DSM – 5:
A Brief Overview
Chuck Pistorio, Ph.D.
Laura Tejada, Ph.D.
Shedeh Tavakoli, Ph.D.
Overview
Outline significant changes
Chapter organizations
New categories
New Diagnoses
Eliminated diagnoses
Review specific changes for some of the most
commonly diagnosed disorders
Changes in Philosophy
Greater emphasis on culture
Cultural Formulation Inventory (CFI)
Awareness of international use
ICD, WHO
Validity rather than reliability
More emphasis on client’s experiences
and reported symptoms/needs
Changes to Chapters
Chapters reorganized
Organized by common etiologies
More dimensional approach
Diagnosis is ongoing
Reflects developmental lifespan
Removed Disorders Usually Diagnosed in Infancy,
Childhood & Adolescence
Individual chapters organized developmentally
Changes to Five-Axis System
DSM-IV Five-Axis System
DSM-5 Equivalent
Axis I: Mental Health Disorders
Record on diagnosis line
List primary reason for visit first
Axis II: Personality Disorders & Mental Record on diagnosis line
Retardation
List primary reason for visit first
Axis III: General Medical Conditions
Record on diagnosis line
List those most important to
understanding mental health first
Axis IV: Psychosocial & Environmental
Problems
Record on diagnosis line
V, Z, or T codes from chapter “Other
Conditions that May be of Clinical
Attention” (p. 715)
Axis V: Global Assessment of
Functioning [GAF]
Optional use of World Health
Organization Disability Schedule
[WHODAS] (p. 745)
Changes to Five-Axis System
DSM-IV Five-Axis System
DSM-5 Equivalent
Axis I: 309.81 PTSD, with delayed
onset; 296.32 Major Depressive
Disorder, recurrent, moderate, with
mild anxious distress
1.
309.81 PTSD, with delayed onset
2.
296.32 Major Depressive Disorder,
recurrent, moderate, with mild
anxious distress
3.
V15.41 Personal history of spouse
or partner violence, physical
4.
V60.1 Inadequate housing
5.
V60.2 Extreme poverty
Axis II: No diagnosis
Axis III: No diagnosis
Axis IV: V.15.41 Personal history of
spouse or partner violence, physical
V60.1 Inadequate housing;
V60.2 Extreme poverty
Axis V: GAF score
Changes to NOS
Not Elsewhere Classified [NEC]
Specific symptoms with code
Other Specified
Allows documentation of why client does not
meet specific diagnostic criteria
Unspecified
Significant distress but does not meet criteria
Insufficient information (crisis, ER)
Organization & Content
Section I
Orientation
Historical back ground
Development of DSM-5
How to use it
Section II
Diagnostic Criteria and codes
“Medication-induced Movement Disorders”
“Other Conditions That May be a Focus of Clinical
Attention.”
Organization & Content
Section III
Emerging Measures and Models
Assessment measures
http://www.psychiatry.org/practice/dsm/dsm5/onlineassessment-measures
Cultural formulation
Alternative DSM-5 model for personality disorders
“Criteria Sets for Conditions for Further Study”
Appendix
Highlights of changes from DSM-IV to DSM-5
Glossary of technical terms
Glossary of cultural terms
Alpha & numeric listings of diagnoses and codes
List of advisors and contributors
Structure for Each Diagnosis
Diagnostic Criteria
Subtypes and/or specifiers
Severity
Codes and recording procedures
Explanatory text (new or expanded)
Structure for Each Diagnosis
Diagnostic and associated features
Prevalence
Development and course
Risk and prognosis
Culture- and gender-related factors
Diagnostic markers
Functional consequences
Differential diagnosis
Comorbidity
New Disorders
Social (Pragmatic) Communication Disorder
Disruptive Mood Dysregulation Disorder
Premenstrual Dysphoric Disorder
Hoarding Disorder
Excoriation (Skin‐Picking) Disorder
Disinhibited Social Engagement Disorder (split from
Reactive Attachment Disorder)
Binge Eating Disorder
New Disorders
Central Sleep Apnea
Sleep-Related Hypoventilation
Rapid Eye Movement Sleep Behavior Disorder
Restless Legs Syndrome
Caffeine Withdrawal
Cannabis Withdrawal
Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to
Other Medical Conditions)
Mild Neurocognitive Disorder
Eliminated
Sexual Aversion Disorder
Polysubstance-Related Disorder
Diagnostic Changes
New categories:
Obsessive-Compulsive and Related Disorders
Trauma- and Stressor-Related Disorders
Transformed:
Neurodevelopmental Disorders
(Infancy, adolescence, childhood)
Somatic Symptom and Related Disorders
Combined:
Language disorders
Insomnia Disorder
Autism spectrum
Alcohol use disorder
Specific Learning Disorder
Cannabis use disorder
Delusional disorder
Stimulant Intoxication
Panic Disorder
Stimulant withdrawal
Dissociative Amnesia
Substance/medicationinduced disorders
Somatic Symptom
Examples of Changes
Trauma and Stress-Related
Disorders
New chapter in DSM-5 brings together anxiety disorders
that are preceded by a distressing or traumatic event
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder (new)
PTSD (includes PTSD for children
6 years and younger)
Acute Stress Disorder
Adjustment Disorders
Posttraumatic Stress Disorder
(PTSD)
There are 8 criterion
Criteria (A)- Exposure to actual or threatened death, serious injury, or sexual
violence
Four symptom clusters, rather than three
Re-experiencing (B)
Avoidance (C)
Persistent negative alterations in mood and cognition (D)
Arousal- describes behavioral symptoms (E)
Duration of B, C, D, and E is more than 1 month
Causes clinically significant distress
Not attributed to substance use or medical condition
PTSD
DSM 5 more clearly defines what constitutes traumatic event
Sexual assault is specifically included
Recurring exposure, that could apply to first responders
Recognition of PTSD in young children
Developmentally sensitive:
Criteria have been modified for children 6 and younger
Thresholds- number of symptoms in each cluster have been lowered
Risk and Prognostic actors:
Pretraumatic factors
Per traumatic factors
Posttraumatic factors
Substance-Related and Addictive Disorders
DSM-5 consolidates substance abuse and dependence into one disorder:
substance use disorder accompanied by criteria for: intoxication,
withdrawal, substance-induced disorders, and unspecified related
disorders.
Criteria are nearly identical to DSM-IV w/ exception of:
-Recurrent substance-related legal problems criterion has been deleted
from DSM-5.
-And new criterion: craving, or a strong desire or urge to use a substance
added.
The threshold is set at 2 or more criteria vs. 1 or more for abuse and 3 or
more for dependence in the DSM-IV.
Substance-Related and Addictive Disorders
New disorders in substance-related & addictive disorders
chapter of DSM-5:
Gambling Disorder (non-substance related disorder)
Cannabis Withdrawal
Caffeine Withdrawal
*
The dx of polysubstance dependence has been
eliminated.
Substance-Related and Addictive Disorders
Specifiers:
In DSM-5 severity for substance use disorders is based on the
number of criteria endorsed:
-mild= 2-3 criteria
-moderate = 4-5 criteria
-Severe= 6 or more criteria
The DSM-IV specifier for psychological subtype has been
eliminated.
Substance-Related and Addictive Disorders
In DSM-5 early remission is defined as at least 3 but less then
12 months without substance use disorder criteria (except
craving).
Sustained remission is defined as at least 12 months without
criteria (except craving).
New specifiers include:
-in a controlled environment
-on maintenance therapy
Neurodevelopmental Disorders
DSM-IV TR – “Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence”
Intellectual Disability (vs mental retardation) – Rosa’s
Law
Assess cognitive capacity (IQ) and adaptive functioning
(the primary determinant of severity).
Autism Spectrum Disorder (gone – Asperger’s, childhood
disintegrative disorder, pervasive developmental disorder)
Addition – Social (Pragmatic) Communication Disorder
Neurodevelopmental Disorders
Attention-Deficit/Hyperactive Disorder (prior to age 12 vs age
7, less symptoms for adults, option for comorbid with ASD)
Specific Learning Disorder (DSM-IV TR = Academic Skills
Disorders; greater detail in diagnosis, e.g., word reading,
fluency, comprehension; clarify requirements for Low
Achievement criterion)
Specifiers – greater detail on severity (e.g., ID – mild,
moderate, severe, profound; ASD – Levels 1, 2, 3)
Removed – Separation Anxiety Disorder, Pica and Rumination
Disorder, Feeding Disorder of Infancy or Early Childhood,
Oppositional Defiant Disorder, Conduct Disorder
Personality Disorders
Criteria for PD’s in Section II of DSM-5 not changed
from DSM-IV
No longer exist as an Axis II disorder (i.e., dropped
multiaxial evaluation system)
PD now coded at same level as other mental disorders
No longer marginalized and treated differently
Personality Disorders
NOS dropped in favor of: (1) Other specified PD and (2)
Unspecified PD
New, alternative approach to diagnosing PD developed
for further study and included in separate section
(Section III)
Personality Change Due to Another Medical Condition
included in PD chapter (vs. DSM-IV’s Mental Disorders
Due to a General Medical Condition)
Alternative DSM-5 Model
for Personality Disorders
New model for assessment of personality disorders and traits
Includes Categorical and Dimensional approaches
Model not accepted by APA for inclusion in Section II
Decision –include in Section III as the “Alternative DSM-5 Model for
Personality Disorders”
Rationale: the model “preserve(s) continuity with current clinical
practice, while also introducing a new approach that aims to address
numerous shortcomings of the current approach to personality
disorders.”
Six PDs (vs. ten) – antisocial, avoidant, borderline, narcissistic, obsessivecompulsive, and schizotypal)
Alternative DSM-5 Model
for Personality Disorders
Based on Five Factor model of personality (Neuroticism, Extraversion,
Openness, Agreeableness, and Conscientiousness)
PD Model (Negative affectivity, Detachment, Antagonism,
Disinhibition, and Psychoticism)
Negative Affectivity
Neuroticism
Detachment
Introversion
Antagonism
Antagonism
Disinhibition
Low Conscientiousness
Psychoticism
Openness
25 Facets (traits): e.g., Anxiousness, Attention Seeking, Depressivity,
Emotional Lability, Hostility, Impulsivity, Separation Insecurity,
Withdrawal
QUESTIONS?
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QUESTIONS?
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QUESTIONS?