DSM-5 Powerpoint
Supplement to Mash/Wolfe
Abnormal Child Psychology
(2013, 5th Edition)
This material is based on a DSM-5 Powerpoint presentation prepared by Kenneth
J. Zucker and on the DSM-5 supplement to Barlow and Durand, Abnormal
Psychology, prepared by Jade Qi Wu, Hannah Tavormina, David Barlow and
Mark Durand. Adapted with permission.
1
Some Early Proposals for the DSM-5
• A revised meta-structure and harmonization with
ICD-11 (~ 2015)
• Reduced usage of NOS (Not Otherwise Specified)
• Dimensional diagnosis to complement categorical
diagnosis
• Deletion of the distress/impairment criterion (X)
• Greater emphasis on a life-course developmental
perspective, culture-related, and gender-related
diagnostic issues
• Elimination of the multiaxial system (Axes I-V)
• Biomarkers
2
• DSM-5 as a “living document” (5.1, 5.2, etc.)
General Changes in DSM-5
• Revised definition of a mental disorder and
distress/impairment criterion
• Some dimensional options described in Section III
(Assessment Measures)
• Not Otherwise Specified Becomes “Other
Specified X Disorder” and “Unspecified X
Disorder”
• Section III contains a chapter on Cultural
Formulation and the Appendix contains a
Glossary of Cultural Concepts of Distress (9
examples: Ataque of nervios, Dhat syndrome, 3
Susto, etc.)
Definition of a Mental Disorder
DSM-IV-TR
“…conceptualized as a clinically significant behavioral or psychological
syndrome or pattern that occurs in an individual and that is associated
with present distress…or disability…or with a significantly increased risk
of suffering death, pain, disability, or an important loss of
freedom….Whatever its origin, it must currently be considered a
manifestation of a behavioral, psychological, or biological dysfunction in
the individual.”
DSM-5
“…a syndrome characterized by clinically significant disturbance in an
individual’s cognition, emotional regulation, or behavior that reflects a
dysfunction in the psychological, biological, or developmental processes
underlying mental functioning. Mental disorders are usually associated
with significant distress or disability in social, occupational, or other
important activities.”
4
The Distress/Impairment Criterion
Examples from DSM-5
• Symptoms cause clinically significant impairment in social,
occupational, or other important areas of current functioning
• The symptoms cause clinically significant impairment in social,
occupational, or other important areas of functioning
• The symptoms cause clinically significant impairment in social,
academic, occupational, or other important areas of functioning
• The condition is associated with clinically significant distress or
impairment in social, school, or other important areas of functioning
• A problematic pattern of X leading to clinically significant impairment
or distress…
• The symptoms…cause clinically significant distress in the individual
• Some diagnoses (e.g., Encopresis) do not have a distress/impairment
criterion or do not require distress or impairment (e.g., Enuresis)
5
Chapter Organization for DSM-5
A. Neurodevelopmental Disorders
B. Schizophrenia Spectrum and Other
Psychotic Disorders
C. Bipolar and Related Disorders
D. Depressive Disorders
E. Anxiety Disorders
F. Obsessive-Compulsive and Related
Disorders
Chapter Organization for DSM-5 (cont’d)
G. Trauma- and Stressor-Related Disorders
H. Dissociative Disorders
I. Somatic Symptom and Related Disorders
J. Feeding and Eating Disorders
K. Elimination Disorders
L. Sleep-Wake Disorders
M.Sexual Dysfunctions
N. Gender Dysphoria
Chapter Organization for DSM-5 (cont’d)
O. Disruptive, Impulse Control, and
Conduct Disorders
P. Substance-Related and Addictive
Disorders
Q. Neurocognitive Disorders
R. Personality Disorders
T. Paraphilic Disorders
U. Other Mental Disorders
Changes in Chapter Structure
DSM-IV-TR
DSM-5
Diagnostic Criteria
Diagnostic Criteria
• Diagnostic Features
• Diagnostic Features
• Associated Features and Disorders
• Associated Features Supporting the Diagnosis
• Prevalence
• Prevalence
• Course
• Development and Course
• Familial Pattern
• Risk and Prognostic Factors
• Specific Culture, Age, and Gender
Features
• Culture-Related Diagnostic Issues
• Gender-Related Diagnostic Issues
• Diagnostic Markers
• Suicide Risk
• Functional Consequences
• Differential Diagnosis
• Differential Diagnosis
• Comorbidity
9
Overview of Key Changes in DSM-5
Relevant to Children and Adolescents
1. Greater Attention to Developmental Issues in
Diagnosis
2. Changes in Organization Related to Childhood
Disorders
3. Other Changes in Organization
4. New Categories for Children
5. Changes to Existing Categories for Children
6. Addition of Subtypes and Specifiers
7. Proposed New Disorders and Features (Section
III)
10
1. Greater Attention to Developmental
Issues in Diagnosis
• Subsections of the text of DSM-5 on “Development
and Course” describe how presentations of the
disorder may change across the lifespan.
