measures
• Clinician-Rated Dimensions of Psychosis
Symptom Severity
• This measures the presence and severity of 8
domains: hallucinations, delusions, disorganized
speech, abnormal psychomotor behavior, negative
symptoms (restrictive emotional expression or
avolition), impaired cognition, depression, and mania.
Assessment Measures
• World Health Organization Disability Assessment
Schedule 2.0 (WHODAS 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.”
– This is intended to replace the imprecise and uninformative
GAF Score
Assessment Measures
• All of these assessments are available online
http://www.psychiatry.org/practice/dsm/dsm5/onlineassessment-measures
• Other clinician-rated severity measures are available
online. These include: autism spectrum and social
communication disorders, somatic symptom disorder,
oppositional defiant disorder, conduct disorder, and
nonsuicidal self-injury.
• Also available online are personality inventories, early
development and home background forms, and the
cultural formulation interviews.
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Cultural Formulation Interview
• In order to obtain the most useful clinical information,
improve therapeutic rapport and efficacy, and to avoid
problems with stereotyping and misdiagnosis, the CFI
can be used with a client of any background.
• “The CFI follows a person-centered approach to
cultural assessment by eliciting information from the
individual about his or her own views and those of
others in his or her social network” (pg 751, DSM-5).
• This can be used with any client, regardless of cultural
background to aid the clinician in determining illness
severity or impairment, agreement on course of care,
and improving treatment compliance.
Alternative DSM-5 Model for
Personality Disorders
Reviewed in Personality Disorder Section of this Seminar
Conditions for Further Study
• These conditions are not to be used for clinical use at
this time. They are included to encourage further
research.
• As such, we will not be going into depth on these
conditions. In earlier drafts of the DSM-5 some of
these were included, which elicited a negative
response from some. Because of this, there has been
some confusion about their inclusion, so it is important
to mention these.
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Conditions for Further Study
• Attenuated Psychosis Syndrome
– This is seen by some as a prodrome for other psychotic or
mood disorders with psychotic features.
– However, there lacks sufficient evidence for the condition
developing into another disorder, and many feared that this
would lead to the overuse of antipsychotics for individuals in
whom they would do more harm than good.
• Depressive Episodes With Short-Duration
Hypomania
– The main difference between this and Bipolar II is the
hypomanic episode lasts 2-3 days as opposed to a minimum
of 4 days in Bipolar II.
Conditions for Further Study
• Persistent Complex Bereavement Disorder
– This is differentiated from normal grief by criteria that the
death had to have occurred a minimum of 12 months prior,
or 6 months for children, and by the presence of severe grief
reactions that interfere with the person’s ability to function.
• Caffeine Use Disorder
– Substance dependence due to caffeine is included in the
ICD-10
– One of the reasons it has not been included in Section II is
that the diagnostic threshold needs to be higher than that of
other substance use disorders to prevent overdiagnosis, and
there needs to be further research to validate and potentially
clarify proposed criteria.
Conditions for Further Study
• Internet Gaming Disorder
– A potential addictive disorder, not including non-gaming
forms of internet use (e.g., facebook, online shopping,
pornography).
• Neurobehavioral Disorder Associated With
Prenatal Alcohol Exposure (ND-PAE)
– This is intended to encompass the full range of
developmental disabilities associated with exposure to
alcohol in utero.
– The physical effects of Fetal Alcohol Syndrome are not
necessary for diagnosis
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Conditions for Further Study
• Suicidal Behavior Disorder
– This involves a suicide attempt within the last 24 months.
Suicidal ideation alone does not qualify
• Nonsuicidal Self-Injury
– Intentional self-inflicted damage to the surface of the body
with the expectation that the injury will lead only to minor or
moderate harm (there is no suicidal intent at the time of the
behavior)
– This is differentiated from Factitious Disorder, in which there
may be injury done to self, though the person exaggerates
the injury or otherwise seeks to deceive, in seeking care;
whereas, with nonsuicidal self-injury, the individual uses the
injury to reduce negative emotions, resolve interpersonal
difficulty, or as a way to punish themselves, and often
attempts to hide the injury from others.
Summary
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