DSM: What and When
11 September 2011
Roger Peele, MD, DLFAPA
Outline - 1
Importance [Slide number – 4]
Fundamentals – 28
History of DSMs – 49
DSM-5, values – 61
DSM-5, organization – 65
DSM-5, Intellectual Disabilities – 67
DSM-5, Mood disorders - 75
Outline - 2
8. Anxiety Disorders – 95
Hoarding Disorder – 96
9. PTSD – 105
10. Somatic Symptom Disorders – 109
11. Eating Disorders – 111
12. Sexual Disorders – 112
13. Gender Dysphoria – 118
14. Substance Use Disorders – 122
15. Multiaxial - 134
• 1. Access to care and treatment. DSMs
“is the cornerstone in the edifice of mental
health care” [Sadler, 2006]. Recognized
by insurance and public agencies.
Importance - 2
• 2. Access to entitlements. Defines the
responsibilities of public agencies
accountable for the psychiatrically ill.
Reimbursements are administered on the
basis of the DSM [in an overlap with
ICDs]. Even the location within DSM can
have an impact on access, e.g., the Axis II
location, some claim, decreases access.
Importance – 3a
• 3. Approved treatments.
FDA, for example, had had a tradition of
asking that medication approval requests
be focused on DSM entities. Some see
this as having a negative consequence,
causing a stall in development of
Importance – 3b
• DSM disorders, which are syndromes,
some believe have not provided specific
treatment targets. In 2006, the Washington
Psychiatric Society had a motion approved
by the APA saying that FDA should
consider signs/symptoms for approval, not
just dx categories.
Importance – 4a
Steve Hyman, Past-Director of NIMH:
“Despite these successes [of the DSMs], there are
clear problems and unresolved controversies related to
DSM-IV-TR, the most recent version of DSM. If a relative
strength of DSM is its focus on reliability, a fundamental
weakness lies in the problems related to validity. Not
only persisting but looming larger is the question of
whether DSM-IV-TR truly carves nature at the joints –
that is, whether the entities described in the manual are
truly ‘natural kinds’ and not arbitrary chimeras.”
Importance 4b
“In reifying DSM-IV-TR diagnoses, one
increases the risk that science will get
stuck, and the very studies that are
needed to better define phenotypes are
held back.”
Importance - 4 c
• “Except for IQ tests to diagnose mental
retardation and polysomnography to
diagnose sleep disorders
[polysomnography was inexplicitly
excluded from DSM-IV-TR criteria sets],
diagnostic tests for mental disorders do
not yet exists.”
Importance 4 - d
“The most important goal is to help the
APA get out of
the DSM-III-R-R-R rut without blowing up
clinical practice. Whatever it
• Steve Hyman
Importance - 5
• 5. Education. The teaching of
psychopathology in the United States and
many other countries follows the DSM.
Importance - 6
• 6. Legal and criminal decisions. Despite
cautionary statements in the DSMs that
the book is not to be used to answer legal
questions, the DSMs are often used to
answer legal questions.
Importance – 7 - a
• 7. Society’s concept of mental illness, of
normality. For example, conceptualized
homosexuality as normal.
-- 1973, substituted “egodystonic
homosexuality” for “homosexuality”
-- 1987, DSM-IIIR, abolished “egodystonic
• -- Many DSM terms have become part of the
American discourse, for example, “ADHD.”
Importance 7 - b
• Alan Schatzberg, APA Presidential
address, May 2010 called for “The
general public, for example, read pop
psychology articles or watch pop
psychologists on TV and think they
know a lot about emotions and
feelings. Adding to this false sense of
understanding is the common language
used in psychiatric nosology.
Importance – 7 -c
• “Other medical specialties have
disorders based on Latin and Greek
terms that are complemented by lay
terminology or descriptors—take, for
example, myocardial infarction and
heart attack.
Importance – 7 - d
• “When you look at psychiatry, you see
disorders that are distinctly unmedical
in sound in many ways—binge-eating
disorder, major depression, panic
disorder, etc., with no real parallel and
more technical medical terminology....
We need to be more medical to be
taken more seriously.”
Importance - 8
• 8. Defines psychiatry. While DSM-IV-TR
has a 147 word definition of mental illness,
which is not used, the aggregation of
disorders in the DSMs tends to define
psychiatry. However, the openness of
DSM-IV’s NOSs, has created unclear
boundaries as to “normal” and “illness.”