• Age-related factors in diagnosis such as symptom
presentation and differences in prevalence are
included.
• The DSM-5 manual is organized to reflect a lifespan
approach, with disorders typically diagnosed in
children (e.g., neurodevelopmental disorders) at the
beginning and those more applicable to older adults
(e.g., neurocognitive disorders) at the end.
11
Greater Attention to Developmental Issues
in Diagnosis (cont’d)
• Age-related factors have been added to the
diagnostic criteria (e.g., revised criteria for
posttraumatic stress disorder in children
under age 6; specific criteria to describe
how symptoms are expressed in children).
• Greater integration of information
regarding sex and gender differences and
cultural issues into diagnosis as relevant.
12
2. Changes in Organization
Related to Childhood Disorders
• Consistent with a lifespan emphasis, and in an effort to integrate
developmental issues throughout, DSM-5 has eliminated the
separate section for “Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence” previously included in
DSM-IV. For the most part, these disorders (e.g., ADHD,
Autism Spectrum Disorder) now appear in a section on
neurodevelopmental disorders, but not entirely.
• For example, a number of disorders usually first diagnosed in
infancy (e.g., reactive attachment disorder, pica) and childhood
(e.g., selective mutism, separation anxiety disorder, oppositional
defiant disorder, conduct disorder) are now integrated
throughout the manual in sections with other disorders that have
a later onset.
13
Changes in Organization Related to
Childhood Disorders (cont’d)
 The goal of emphasizing a lifespan approach and greater
recognition of the fact that many disorders can and do manifest
across the lifespan has merit.
 While true that boundaries drawn between disorders of
childhood and other age groups are arbitrary, and potentially
hamper tests of continuity of disorders over time, the long-term
implications of this significant change to DSM organization are
unclear.
 The addition of a specific section dedicated to disorders of
childhood in DSM-III was widely regarded as having played a
critical role in increasing research interest in childhood
disorders; whether removing this distinction will result in a
decrease in the level of attention being paid to disorders of
14
children remains to be seen (Hayden and Mash, in press).
3. Other Changes in Organization
• DSM-5 has moved to a nonaxial documentation of
diagnosis, eliminating the multiaxial system (Axis I,
II, III, IV, and V) included in DSM-IV-TR.
• The melding of Axes I, II, and III reflects the view
that different mental disorders are fundamentally
conceptualized in a similar way, integrating
biological, physical, behavioral, and psychosocial
factors and processes.
• Separate notations are now made for important
psychosocial and contextual factors (formerly Axis
15
IV) and disability (formerly Axis V).
Other Changes in Organization
(cont’d)
• Obsessive-Compulsive Disorder is no longer
included in the section on anxiety disorders,
but in a new separate section on Obsessive
Compulsive and Related Disorders (e.g.,
trichotillomania [hair-pulling disorder].
• