DSM-5 Update:
Transitioning to the Fifth Edition
NASWIL
October 28, 2013
Susan McCracken, Ph.D.
Private Practice & Adjunct Faculty
[email protected]
Stanley G. McCracken, Ph.D., LCSW, RDDP
Senior Lecturer
[email protected]
The University of Chicago School of Social Service Administration
Agenda
• Introduction. Process of revision. General
characteristics.
• Structural, Conceptual, and Cross-cutting Changes
– Dimensional approach
• Severity Ratings and Assessment Tools
• Spectra and clusters
– Developmental Perspectives in DSM-5
• Changes to selected disorders and clusters
• We will focus on DSM-5 changes to the DSM-IVTR.
We will not cover all disorders. This workshop is not
recommended for people preparing to take a licensing
exam this year.
Process of Revision
• DSM-5 represents the first major revision in 30
years.
• Revisions of both DSM (5) and ICD (11 [2015]).
Continuing effort to make DSM/ICD compatible
– NIMH: Research Domain Criteria (RDoC).
• Workgroups. Conferences. Field trials. APA
website w/ updates & opportunity for feedback.
• Both APA and WHO committed to making the
DSM-5 and ICD-11 a “living document.”
– Print and electronic versions plus a mobile app of diagnostic
criteria for iOS and Android.
DSM-5 Structure
• No more Axes I-V. Just list diagnostic codes.
– There are still V codes ( Z codes in ICD-10CM).
• 3 Sections and Appendix.
– Section I, DSM-5 Basics: Introduction, Use of the
Manual, Cautionary Statement for Forensic Use of DSM-5
– Section II, Diagnostic Criteria and Codes.
– Section III, Emerging Measures and Models:
Assessment Measures, Cultural Formulation, Alternative
DSM-5 Model for Personality Disorders, Conditions for
Further Study.
– Appendix: Highlights of Changes from DSM-IV to DSM-5,
Glossary of Technical Terms, Glossary of Cultural Concepts
of Distress, etc.
Characteristics of DSM-5
• Final draft approved Dec. 1, 2012 and released
May, 2013.
• APA recommended implementation early 2014.
Illinois DMH has not yet decided on a date.
[Rumor: October, 2014 being considered???]
• Coding:
– Now: continue to use ICD-9CM (numbers only).
– ICD-10CM scheduled for implementation in US in
October, 2014. Use letter and number, e.g., F43.0.
The specific code will depend on specifier.
– ICD-11 due for release, 2015. Implementation???
Characteristics of DSM-5, cont.
• DSM-5 website:
http://www.psychiatry.org/dsm5
http://www.dsm5.org/Pages/Default.aspx
• No more NOS. Instead:
– Other specified _____ disorder
– Other unspecified _____ disorder
– Provisional diagnoses still allowed.
• Many specifiers.
Diagnostic Groupings
• Neurodevelopmental Disorders
• Schizophrenia Spectrum and Other Psychotic
Disorders
• Bipolar and Related Disorders
• Depressive Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related Disorders
• Trauma- and Stressor-Related Disorders
• Dissociative Disorders
• Somatic Symptom and Related Disorders
• Feeding and Eating Disorders
• Elimination Disorders
Diagnostic Groupings, cont.
•
•
•
•
•
•
•
•
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse-Control, and Conduct Disorders
Substance-Related and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
• Other Mental Disorders
• Medication-Induced Movement Disorders and Other Adverse
Effects of Medication
• Other Conditions that may be a Focus of Clinical Attention
Developmental Perspectives in DSM-5
• The full diagnostic manual provides many of the same
informational features as did DSM IV but in expanded
form – diagnostic criteria and recording codes with ICD
9 and 10, diagnostic features, description of symptoms,
associated features supporting diagnosis, culture-related
diagnostic issues, gender-related diagnostic issues,
prevalence, and differential diagnoses.
• New sections have been added (suicide risks,
comorbidity) and applied to many different disorders.
The addition of a developmental section, however, is a
major thread throughout the DSM-5.
Developmental Perspective
• DSM-5 diagnoses are anchored in the perspective that
pathology in youth = deviation from developmental
norms ( from delay in accomplishing developmental
task to not accomplishing it at all). Diagnoses fall
along a continuum or within a spectrum.
• The “Development and Course” section for each
disorder reflects a lifespan approach:
– age at which typical symptoms present
– detailed symptom presentation specific to each age group &
descriptions of how presentations change over the lifespan
– the trajectory over time of one disorder becoming another at
a later point in time (fluidity of diagnoses)
Developmental Perspective (cont)
• Risks and Prognostic Factors includes
– Temperament, genetic or physiological factors
– Descriptions of situations associated w/each age group in which
the disorder would disrupt normal functioning
– Expected long term outcome, points of increased risk, and
course modifiers  improvement or stability
– Recognition that changes in environment can moderate level of
impairment in children (i.e. enabling parents as compared to
non-enabling parents)
• Associated Features section in DSM -5
– includes comprehensive information than DSM IV to support
the diagnosis (medical, other behavioral or emotional signs,
other common associations) as well as parent-child associations
Developmental Perspectives, cont.
• Functional Consequences Section
– Refers to consequences of having a disorder during different
ages/stages of development
• Comorbidity Section (greater number in DSM-5)
– For some comorbidities, associations at different ages are
highlighted
• Some disorders in DSM-5 include:
– Explicit descriptions of developmental manifestations as part
of the diagnostic criteria for each disorder
– Procedures for evaluating developmental subtypes of
disorders
Dimensional Approach in DSM-5
• DSM-5 is shifting toward a more
dimensional approach.
• Disorders in several groups are structured
or discussed as spectrum disorders or
dimensions, e.g., Autism Spectrum, Mild
and Major Neurocognitive Disorders.
Dimensional Assessment
• Assessment measures placed in Section III.
Available: http://www.psychiatry.org/practice/dsm/dsm5/online-assessmentmeasures
• Cross-cutting symptom measures.
– Level 1 (Screening) brief survey of 13 (adults) or 12
(child and adolescent) symptom domains.
• Adults: Depression, Anger, Mania, Anxiety, Somatic
symptoms, Suicidal ideation, Psychosis, Sleep problems,
Memory, Repetitive thoughts & behaviors, Dissociation,
Personality functioning, Substance use.
• Child/adolescent (6-17): Somatic symptoms, Sleep problem,
Inattention, Depression, Anger, Irritability, Mania, Anxiety,
Psychosis, Repetitive thoughts & behaviors, Substance use,
Suicidal ideation/suicide attempt.
Dimensional Assessment, cont
• Cross-cutting symptom measures, cont
– Level 1
• Items rated on 5-point scale: 0=none/not at all;
1=slight or rare; <a day or two; 2=mild or several
days; 3=moderate or >half the days; 4=severe or
nearly every day.
• Items rated >mild or >slight (Suicidal, Psychosis,
Substance use; Inattention) or Yes/Don’t Know
(Substance use and Suicidal ideation/suicide attemptschild/adol)  further assessment with relevant Level
2 measure.
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1
Dimensional Assessment, cont
• Cross-cutting symptom measures.
– Level 2. Detailed clinical inquiry. Currently available:
• Adult: Depression, Anger, Mania, Anxiety, Somatic Symptom,
Sleep Disturbance, Repetitive Thoughts and Behaviors,
Substance Use. None currently available for: Dissociation
or Psychosis (see Clinician-Rated Dimensions of Psychosis
Symptom Severity).
• Child (6-17) (Child Self-Report ages 11-17; Parent/Guardianrated ages 6-17): Somatic Symptoms, Sleep Disturbance,
Inattention, Depression, Anger, Irritability, Mania, Anxiety,
Substance Use. None currently available for: Psychosis,
Repetitive thoughts and behaviors, Suicidal ideation/suicide
attempts.
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level2
Assessment, cont
• Other Measures of Symptoms and Functioning
– Disorder-specific Severity Measures
• Adult: Depression, Separation Anxiety, Specific Phobia, Social
Anxiety Disorder, Panic Disorder, Agoraphobia, Generalized
Anxiety Disorder, Post-traumatic Stress Symptoms, Acute
Stress Symptoms, Dissociative Symptoms
• Children S-R (11-17): Depression, Separation Anxiety, Specific
Phobia, Social Anxiety Disorder, Panic Disorder, Agoraphobia,
Generalized Anxiety Disorder, Post-traumatic Stress
Symptoms, Acute Stress Symptoms, Dissociative Symptoms
• Clinician-rated: Severity of Autism Spectrum and Social
Communication Disorders, Dimensions of Psychosis Symptom
Severity, Severity of Somatic Symptom Disorder, Severity of
Conduct Disorder, Severity of Oppositional Defiant Disorder,
Severity of Nonsuicidal Self-Injury
Assessment, cont
• Other Measures of Symptoms and Functioning
– Disability Measures
• World Health Organization Disability Schedule (WHODAS
2.0) 36 item self-administered.
• World Health Organization Disability Schedule (WHODAS
2.0) 36 item proxy-administered.
– Personality Inventories
• Adult: Personality Inventory for DSM-5—Brief form (PID-5BF)—Adult; Personality Inventory for DSM-5 (PID-5)—
Adult; Personality Inventory for DSM-5-Informant form
(PID-5-IRF)—Adult.
• Child S-R (11-17): Personality Inventory for DSM-5—Brief
form (PID-5-BF)—Child 11-17; Personality Inventory for
DSM-5 (PID-5)—Child 11-17.
Assessment, cont
• Other Measures of Symptoms and Functioning
– Early Development and Home Background
• For Parents of Children Ages 6–17: Early Development and
Home Background (EDHB) Form—Parent/Guardian.
• Clinician Rated: Early Development and Home Background
(EDHB) Form—Clinician.
– Cultural Formulation Interviews
• Cultural Formulation Interview.
• Cultural Formulation Interview—Informant version.
• Supplementary Modules to the Core Cultural Formulation
Interview (CFI).
• The question is whether, how, and when will any of
these be used, and who will require. (Too early to tell.)
Disorders Usually First Diagnosed in Childhood
Disorders: Where are they ? What Changed?
DSM IV
DSM-5
• Disorders Usually First
• “Disorders Usually First” has been
Diagnosed in Childhood and
eliminated and several disorders
Early Adolescence….
moved to new a group category Neurodevelopmental Disorders
which includes:
– Mental Retardation
– 3 Learning Disorders
– Developmental Coordination
Disorder
– ADHD
– MR -Renamed Intellectual Disability,
changes in criteria
– One LD Renamed “Specific Learning
Disorder” (specifiers w/ impairment in
reading, in written expression, in math)
– Developmental Coordination Disorder
– ADHD
Other Disorders Moved from “First Diagnosed..
in….” to “Neurodevelopmental Disorders”
DSM IV
DSM-5
• Communication Disorders
• Communication Disorders
– Expressive Language
Disorder (ELD)
– Mixed Receptive-Expressive
Language Disorder (MRELD)
– Stuttering Disorder
– Phonologic Disorder (PD)
• Motor Skills/Tic Disorders
– Tourettes, Dev. Coord Disord
– Chronic Vocal & Motor Tics
– Stereotypic Movement Disor.
– ELD and MRELD eliminated and
subsumed under new dx
“Language Disorder”
– Stuttering renamed “Childhood
Onset Fluency Disorder”
– PD renamed “Speech-Sound
Disorder”
• Motor Disorders subsection
– Specifiers added to Stereotypic
Movement Dis.-w/ SI, w/out SI,
assoc. w/ other known dis./med
More Disorders Moved from “Disorders First
Seen” to Other Groups in DSM-5
DSM IV
• PDD’s (Autistic Disorder,
Asperger’s, Childhood
Disintegrative Disorder ,
Rett’s, PDD NOS)
• Separation Anxiety D. and
Selective Mutism
• Pica, Rumination Disorder
& Feeding D. of Infancy
• Reactive Attachment Dis.
• Encopresis & Enuresis
• Conduct Disorder & ODD
& Intermittent Explosive D.
DSM-5
• Included in Neurodevelopmental
Disorders, all subsumed under
Autism Spectrum Disorder except
Rett’s which is a genetic disorder
• SAD & SM moved to Anxiety D.
• Pica & RD in “ Feeding & Eating
Disorders ” & FDI new name
“Restrictive Food Intake D”
• RAD in Trauma & Stress-Related D
• E & E in “Elimination Disorders”
• CD/ODD in “Disrupt, Impulse-C &
Conduct Disorders” w/ IED
List of Neurodevelopmental Disorders
• Include the following disorders:
– Intellectual Disability (Intellectual Development
Disorder), Global Developmental Delay (children < 5)
– Communication Disorders –
• Language Disorder, Speech Sound Disorder, ChildhoodOnset Fluency Disorder, Social Communication Disorder
–
–
–
–
Attention Deficit Hyperactivity Disorder
Specific Learning Disorder
Autism Spectrum Disorder
Motor Disorders
• Developmental Coordination Disorder, Stereotypic
Movement Disorder, Tic Disorders/Tourette’s Disorder
Changes in MR: Intellectual Disability
• In DSM -5, IQ below 70 is no longer the only criteria
• Severity based on functional ability, not IQ, or adaptive
functioning in comparison with same age norms has been
added as a criteria and must be assessed in 3 domains.
(1) Conceptual deficits: language, reading, writing,
math, reasoning, knowledge and memory
(2) Social deficits: interpersonal communication skills,
friendships, social judgment, empathy
(3) Practical deficits: personal care, organizing school and
work activities, money management, job duties
Severity rating scale for each domain is based on the level
of support required. Mild, Moderate, Profound
Changes in Criteria for ADHD
• Required age on onset of sxs changed from 7 to 12
• Greater emphasis on identifying adults ( & sx suited to age)
– Addition of sx descriptions more applicable to older teens and
adults (“forgetful in keeping appointments or returning calls”)
– Symptom threshold reduced to 5 for ages 17 and older, still 6 for
children and younger teens
• Symptom lists for hyperactive-inattentive and inattentive
basically unchanged (sx description more age appropriate)
• Cross-situational requirement increased to several
symptoms in > 2 settings
• Included in Neurodevelopmental Disorders to reflect brain
development corrrelates w/ ADHD
• Comorbid dx of ADHD & Autism Spectrum D. allowed
ADHD (cont)
• Subtypes replaced with specifiers “presentations
within the past 6 months predominantly_______”
• Added duration of 6 months to the specifier “In partial
remission” when full criteria were previously met but have
not been met for past 6 mos., still evidence of impairment.
• Severity ratings
– Mild = no symptoms (or few) in excess of number required for
diagnosis with minor impairments,
– Moderate = functional impairment falls between mild and severe
– Severe = more symptoms than required or several symptoms
result in marked impairment in social, school or occupational
areas
Communication Disorders
• Language Disorder (new dx =ELD & RELD combined)
– Difficulties in language acquisition and use of language
across modalities including written, spoken and sign
language
– Difficulties are not better accounted for by intellectual
disability, hearing or sensory impairment
• Speech Sound Disorder (phonological disorder renamed)
– difficulties with sounds articulation and voice quality
impact behavior, ideas and attitudes of others
• Childhood Onset Fluency Disorder (stuttering renamed)
• Social (Pragmatic) Communication Disorder
Social (Pragmatic) Communication Disorder
• New diagnosis characterized by difficulty in social
uses of verbal and nonverbal communication in
naturalistic contexts
– Use of communication for greeting and sharing is not
appropriate to the context
– Impairment in ability to adjust communication to the
needs of the listener or the context
– Difficulties following the rules for conversation
• Difficulties impact development of social
relationships and can’t be explained by low abilities
in areas of word structure and grammar
Social (Pragmatic) Communication Disorder
• There are no repetitive patterns or restricted
interests (i.e. criteria for ASD would not be met).
• Language impairment is a common associated
feature as is ADHD, behavior problems and
specific learning disorders
• Symptoms present in early childhood yet may
not be fully manifested until social demands
exceed capabilities
• Replaces the PDD, NOS
Autism Spectrum Disorder (ASD)
• The change from Pervasive Developmental
Disorders (PDD) to Autism Spectrum Disorder
and to that one diagnosis, ASD, was justified by
the following research:
– differentiation between Autism and the other DSM IV
PDD’s (including Asperger’s ) as well as among the
other PDD’s has been inconsistent, & often associated
with severity, language level or IQ instead of features
of the disorder.
– PDD,NOS – too many, >50% of diagnosed PDD
Rationale for ASD: Research on Asperger’s
• A key difference in DSM IV to discriminate
between Autism and Asperger’s is that an
individual with Asperger’s has no general delay
in language and there is no significant delay in
cognitive development or adaptive skills.
• However, individuals with Asperger’s
technically do meet the criterion for Autistic
Disorder… “in individuals with no language
delay, have marked impairment in the ability to
initiate or sustain a conversation with others”.
DSM 5 Conclusions for ASD
• The 3 defining areas of impairment (social
deficits; communication deficits; and restricted,
repetitive behaviors and interest) were reduced to
2 domains by combining social and
communication to “social/communication deficits”
and retaining the behavioral impairment domain
(RRB’s).
– Too difficult to separate social deficits from
communication deficits  combine into one unit
– Delays in language should be considered factors that
influence symptoms rather than define the disorder
Reconciling the Changes
• Individuals previously diagnosed with CDD,
Asperger’s or PDD,NOS will meet criteria for
ASD. If they do not meet criteria for ASD, they
should be evaluated for Social (Pragmatic)
Communication Disorder
• Individual’s currently receiving
accommodations in Illinois public schools will
continue to receive accommodations
Schizophrenia Spectrum and
Other Psychotic Disorders
• Disorders in this group:
–
–
–
–
–
–
Schizotypal Personality Disorder criteria
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophrenia
Schizoaffective Disorder
in Personality Disorders
– Substance/Medication-Induced Psychotic Disorder
– Psychotic Disorder Due to Another Medical Condition
– Catatonia Associated with Another Mental Disorder (Catatonia Specifier)
– Other Specified… and Unspecified…
Schizophrenia Spectrum/Other Psychotic
Disorder, cont.
• Major changes.
– Elimination of special attribution of certain symptoms
(e.g., bizarre delusions, voices talking to each other) in
Criterion A of Schizophrenia (only one of these needed
in DSM-IV).
– Criterion A now requires 2 sx, at least 1 of 3 psychotic sx
(Delusions, Hallucinations, or Disorganized Speech).
– Schizophrenia subtypes eliminated.
– Schizoaffective Disorder now requires that a major mood
episode be present for a majority of the disorder’s total
duration (not just current episode) after Criterion A met.
Schizophrenia Spectrum & Psychotic, cont.
• Major changes.
– Delusional disorder. Elimination of requirement that
delusions be non-bizarre.
• Differential diagnosis: if an individual with OCD or Body
Dysmorphic Disorder is completely convinced that his/her
OCD/BDD beliefs are true, then Delusional Disorder is
not diagnosed in addition to OCD or BDD (more on this
later).
– Criteria for catatonia are same regardless of the
context in which it is used as a specifier
(Schizophrenia, Bipolar Disorders, Depressive
Disorders, or Other Medical Condition).
Schizophrenia Spectrum & Psychotic, cont.
• Major changes.
• Rate symptoms on Clinician-Rated Dimensions of
Psychosis Symptom Severity (Section III).
• Symptoms (clusters)
– Psychotic symptoms: Hallucinations, Delusions,
Disorganization
– Psychomotor symptoms: Abnormal Psychomotor
Behavior
– Negative symptoms: Restricted Emotional Expression,
Avolition
– Cognition: Impaired Cognition
– Mood: Depression, Mania
– You may still make a diagnosis in this group even without
this rating.
Bipolar and Related Disorders
• Disorders in this group
– Bipolar I Disorder
– Bipolar II Disorder
– Cyclothymic Disorder
– Substance/Medication-Induced Bipolar and Related
Disorder
– Bipolar and Related Disorder Due to Another Medical
Condition
– Other Specified…
– Unspecified...
Bipolar and Related Disorders, cont.
• Bipolar and Related Disorders are separated
from Depressive Disorders and placed
between Depressive Disorders and
Schizophrenia Spectrum and Other Psychotic
Disorders to recognize their place as a bridge
in terms of symptoms, family history, and
genetics.
Bipolar and Related Disorders, cont.
• Major changes.
– Criterion A for manic and hypomanic episodes now
includes emphasis on changes in activity and energy as
well as mood. (“A distinct period of abnormally and
persistently elevated, expansive, or irritable mood and
abnormally and persistently increased goal-directed
activity or energy, lasting at least….”
– Removal of Mixed Episode and addition of mixed
features specifier that can be added to mania and
hypomania if depressive features are present or to
episodes of depression when features of mania or
hypomania are present (> 3 symptoms from other pole).
Bipolar and Related Disorders, cont.
• Major changes, cont
– Specifiers
•
•
•
•
•
•
•
•
•
•
With anxious distress (see next slide)
With mixed features
With rapid cycling
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia.
With peripartum onset (see next slide)
With seasonal pattern (see next slide)
Bipolar and Related Disorders, cont.
• Major changes: specifiers
– Anxious distress: at least two anxiety symptoms
during the majority of days of the current/most recent
episode of mania, hypomania or depression.
• Symptoms: Feeling keyed up or tense, feeling unusually
restless, difficulty concentrating because of worry, fear that
something awful may happen, feeling that the individual
might lose control of himself or herself.
• High levels of anxiety have been associated with higher risk
of suicide, longer duration of illness, higher risk of poor
treatment response.
• Specify severity based on number of anxiety symptoms:
mild to severe.
Bipolar and Related Disorders, cont.
• Major changes: Specifiers
– Peripartum onset. Can be applied to current/most
recent episode of mania, hypomania, or depression in
Bipolar I or II if onset of mood symptoms was during
pregnancy or in the 4 weeks following delivery.
– Seasonal pattern. Regular temporal relationship
between onset (and remission) of manic, hypomanic,
or depressive episodes and a particular time of year.
Does not include cases where there is an obvious
psychosocial stressor related to the season.
Depressive Disorders
• Disorders in this group.
–
–
–
–
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder
Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric Disorder
–
–
–
–
Substance/Medication-Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition
Other Specified Depressive Disorder
Unspecified Depressive Disorder
– Specifiers for Depressive Disorders
– [Persistent Complex Bereavement Disorder in Section III.]
– [Suicidal Behavior Disorder and Nonsuicidal Self-Injury in
Section III.]
Depressive Disorders, cont.
• Major changes
– New disorders.
• Disruptive Mood Dysregulation Disorder—new.
• Persistent Depressive Disorder—replaces Dysthymic Disorder
and Chronic Major Depressive Disorder.
• Premenstrual Dysphoric Disorder—moved to this group from
DSM-IV Appendix B (Criteria Sets…for Further Study).
– Mixed features specifier may be added to major
depression episode if features (at least three symptoms)
of mania or hypomania are present. (Increases probability
that the illness is in a bipolar spectrum, though if the person has
never had an illness that met criteria for a manic or hypomanic
episode the diagnosis of Major Depressive Disorder is retained.)
Depressive Disorders, cont.
• Major changes, cont.
– Bereavement exclusion eliminated.
• DSM-IV stated that symptoms that begin within 2 months of
loss of a loved one and do not persist beyond these 2 months
are “generally considered to result from Bereavement” unless
associated with functional impairment, preoccupation with
worthlessness, suicidal ideation, psychotic symptoms, or
psychomotor retardation. (Note: it did not say major depression
could not be diagnosed.)
– Implied that bereavement only lasts 2 months, when duration is more
commonly 1-2 years (depending on culture and other factors).
– Bereavement is severe psychosocial stressor that can precipitate major
depression in a vulnerable person, e.g., past history of depression.
– Major depression in context of bereavement adds: increased suffering,
suicidal ideation; increased risk complex bereavement; and responds to
same treatment (meds & verbal) as non-bereavement depression.
Comparison of Grief and Depression
Symptom
Grief
Depression
Affect
Emptiness and loss
Depressed mood, inability to
anticipate happiness or pleasure
Pattern
Dysphoria decreases in
intensity over days-weeks,
comes in waves associated
with thoughts/reminders of
deceased. Pain of grief
associated with positive
emotions and humor.
More persistent, not tied to specific
thoughts or preoccupations.
Pervasive unhappiness and misery.
Thought
Content
Preoccupation with thoughts Self-critical or pessimistic
and memories of the
ruminations
deceased
Self-esteem
Generally preserved
Thoughts of If present, focused on
death &
deceased and joining
dying
deceased.
Worthlessness, self-loathing
Thoughts of ending one’s life
because of worthlessness,
undeserving, unable to cope with
pain of depression
Depressive Disorders, cont.
• Disruptive Mood Dysregulation Disorder
• A new diagnosis intended to address concerns of over
diagnosis of bipolar disorder in children and unnecessary
and potentially harmful treatment
• These are children who are described by parents as
having “mood swings,” who have explosive outbursts of
extreme intensity and duration. Parents have to “walk on
eggshells.”
• These children present with persistent irritability and
outbursts of temper and the sxs overlap sxs of ADHD,
may be comorbid w/ ADHD but not w/ Bipolar or ODD
ADHD
DMDD
More aggressive
BIPOLAR
More continuous
More
labile
Disruptive
Behavior
Disorders
DMDD
• Recurrent severe temper outbursts,
– verbal and/or behavioral and inappropriate developmentally
– frequency of outbursts 3 or more times/week
• Symptom duration at least 12 months, no more than 3
months symptom-free
• The outbursts are present in at least two settings, severe in
at least one setting
• Child is at least 6, but no older than 18, & onset before 10
• Criteria never been met for manic or hypomanic episode
• Mood between outbursts is persistently irritable or angry
most of the day and mood is observable by others
• Trajectory is anxiety and/or unipolar mood disorders
Non-Suicidal Self Injury (NSSI)
• Self inflicted injury in the absence of suicidal intent
(NSSI) is included in Section 3 of DSM-5
– Many practitioners wanted NSSI to be identified as a
specifier due to the recent rapid increase in SI in youth
and across diagnoses. The need for early recognition,
development of preventative measures, and concerns
about associated medical risk may lead to stronger
research and treatment implications in DSM5.1, .2
– DSM-5 Task Force concern: SI is inappropriately
represented in DSM IV as associated with BPD even
though it occurs in a variety of disorders
NSSI
• Proposed criteria
– The individual engages in the self-injurious behavior
with one or more of the following expectations:
• To obtain relief from a negative feeling or cognitive state.
• To resolve an interpersonal difficulty.
• To induce a positive feeling state.
• Note: The desired relief or response is experienced during
or shortly after the self-injury, and the individual may
display patterns of behavior suggesting a dependence on
repeatedly engaging in it.
NSSI, cont’d
• The intentional self-injury is associated with at
least one of the following:
– Interpersonal difficulties or negative feelings or
thoughts, depression, anxiety, tension, anger,
generalized distress, or self-criticism, occurring in
the period immediately prior to the SI act.
– Preoccupation with the SI is difficult to control.
– Thinking about SI occurs frequently, even when it
is not acted upon.
– The SI is not socially sanctioned not restricted to
nail biting or picking a scab
Anxiety Disorders
• Disorders in this group. (Disorders listed developmentally.)
–
–
–
–
–
–
–
–
Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder (Social Phobia)
Panic Disorder
Panic Attack Specifier
Agoraphobia
Generalized Anxiety Disorder
– Substance/Medication-Induced…, … Due to Another Medical
Condition
– Other Specified…; Unspecified…
Anxiety Disorders, cont.
• Major changes.
– DSM-IV Anxiety Disorders separated into three
groups:
• Anxiety Disorders (excessive fear and anxiety and
related behavioral disturbances);
• Obsessive Compulsive and Related Disorders
(preoccupations and repetitive behaviors or mental
acts in response to preoccupations);
• Trauma- and Stressor-Related Disorders (exposure
to traumatic or stressful event leading to
psychological distress of varying kinds). Sequential
ordering reflects close relationship among these disorders.
Anxiety Disorders, cont.
• Anxiety disorders differ from developmentally normative
fear/anxiety by being excessive or persisting beyond
developmentally appropriate period.
• Anxiety disorders differ from transient fear/anxiety, often
stress induced, by being persistent, though the > 6 month
duration is a guide with some flexibility (shorter in children)
• Since people with anxiety disorders typically overestimate
the danger in situations they fear/avoid, determination of
excessive is made by clinician, considering cultural factors.
• Separation Anxiety Disorder and Selective Mutism moved
from DSM-IV childhood disorders group and placed into
Anxiety Disorders group.
Anxiety Disorders, cont.
• Major changes, cont.
– Panic Disorder and Agoraphobia are diagnosed
separately (unlinked) with separate criteria.
– Panic attacks may be added as a specifier to other DSM-5
disorders, e.g., depressive, bipolar, eating, psychotic, OCD.
– Panic Disorder requires 1 month of either persistent
worry about additional panic attack OR a significant
maladaptive change in behavior related to the attacks
(e.g., designed to avoid having a panic attack, such as avoiding
exercise, unfamiliar situations).
– Agoraphobia requires fears of > 2 situations—open
spaces, public transportation, enclosed spaces, standing
in a line or being in a crowd, or being outside of home.
Separation Anxiety & Selective Mutism
– Changes to Separation Anxiety Disorder:
• Diagnosis applies to all ages. Typical onset is in
childhood, yet it can persist into adulthood.
• Duration of the symptoms is specified as typically lasting
at least 4 weeks in children and 6 months or more in adults
• Specifier of early onset before the age of 6 was eliminated
• Descriptions of age-related functional consequences and
risk factors are provided.
– Changes to Selective Mutism
• Applies to all ages, wording changed to “failure to speak
in specific social situations”
• Considered a precursor to Social Anxiety Disorder; can
also be comorbid
Obsessive Compulsive and Related
Disorders
• Disorders in this group.
–
–
–
–
–
Obsessive-Compulsive Disorder
Body Dysmorphic Disorder
Hoarding Disorder
Trichotillomania (Hair-Pulling Disorder)
Excoriation (Skin-Picking) Disorder
–
–
–
–
Substance/Medication-Induced…
…Due to Another Medical Condition
Other Specified…
Unspecified…
Obsessive Compulsive and Related
Disorders, cont.
• Major changes.
– Separated from DSM-IV Anxiety Disorders.
– Body Dysmorphic Disorder moved to this group
from DSM-IV Somatoform Disorders.
– Trichotillomania order moved from DSM-IV
Impulse Control Disorders.
– Hoarding Disorder added.
– Skin-Picking Disorder added.
Obsessive Compulsive and Related
Disorders, cont.
• Major Changes.
– Specifiers
• Insight specifiers reflect full range of insight from
good/ fair insight to poor insight to absent
insight/delusional beliefs. No longer necessary to add
diagnosis of delusional disorder. (applies to OCD, Hoarding,
Body Dysmorphic Disorders.)
• With muscle dysmorphia (for Body Dysmorphic Disorder)
preoccupation with the idea that body build is too small or
insufficiently muscular.
• Tic-related (for OCD).
• With excessive acquisition (for Hoarding Disorder).
Trauma- and Stressor-Related
Disorders
• Disorders in this group.
–
–
–
–
–
–
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
Other Specified Trauma- and Stressor-Related
Disorder
– Unspecified Trauma- and Stressor-Related Disorder
– [DESNOS not in DSM-5]
Trauma- and Stressor-Related Disorders
• Major changes.
– Wide range of reactions to trauma and stress.
Sometimes responses can be understood in the context
of anxiety and fear. For other people the most
prominent symptoms are anhedonic and dysphoric,
externalizing angry and aggressive, dissociative, or
some combination (with or without anxiety and fear).
Because of this range of reactions, these disorders were
placed in their own group based on precipitants rather
than symptoms.
– Reactive Attachment Disorder moved to this group and
Disinhibited Social Engagement added.
Trauma- and Stressor-Related Disorders
• Major Changes.
– Adjustment Disorders moved to this group.
– Different set of PTSD criteria for children < 6.
– Sexual violence specifically included as a trauma.
Definition of trauma for PTSD and ASD are more
explicit and no longer require reaction of intense fear,
helplessness, or horror .
– Four symptom clusters for PTSD (3 clusters in DSMIV): Re-experiencing and intrusive symptoms;
Avoidance; Arousal and reactivity; Negative
alterations in cognitions and mood added.
Trauma- and Stressor-Related Disorders
• PTSD & ASD—Traumatic event:
– Exposure to actual or threatened death, serious injury,
or sexual violence in > 1 of the following ways:
• Directly experiencing the traumatic event(s).
• Witnessing, in person, the event(s) as it occurred to others.
• Learning that the traumatic event(s) occurred to a close
family member or close friend. In cases of actual or
threatened death of a family member or friend, the event(s)
must have been violent or accidental.
• Experiencing repeated or extreme exposure to aversive
details of the traumatic event(s).
– Note: Criterion A4 does not apply to exposure through electronic
media, television, movies, or pictures, unless this exposure is work
related.
PTSD in Children (6 or younger)
• Criteria for Exposure almost identical to adults w/
changes in wording to match age & developmental level.
– Vicarious: Learning that a trauma occurred “to a parent or caregiver”
acceptable,
– learning by electronic media does not meet diagnostic criteria
• Reacting with intense fear, helplessness or horror
was omitted (Preschool kids react to trauma on a
continuum from distress to overbright and “helplessness
or horror ” not clear in young children)
• “in children traumatic reactivity may be expressed
by disorganized or agitated behavior” was omitted,
unclear open for question what constitutes disorganized
or agitated behavior in children under the age of 6.
PTSD in Preschoolers, cont’d
• Presence of 1 or more intrusive symptoms
– Reenactment as a symptom of re-experiencing in DSM IV was
identified as “Repetitive behavior.” In DSM-5 it was replaced
by “play reenactment”
– Dissociative reactions ( flashbacks in young children) do occur
on a continuum from trauma-specific reenactment play, to
blocking eyes & ears, to loss of awareness of present
surroundings.
– Marked physiological arousal to reminders of the traumatic
event or intense & prolonged psychological distress to internal
or external cues symbolizing some aspect of the trauma also
are seen in young children
PTSD in Preschoolers, cont’d
• Lower symptom threshold; only 1 sx from either:
– Persistent Avoidance
• avoidance of or efforts to avoid people, or interpersonal
situations, or avoidance of places and activities assoc. w/ the
trauma
• “inability to recall important aspects of the trauma and sense
of foreshortened future” was omitted, isn’t applicable to < 6.
– Negative Alterations in Mood and Cognition
• Addition of “constriction of play” to “marked, diminished
interest or participation in significant activities”
• “detachment or estrangement” replaced w/social withdrawal
• Substantial increased frequency of negative emotional states
and decreased frequency in positive emotional states.
PTSD in Preschoolers, cont’d
• “Negative alterations in cognition or mood” with
the condition “that increases after the traumatic
experience”
• Changes to Increased Arousal:
– Adding to the “extreme temper tantrums in young
children” the clarification of a departure from the norm.
(“extreme tantrums have to be new for the child or onset
after the trauma or worsened after the trauma” to be
counted in the criteria for the DSM-5)
• Distress/impairment is anchored in relationships with
parents, peers or caregivers or in school behavior
Trauma- and Stressor-Related Disorders
• Reactive Attachment Disorder
– The two subtypes in DSM IV – inhibited and
disinhibited- have been conceptualized as traumarelated and transformed into 2 separate disordersone internalizing & one externalizing.
• In DSM-5 the dx of RAD is essentially the inhibited type
and the new dx of Disinhibited Social Engagement
Disorder ( (formerly the disinhibited type) but
conceptualization changed to violations in boundaries
– Cause of disorders unchanged. Both disorders are
presumably caused by insufficient care, comfort and
affection or from neglect and deprivation.
Reactive Attachment Disorder
• The child rarely seeks comfort when distressed and
shows emotional distress when others attempt to provide
comfort evident before age 5, develop = 9 mos.
• Persistent social/emotional disturbance in at least 2:
– Minimal social and emotional responsiveness
– Limited positive affect
– Unexplained irritability, sadness, or fearfulness evident during
nonthreatening interactions with caregivers
• Duration > 1 yr; severe if all sxs present & at high levels
Disinhibited Social Engagement Disorder
• The child is overly familiar with strangers and does not
hesitate to leave familiar caregivers
• Has loose boundaries with people, reduced or absent
reticence in approaching unfamiliar adults
• Doesn’t check back with caregiver after venturing away
• Behavior patterns not limited to impulsivity but also
include socially disinhibited behavior
• Pathogenic care is presumed to be responsible
• Child has developmental level of at least 9 months
• Specifier of Persistent if duration > 12 months.
Trauma- and Stressor-Related Disorders
• Adjustment Disorders.
– While criteria essentially unchanged, adjustment
disorders are now conceptualized as a diverse
array of stress-response syndromes that occur
after exposure to a distressing (either traumatic or
non-traumatic) event, rather than as a residual
category for individuals who exhibit clinically
significant distress but whose symptoms do not
meet criteria for a more discrete disorder (as in
DSM-IV).
Feeding and Eating Disorders
• Category includes the following disorders and
presentations across the lifespan
– Pica
– Rumination Disorder
– Avoidant/Restrictive Food Intake Disorder (this was
Feeding Disorder of Infancy yet with changes in
conceptualization - lifespan, restricted intake w/out body
image distortions, orthorexia …)
– Anorexia
– Bulimia
– Binge Eating Disorder ( has been in the Appendix of
DSM IV), in DSM-5 included as a coded diagnosis
Disruptive, Impulse Control, and
Conduct Disorders
• Includes
–
–
–
–
Oppositional Defiant Disorder
Conduct Disorder
Intermittent Explosive Disorder
Antisocial Personality Disorder (this disorder is also
included and criteria listed in the Personality Disorders Grouping)
– Pyromania
– Kleptomania
– Other Specified and Unspecified Disorders
Changes to Oppositional Defiant
Disorder & Conduct Disorder
• ODD minor changes only- symptom criteria “grouped” by
behaviors (argumentative/defiant), emotions (angry,
irritable mood), or vindictiveness.
– The grouping has some discriminative validity for determining
other disorders (i.e. mood) that can be comorbid or are moving in
direction of comorbidity.
– Symptoms must be observed toward others who are not siblings
and fall outside a range that is normative for developmental
level, gender and culture.
– Specifiers for current severity have been added (mild, moderate,
severe) and are based on the number of settings (1, 2, 3 or more)
in which symptoms are present
– ODD and CD comorbidity allowed in DSM-5
New Specifier for CD “With Limited
Prosocial Emotions”
• To qualify for this specifier, the individual
– Must have displayed at least 2 of the following
characteristics persistently over at least 12 months and
in multiple relationships and settings. ( Multiple
information sources are necessary)
• Lack of remorse or guilt
• Callous – lack of empathy (unconcerned about his/her impact
on others even when results in substantial harm to others)
• Unconcerned about performance at school, work, or other
activity
• Shallow or deficient affect (insincere, used to manipulate)
Rationale for the New Specifier
• CD classification in DSM IV represents a
heterogeneous group ( severity, course & etiology)
– Research into psychopathy has highlighted 3 “traits”
• behavior (i.e. severe aggression, destructive)
• affect (lack of empathy, shallow) and
• interpersonal (using others for own gain )
– Research findings for > 20 yrs indicate that individuals
displaying the affect and interpersonal traits differ from
those primary displaying behaviors w/ respect to course
of the disorder and response to treatment
• Interpersonal could be subdivided into callous-unemotional,
narcissistic & impulsive with the callous-unemotional
predictive of severe & prolonged antisocial pathology.
Intermittent Explosive Disorder
• Changes/Additions to Criteria
– Frequency of 2x a week, on average for a period of 3
months without damages to people, animals or property;
if damages, frequency of 3 times in 12 mos.
– Aggressive outbursts are not premediated ; they are
anger-based with no tangible objective
– Outbursts cause distress to the individual (interpersonal,
financial or otherwise)
– Must be at least 6 years old or developmental equivalent
– r/o aggressive behavior during Adjustmt Dis in 6-18 y.o.
• Exclusion Added: DMDD supersedes I.E.D.
Substance Use and Addictive Disorders
• Disorders in this group:
– Substance Use Disorders.
– Substance Induced Disorders
• Intoxication.
• Withdrawal.
• Other Substance Induced Disorders (psychotic disorders,
bipolar and related disorders, depressive disorders, anxiety
disorders, obsessive-compulsive and related disorders,
sleep disorders, sexual dysfunctions, delirium, and
neurocognitive disorders). Described in group with
disorders with which they share phenomenology.
– Gambling Disorder
Substance Use and Related Disorders, cont.
• Major changes.
– Collapses abuse and dependence into a single diagnosis
“Substance Use Disorder” (e.g., Cocaine Use Disorder,
Alcohol Use Disorder)
• Abuse & dependence seen as a single disorder with a
continuum of severity. Severity specifier: Mild = 2-3,
Moderate = 4-5, Severe > 6 symptoms.
– Dependence and Abuse symptoms combined. Craving
added as symptom, and recurrent legal problems
deleted.
– Adds criteria for Cannabis Withdrawal.
– Gambling (moved from impulse control disorder).
Neurocognitive Disorders
• Disorders in this group
–
–
–
–
–
Neurocognitive Domains
Delirium
Other Specified Delirium
Unspecified Delirium
Major and Mild Neurocognitive Disorders
• Specify underlying pathology, where known, e.g., Major or
Mild Neurocognitive Disorder due to Alzheimer’s Disease.
– Criteria for Delirium are quite similar to DSM-IV.
Changes clarify some criteria.
Neurocognitive Disorders, cont.
• Major changes.
– Group renamed. Replaces DSM-IV, Dementia,
Delirium, Amnestic, and Other Cognitive Disorders.
– Disorders in this group attributable to changes in brain
structure, function, or chemistry. Etiologies will be
coded as subtypes, e.g., Alzheimer’s.
– “Dementia is subsumed under the newly named entity
major neurocognitive disorder, although the term
dementia is not precluded from use in the etiological
subtypes in which that term is standard.”
– Mild neurocognitive disorder added—similar to Mild
Cognitive Impairment (MCI).
Neurocognitive Disorders, cont.
• Domains of cognitive function. (Note: domains not
entirely independent, boundaries are indistinct, variable
definitions in literature):
– Complex attention (ability to sustain, divide, &
selectively focus attention; processing speed)
– Executive function (planning, decision making, working
memory, responding to feedback/error correction, overriding habits/inhibition, mental flexibility)
– Learning & memory (immediate & recent memory
[includes both free & cued recall, recognition memory],
very long-term memory, implicit learning)
Neurocognitive Disorders
• Domains of cognitive functioning, cont.
– Language (expressive language [including naming,
word finding, fluency, grammar, & syntax] and
receptive language)
– Perceptual-motor (includes abilities subsumed under
visual perception, visuo-constructional, perceptualmotor, praxis, and gnosis)
– Social cognition (recognition of emotions, theory of
mind)
Neurocognitive Disorders, cont.
• Major neurocognitive disorder.
– Evidence of significant cognitive decline [distinguishes
from neurodevelopmental disorders] from a previous
level of performance in one or more cognitive domains
based on:
• Concern of the individual, a knowledgeable informant (e.g.,
family member, caregiver), or the clinician that there has been
a significant decline in cognitive function; and
• A substantial impairment in cognitive performance.
– The cognitive deficits interfere with independence in
everyday activities (IADL’s) (i.e., the individual
requires assistance in performing complex IADL’s).
Neurocognitive Disorders, cont.
• Mild Neurocognitive Disorder
– Evidence of modest cognitive decline from a previous
level of performance in one or more cognitive domains…
– The cognitive deficits do not interfere with capacity for
independence in everyday activities (i.e., complex
IADL’s are preserved, but greater effort, compensatory
strategies, or accommodation may be required).
• Specifiers for Neurocognitive Disorders.
– With or Without Behavioral Disturbance.
– Severity
– Presumed etiology.
Personality Disorders
• Personality disorders are listed in two sections.
– “The criteria for personality disorders in Section II
have not changed from those in DSM-IV.”
– Section III includes the alternative dimensional
model for personality disorders. This model, an
alternative to the categorical approach, reflects a
dimensional perspective that personality disorders
represent maladaptive variants of personality traits
that merge imperceptibly into normality and into
one another.
– Personality Change due to Another Medical
Condition added to group.
Gender Dysphoria
• “Gender dysphoria refers to the distress that may
accompany the incongruence between one’s
experienced or expressed gender and one’s assigned
gender….Gender assignment refers to the initial
assignment , usually at birth, as male or
female….Many are distressed if the desired physical
interventions by means of hormones or surgery are
not available. The current term is more descriptive
than the previous DSM IV term, gender identity
disorder, and focuses on dysphoria as the clinical
problem, not identity per se.” (DSM-5, p.451)
Gender Dysphoria, cont.
• Gender Dysphoria can be diagnosed in children,
adolescents and adults if it causes significant
distress to the individual.
• Gender Identity Disorder has been eliminated
– desire is to reduce stigma and retain coverage for
treatment yet insurance companies may refuse to pay if
the word “disorder” is omitted.
• Gender nonconformity itself is not considered to
be a mental disorder.
• Instead of the wording “the other sex”, the
wording “some alternative gender” is used.