Since medicine does not have a definition of
“disorder,” or “illness,” or “disease.” Psychiatry
should not feel a need, but, if presses, the
following very unofficial definition of mental
disorder might be adequate for some
Behavioral, emotional, cognitive, or conative
symptoms that reach a clinically significant
level of distress or disability.
Importance – 8a
SPECIFIED defined as “This category is a
residual category for disorders with onset
in infancy, childhood, or adolescence that
do not meet criteria for any specific
disorder in the Classification.” [WPS had a
motion to correct this.]
Importance – 8 b
Positive illusion - 1
• Nassir Ghaemi, 2011:
• "Normal" non-depressed persons have
what psychologists call "positive illusion"—
that is, they possess a mildly high selfregard, a slightly inflated sense of how
much they control the world around them.
Importance 8 – b
Positive Illusion - 2
• Mildly depressed people, by contrast, tend
to see the world more clearly, more as it is.
In one classic study, subjects pressed a
button and observed whether it turned on
a green light, which was actually controlled
by the researchers. Those who had no
depressive symptoms consistently
overestimated their control over the light;
those who had some depressive
symptoms realized they had little control.
Importance 8 - c
“Diagnostic Combat”-1
• I've got a way with words that's slick.
I'm sometimes troubled, you are sick.
You are phobic, I'm just shy‹
I'll explain the reason why.
I am healthy, you are nuts;
I'm quite normal, you're a putz.
I can brandish words about;
I can call you a dumb lout.
Importance – 8 – c
Diagnostic Combat” - 2
• If you try to out-talk me
I'll call that pathology.
My advice? Concede defeat.
No one can my verbiage beat.
• Tom Greening
• [Ethical issues for professionals]
Importance - 9
• Defines for what clinicians can be held
accountable in terms of knowledge and
• [A happy hunting ground for test
Importance - 10
Defines responsibility for the public
psychiatric sector.
Defines reimbursibility for the private
psychiatric sector.
Importance - 11
While respecting the DSM, it is important not
to worship the DSM
Fundamental - 1
• 1. To communicate [e.g., “bipolar disorder,
mixed type“]
Fundamental - 2
To give the clinician and patient a tie to
information as to cause, course and
Fundamentals - 3
To avoid stigmatizing the person with the
illness, the environment, or the family
[e.g., in the DSMs, almost no implications
that inadequate parenting causes mental
Fundamentals - 4
To provide coverage, that is, to have a term
for all patients in psychiatric treatment.
Fundamentals – 5a
To give the clinician and patient a tie to
empirical information that:
a. Provides a sense that the patient is not
alone, that the patient signs and
symptoms are tied to knowledge. [It
increases the distraughtness for a patient
to hear that their physician has no
diagnosis for their condition.]
Fundamentals – 5 b
• b. Provides a prediction as to:
• i. Course [e.g., “Alzheimer’s is not
• ii. Treatment [e.g., “perphenazine is FDA
approved for schizophrenia”]
• c. May explicate the cause [e.g.,
“dementia due to Huntington’s disease”]
Fundamentals - 6
• Communicative validity. The definitions are
to facilitate communications, to describe
the disorder:
A] To the patient
B] To others working with the
C] To the profession in order to
increase the knowledge about psychiatric
illnesses, their treatment, and their
Fundamentals - 7
• Treatment validity, part of predictive
validity. Each treatment decision is a
To communicate
Evaluate consensually
to treat
• Complicated
• Flexible
• Evaluate empirically
DSM’s choice
To focus on communicating, not on
DSM and Treatment
• Kupfer, First and Regier:
“With regard to treatment, lack of
treatment specificity is the rule rather than
the exception.”
“The efficacy of many psychotropic
medications cut across the DSM-defined
categories. For example, the SSRIs have
been demonstrated to be efficacious in a
wide variety of disorders, described in
many sections of DSM.”
Fluoxetine Uses
Major depressive disorder*
Obsessive-compulsive disorder*
Premenstrual dysphoric disorder*
Bulimia nervosa*
Panic disorder*
Bipolar Depression [combined with olanzapine]*
Social anxiety disorder
Posttraumatic stress disorder
* = FDA approved
Chlorpromazine use - 1
1. Schizophrenia*
2. Nausea*
3. Vomiting*
4. Restlessness/apprehensiveness before
5. Acute intermittent porphyria
6. Mania
7. Tetanus [adjunct]
Chlorpromazine uses - 2
8. Intractable hiccups*
9. Combativeness or explosive hyperactivity
in children*
10. Impulsiveness, inattentiveness,
aggressiveness, mood lability, and poor
frustration tolerance in children*
11. Psychosis*
DSMs and validity - 1
• 1 - Event/environmental
• 2 – stress/trauma,
3 - Genetic – e.g., Huntington’s.
4 – Biological marker – e.g.,
5 – Psychological test finding -- IQ
DSMs and Validities - 2
• Dx related to substances = 124
• Dx related to illnesses shared with the rest
of medicine = 36 [obviously there are
many more not mentioned in DSM-IV-TR]
• Dx related to stress/trauma = 9
DSMs and validity - 3
• Dx related to season = 1
• Dx related to post-partum time = 1
• Total having some etiological elements,
substances and somatic illnesses: 171
[about half of the DSM-IV-TR]
DSMs and Validity - 4
Prognosis – none in the DSM-IV-TR’s
criteria sets. Although some criteria,
through a retrospective approach, have
attempted to build in some prognosis, for
example, schizophrenia’s minimum six
month requirement, and the six month
limitation on adjustment disorders. [Also,
the text of each Disorder in DSM-IV-TR
has a section on course.]
As to prediction
DSMs Provide a framework for prediction as
• i. Course [e.g., “Alzheimer’s is not
• ii. Treatment [e.g., “perphenazine is FDA
approved for schizophrenia”]
• c. May explicate the cause [e.g.,
“dementia due to Huntington’s disease”]
• Phenotypes, the result of an interaction
between a person’s genetic manifestations
and their environment, may provide a
classification that will avoid the difficulties
of the infinite possibilities, but so far, no
phenotype is part of psychiatric
Hx of DSMs
DSM-I – 1952
DSM-II – 1968
DSM-III – 1980
DSM-IIIR – 1987
DSM-IV – 1994
DSM-IV-TR – 2000
DSM-5 - 2013
International Classification of Diseases:
ICD-I, 1893.
ICD-9, 1977
ICD-9-CM changed annually, and will be
used until September 30, 2013.
ICD-10, 1994
ICD-10-CM, begins use 1 October 2013
Accessing ICD Codes
Search name of disorder and “ICD-9-CM.”
Or search name of disorder and “ICD-10CM.”
Complete: DSMs have to be within the ICDs.
DSM-I, 1952
-- Described terms, for example, Schizophrenic Reactions
was defined as: “It represents a group of psychotic
disorders characterized by fundamental disturbances in
reality relationships and concept formations, with
affective, behavioral, and intellectual disturbances in
varying degrees and mixtures. The disorders are marked
by strong tendency to retreat from reality, by emotional
disharmony, unpredictable disturbances in stream of
thought, regressive behavior, and in some, a tendency to
DSM-II, 1968
• -- Described terms
-- 94% changes in nomenclature from DSM-I.
Goal of using terms that coincided with ICD8's.
Removed all “Reactions.”
• -- All disorders had a code for dimensions. One
could avoid choosing between, “mild,”
“moderate,” etc by selecting “unspecified,”
coded “0.”
• Post-DSM-II, 1973, “Homosexuality”
replaced with “Egodystonic
Homosexuality.” This was an APA Board of
Trustee decision. A membership-wide vote
on a referendum to overturn the Board’s
decision failed. Thus, DSM-II printings
from 1973-1979, had this change.
DSM-III, 1980
Adopted many new subjects to the Manual:
• -- Criteria sets, to increase reliability.
-- Five axes, to assure a comprehensive
evaluation of the pt. This was felt to
reduce the concerns of some that
psychosocial interests were being
forgotten in DSM-III.
DSM-III - text
• -- Vast increase in background information about each
disorder, making it a text for psychopathology, by adding:
Diagnostic features
Associated features
Cultural and gender features
Familiar patterns
Differential Dx
Decision trees,
DSM-IIIR - 1987
-- Modifications of some criteria sets,
-- removed “Egodystonic Homosexuality,”
so no form of homosexuality in the DSM.
-- established a category of Disorders to
Be Studied,
-- contained a symptom index,
DSM-IV, 1994 - 1
-- Modifications of some criteria sets,
-- removed “organic” as a concept and
replaced with conditions related to
“General Medical Conditions,”
-- removed Self-defeating and Sadistic
Personality Disorder from Disorders to be
-- removed symptom index.
• -- removed “neuroses.”
-- allowed non-Axial system as opposed
to implying, as DSM-III and DSM-IIIR did,
that everyone should use multiaxial
Virtually no changes in criteria sets or
nomenclature. Text was vastly improved.
DSM-5 2013 - 1
To be published in early 2013. Values outlined so
A. Recommendations should be
guided by research evidence.
B. Continuity with previous editions
should be maintained.
C. No a priori constraints on the
degree of change between DSM-IV and DSM-V.
DSM-5 - 2
D. Cross-cutting issues should be
addressed when looking at all criteria:
1. Developmental, prevention,
dimensional, gender, and race/ethnicity
2. Cross-cultural applications
3. Operationalization of
“clinical significant.”
DSM-5 - 3
E. A living document that can
advance with the state of the research
should be produced. Thus, it is anticipated
that future editions will be much more
frequent, maybe every two years. [The
reason the name was changed from
“DSM-V” to “DSM-5” was to make it easier
to title, e.g. “DSM-5.1” would be harder
with Roman numbering.]
DSM-5 - 4
• Has a website, “DSM5-org,” that shows
latest thinking and has an opportunity
periodically for public input. So far, public
input of several thousand comments in
February-March, 2010, and again in MayJune. 2011.
DSM-5 organization - 1
1. Neurodevelopmental Disorders
2.Schizophrenia Spectrum and Other Psychotic Disorders
3. Bipolar and Related Disorders
4. Depressive Disorders
5.Anxiety Disorders
6.Obsessive-Compulsive and Related Disorders
7. Trauma- and Stressor-Related Disorders
8. Dissociative Disorders
9. Somatic Symptom Disorders
10.Feeding and Eating Disorders
DSM-5 organization
12. Elimination Disorders
13. Sleep-Wake Disorders
14. Sexual Dysfunctions
15.Gender Dysphoria
16.Disruptive, Impulse Control, and Conduct Disorders
17. Substance Use and Addictive Disorders
18. Neurocognitive Disorders
19. Personality Disorders
20. Paraphilias
21. Other Disorders
Intellectual Developmental
Disorders - 1
Intelligence Quotient (IQ) below the
population mean for a person’s age and
cultural group, which is typically an IQ
score of approximately 70 or below,
measured on an individualized,
standardized, culturally appropriate,
psychometrically sound test.
Intellectual Development
Disorders - 2
• Intellectual Disability also requires a
significant impairment in adaptive
• Code no longer based on IQ level.
Autism Spectrum Disorder - 1
New name for category, autism spectrum
disorder, which includes autistic disorder
(autism), Asperger’s disorder, childhood
disintegrative disorder, and pervasive
developmental disorder not otherwise
Autism Spectrum Disorder - 2
• Three domains become two:
• 1) Social/communication deficits
• 2) Fixated interests and repetitive behaviors
Autism spectrum disorder is a neurodevelopmental
disorder and must be present from infancy or
early childhood, but may not be detected until
later because of minimal social demands and
support from parents or caregivers in early
• Schizophrenia Subtypes
• The work group is recommending that the
subtypes, paranoid type, disorganized
type, undifferentiated type not be included
in DSM-5. Only catatonic would remain.
Attenuated Psychosis Syndrome
Characteristic symptoms: at least one of
the following in attenuated form with intact
reality testing, but of sufficient severity
and/or frequency that it is not discounted
or ignored;
• (i)
• (ii)
• (iii)
disorganized speech
Depressive Disorders
Outline - 1
• Disruptive Mood Dysregulation
• Disorder Major Depressive Disorder,
Single Episode
• Major Depressive Disorder,
Recurrent Disorder
• Chronic Depressive Disorder (Dysthymia)
• Premenstrual Dysphoric Disorder
• Mixed Anxiety/Depression
Depressive Disorder
Outline - 2
• Substance-Induced Depressive Disorder
• Depressive Disorder Associated with a
Known General Medical Condition
• Other Specified Depressive Disorder
• Unspecified Depressive Disorder
Disruptive Mood Dysphoric
Disorder - 1
• A. The disorder is characterized by severe recurrent
temper outbursts in response to common stressors.
• 1. The temper outbursts are manifest verbally and/or
behaviorally, such as in the form of verbal rages, or
physical aggression towards people or property.
• 2. The reaction is grossly out of proportion in intensity or
duration to the situation or provocation.
• 3. The responses are inconsistent with developmental
• B. Frequency: The temper outbursts occur, on average,
three or more times per week.
Disruptive Mood Dysphoric
Disorder - 2
• C. Mood between temper outbursts:
• 1. Nearly every day, the mood between temper
outbursts is persistently negative (irritable,
angry, and/or sad).
• 2. The negative mood is observable by others
(e.g., parents, teachers, peers).
• D. Duration: Criteria A-C have been present for
at least 12 months. Throughout that time, the
person has never been without the symptoms of
Criteria A-C for more than 3 months at a time.
Disruptive Mood Dysphoric
Disorder - 3
E. The temper outbursts and/or negative
mood are present in at least two settings
(at home, at school, or with peers) and
must be severe in at least in one setting.
F. The onset is before age 10 years
MDD, Single Episode - 1
A. Presence of a single Major Depressive
• B. The Major Depressive Episode is not
better accounted for by Schizoaffective
Disorder and is not superimposed on
Schizophrenia, Schizophreniform Disorder,
Delusional Disorder, or Psychotic Disorder
Not Otherwise Specified.
MDD – Single episode - 2
• C. There has never been a Manic Episode
or a Hypomanic Episode.
• Note: This exclusion does not apply if all
of the manic-like, mixed-like, or
hypomanic-like episodes are substance or
treatment induced or are due to the direct
physiological effects of a general medical
MDD - 3
• If the full criteria are currently met for a
Major Depressive Episode, specify its
current clinical status and/or features:
• Mild, Moderate, Severe Without Psychotic
Features/With Psychotic Features
MDD - 4
• Mood-Congruent Psychotic Features: The
content of all delusions and hallucinations
is consistent with the typical depressive
themes of personal inadequacy, guilt,
disease, death, nihilism or deserved
MDD - 5
• Mood-Incongruent Psychotic Features:
Delusions or hallucinations whose content
does not involve typical depressive
themes of personal inadequacy, guilt,
disease, death, nihilism or deserved
punishment are present with or without
mood-congruent psychotic features.
MDD - 6
• Chronic. This subtype is to be eliminated
from MDD. Dysthymia will take on the
word “chronic,” becoming Chronic
Depressive Disorder.
MDD - 7
With Mixed Features
With Catatonic Features
With Melancholic Features
With Atypical Features
With Anxiety, mild to severe
With Suicide Risk Severity
MDD - 8
With Postpartum Onset (can be applied to
the current or most recent Major
Depressive, Manic, or Mixed Features in
Major Depressive Disorder, Bipolar I
Disorder, or Bipolar II Disorder; or to Brief
Psychotic Disorder). Onset of episode
within 6 months postpartum.
MDD - 9
• Criteria for Severity .x3 Severe without Psychotic
Features: Several symptoms in excess of those
required to make the diagnosis, and symptoms
markedly interfere with occupational functioning
or with usual social activities or relationships
with others.
• Criteria for Severity .x4 With Psychotic Features:
Delusions or hallucinations. If possible, specify
whether the psychotic features are moodcongruent or mood-incongruent.
MDD - 10
• If the full criteria are not currently met for a Major
Depressive Episode, specify the current clinical status of
the Major Depressive Disorder or features of the most
recent episode:
• In Full Remission:
With Mixed Features
With Catatonic Features
With Melancholic Features
With Atypical Features
With Anxiety, mild to severe
With Suicide Risk Severity
With Postpartum Onset
MDD - 11
• The Work Group is proposing several
options for severity:
• -PHQ-9 (see also PHQ-9 scoring)
• -CGI
• Severity of Illness Rating (applied to previous
• Considering your total clinical experience with
this particular population, how mentally ill
• is the patient at this time?
• 0 = Not Assessed
• 1 = Normal, not at all ill
MDD - 12
2 = Borderline mentally ill
3 = Mildly ill
4 = Moderately ill
5 = Markedly ill
6 = Severely ill
7 = Among the most extremely ill patients
Prementrual Dysphoric Disorder - 1
A. In most menstrual cycles during the
past year, five (or more) of the symptoms
occurred during the final week before the
onset of menses, started to improve within
a few days after the onset of menses, and
were minimal or absent in the week
Prementrual Dysphoric Disorder - 2
B. The symptoms are associated with
clinically significant distress or
interferences with work, school, usual
social activities or relationships with others
(e.g. avoidance of social activities,
decreased productivity and efficiency at
work, school or home).
Prementrual Dysphoric Disorder - 3
In oral contraceptives users, a diagnosis of
Premenstrual Dysphoric Disorder should
not be made unless the premenstrual
symptoms are reported to be present, and
as severe, when the woman is not taking
the oral contraceptive.
Mixed Anxiety/Depression - 1
• The patient has three or four of the
symptoms of major depression (which
must include depressed mood and/or
anhedonia), and they are accompanied by
anxious distress. The symptoms must
have lasted at least 2 weeks, and no other
DSM diagnosis of anxiety or depression
must be present, and they are both
occurring at the same time.
Mixed Anxiety/Depression - 2
• Anxious distress is defined as having
two or more of the following symptoms:
irrational worry, preoccupation with
unpleasant worries, having trouble
relaxing, motor tension, fear that
something awful may happen.
A separate, codable diagnosis rather than
occurring solely within the context of Panic
Hoarding Disorder - 1
The work group is recommending that this
be included in DSM-5 but is still examining
the evidence as to whether inclusion is
merited in the main manual or in an
Appendix for Further Research.
Hoarding Disorder - 2
• A. Persistent difficulty discarding or parting
with possessions, regardless of the value
others may attribute to these possessions.
• B. This difficulty is due to strong urges to
save items and/or distress associated with
Hoarding Disorder - 3
• C. The symptoms result in the
accumulation of a large number of
possessions that fill up and clutter active
living areas of the home or workplace to
the extent that their intended use is no
longer possible. If all living areas are
uncluttered, it is only because of the
interventions of third parties (e.g., family
members, cleaners, authorities).
Hoarding Disorder - 3
• D. The symptoms cause clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning (including maintaining a safe
environment for self and others).
Hoarding Disorder - 4
E. The hoarding symptoms are not due to a
general medical condition (e.g., brain
injury, cerebrovascular disease).
Hoarding Disorder - 5
• F. The hoarding symptoms are not restricted to
the symptoms of another mental disorder (e.g.,
hoarding due to obsessions in ObsessiveCompulsive Disorder, decreased energy in
Major Depressive Disorder, delusions in
Schizophrenia or another Psychotic Disorder,
cognitive deficits in Dementia, restricted
interests in Autism Spectrum Disorder, food
storing in Prader-Willi Syndrome).
Hoarding Disorder - 6
• Specify if:
• With Excessive Acquisition: If symptoms
are accompanied by excessive collecting
or buying or stealing of items that are not
needed or for which there is no available
Hoarding Disorder - 7
• Specify whether hoarding beliefs and
behaviors are currently characterized by:
• Good or fair insight: Recognizes that
hoarding-related beliefs and behaviors
(pertaining to difficulty discarding items,
clutter, or excessive acquisition) are
Hoarding - 8
• Poor insight: Mostly convinced that hoardingrelated beliefs and behaviors (pertaining to
difficulty discarding items, clutter, or excessive
acquisition) are not problematic despite
evidence to the contrary.
• Absent insight: Completely convinced that
hoarding-related beliefs and behaviors
(pertaining to difficulty discarding items, clutter,
or excessive acquisition) are not problematic
despite evidence to the contrary.
PTSD - 1
The person was exposed to one or more
of the following event(s): death or
threatened death, actual or threatened
serious injury, or actual or threatened
sexual violation, in one or more of the
following ways: **
Experiencing the event(s) him/herself
Witnessing, in person, the event(s) as
they occurred to others
PTSD - 2
• Learning that the event(s) occurred to a close
relative or close friend; in such cases, the actual
or threatened death must have been violent or
• Experiencing repeated or extreme exposure to
aversive details of the event(s) (e.g., first
responders collecting body parts; police officers
repeatedly exposed to details of child abuse);
this does not apply to exposure through
electronic media, television, movies, or pictures,
unless this exposure is work related
Somatic Symptom Disorders
1. Complex Somatic Symptom Disorder
2. Simple Somatic Symptom Disorder
3. Illness Anxiety Disorder
4. Functional Neurological Disorder
(Conversion Disorder)
5. Psychological Factors Affecting Medical
Complex Somatic Symptom
Since Somatization Disorder,
Hypochondriasis, Undifferentiated
Somatoform Disorder, and Pain Disorder
share certain common features, namely
somatic symptoms and cognitive
distortions, the proposal is that these
disorders be grouped under this common
Simple Somatic Symptom Disorder
• One or more somatic symptoms that are
distressing and/or result in significant
disruption of daily life
• B. Excessive thoughts, feelings, and
behaviors related to these somatic
symptoms or associated health
concerns: This diagnosis requires one of
the following:
simple somatic symptom disorder
• (1) Disproportionate and persistent
thoughts about the seriousness of one's
(2) High level of anxiety about health or
(3) Excessive time and energy devoted
to these symptoms or health concerns
Eating Disorders
1. Binge Eating Disorder be recognized as a
free-standing diagnosis [in main text, not
in Appendix].
2. Eating Disorders category be renamed
Feeding and Eating Disorders to reflect
the proposal for inclusion of feeding
Hypersexual Disorder - 1
New disorder for Appendix:
A. Over a period of at least six months,
recurrent and intense sexual fantasies,
sexual urges, and sexual behavior in
association with four or more of the
following five criteria:
Hypersexual Disorder - 2
(1) Excessive time is consumed by sexual
fantasies and urges, and by planning for
and engaging in sexual behavior.
(2) Repetitively engaging in these sexual
fantasies, urges, and behavior in response
to dysphoric mood states (e.g., anxiety,
depression, boredom, irritability).
Hypersexual Disorder - 3
• (3) Repetitively engaging in sexual fantasies,
urges, and behavior in response to stressful life
events. [17]
• (4) Repetitive but unsuccessful efforts to
control or significantly reduce these sexual
fantasies, urges, and behavior. [18]
• (5) Repetitively engaging in sexual behavior
while disregarding the risk for physical or
emotional harm to self or others. [19]
Hypersexual Disorder - 4
B. There is clinically significant personal distress or
impairment in social, occupational or other
important areas of functioning associated with
the frequency and intensity of these sexual
fantasies, urges, and behavior.
C. These sexual fantasies, urges, and behavior
are not due to direct physiological effects of
exogenous substances (e.g., drugs of abuse or
medications) or to Manic Episodes.
D. The person is at least 18 years of age.
Hypersexual Disorder - 5
Specify if: [22]
Sexual Behavior With Consenting Adults
Telephone Sex
Strip Clubs
Hypersexual Disorder - 6
• Specify if:
• In Remission (No Distress, Impairment,
or Recurring Behavior and in an
Uncontrolled Environment): State
duration of remission in months:____
• In a Controlled Environment
Gender Dysphoria
Gender Dysphoria in Children
Gender Dysphoria in Adolescents or Adults
Gender Disorder in Children
• A marked incongruence between one’s
experienced/expressed gender and assigned
gender, of at least 6 months duration.
• 1. a strong desire to be of the other gender or an
insistence that he or she is the other gender (or
some alternative gender different from one's
assigned gender)
• 2. in boys, a strong preference for crossdressing or simulating female attire; in girls, a
strong preference for wearing only typical
masculine clothing and a strong resistance to
the wearing of typical feminine clothing
Gender Dysphoria in Adults
or Adolescents
A marked incongruence between one’s
experienced/expressed gender and assigned
gender, of at least 6 months duration.
• 1. a marked incongruence between one’s
experienced/expressed gender and primary
and/or secondary sex characteristics (or, in
young adolescents, the anticipated secondary
sex characteristics)
Gender Dysphoria in
Adolescents or Adult - 2
• 2. a strong desire to be rid of one’s primary
and/or secondary sex characteristics because of
a marked incongruence with one’s
experienced/expressed gender (or, in young
adolescents, a desire to prevent the
development of the anticipated secondary sex
• B. The condition is associated with clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning, or with a significantly increased risk
of suffering, such as distress or disability**
Substance Use Disorders - 1
Combines DSM-IV’s Abuse and
Dependence, replacing with term, “use
Add Gambling to this part of DSM-5
Substance Use Disorders - 2
• A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as
manifested by 2 (or more) of the following, occurring
within a 12-month period:
• recurrent substance use resulting in a failure to fulfill
major role obligations at work, school, or home (e.g.,
repeated absences or poor work performance related to
substance use; substance-related absences,
suspensions, or expulsions from school; neglect of
children or household)
• recurrent substance use in situations in which it is
physically hazardous (e.g., driving an automobile or
operating a machine when impaired by substance use)
Substance Use Disorders - 3
Continued substance use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance (e.g.,
arguments with spouse about consequences of
intoxication, physical fights)
tolerance, as defined by either of the following:
a. a need for markedly increased amounts of the
substance to achieve intoxication or desired effect
b. markedly diminished effect with continued use of
the same amount of the substance
(Note: Tolerance is not counted for those taking
medications under medical supervision such as
analgesics, antidepressants, ant-anxiety medications
or beta-blockers.)
Substance Use Disorders - 4
withdrawal, as manifested by either of the following:
a. the characteristic withdrawal syndrome for the
substance (refer to Criteria A and B of the criteria sets
for Withdrawal from the specific substances)
b. the same (or a closely related) substance is taken
to relieve or avoid withdrawal symptoms
(Note: Withdrawal is not counted for those taking
medications under medical supervision such as
analgesics, antidepressants, anti-anxiety medications
or beta-blockers.)
Substance Use Disorders - 5
• the substance is often taken in larger
amounts or over a longer period than was
• there is a persistent desire or unsuccessful
efforts to cut down or control substance
• a great deal of time is spent in activities
necessary to obtain the substance, use
the substance, or recover from its effects
Substance use Disorders - 6
• important social, occupational, or recreational
activities are given up or reduced because of
substance use
• the substance use is continued despite
knowledge of having a persistent or recurrent
physical or psychological problem that is likely to
have been caused or exacerbated by the
• Craving or a strong desire or urge to use a
specific substance.
Substance Use Disorders - 7
Severity specifiers:
Moderate: 2-3 criteria positive
Severe: 4 or more criteria positive
Specify if:
With Physiological Dependence: evidence of
tolerance or withdrawal (i.e., either Item 4 or 5 is
• Without Physiological Dependence: no evidence
of tolerance or withdrawal (i.e., neither Item 4
nor 5 is present)
Substance Use Disorders - 8
Course specifiers:
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment
Neurocognitive Disorders
• Use “neurocognitive” in place of “dementia” and divides into
“Mild” and “Major.”
• Recognizes the following specifically:
• Alzheimer's Disease
• Vascular Disease
• Fronto-Temporal Lobar Degeneration
• Traumatic Brain Injury
• Lewy Body Disease
• Parkinson's Disease
• HIV Infection
• Substance Use
• Huntington's Disease
• Prion Disease
• Other
Pedohebephilic Disorders
• Pedophilic Type—Sexually Attracted to
Prepubescent Children (Generally
Younger than 11)
• Hebephilic Type—Sexually Attracted to
Pubescent Children (Generally Age 11
through 14)
Paraphilic Coercive Disorder
Might be put in appendix:
A. Over a period of at least six
months, recurrent, and intense sexual arousal
from sexual coercion, as manifested by
fantasies, urges, or behaviors.
• B. The person has clinically significant
distress or impairment in important areas of
functioning, or has sought sexual stimulation
from forcing sex on three or more nonconsenting
persons on separate occasions.
Self-injury co-occurs with a variety of
diagnoses and that many individuals who
engage in repeated self-injury do not meet
criteria for borderline.
Multiaxial - 1
• Beginning in 2001, Washington Psychiatric
Society had motions passed as to the
Multiaxial System including a motion in
2004 to abolish is. As of mid-July,2011, it
appears that DSM-IV-TR’s Multiaxial
System will not be retained.
Multiaxial - 2
The information of Axis IV can be conveyed
using the codes used in the rest of
medicine [ICD-9-CM’s V-codes; ICD-10CM’s Z-codes].
Multiaxial System - 3
• Axis V’s three scales, confused by having
one number, might be replaced with
WHODAS [World Health Organization
Disability Scale].
Multiaxial - 4
• Washington Psychiatric Society has taken
the position that requiring the use of
Multiaxial determination results to bill for
services is unscientific, discriminatory,
unjustified burden.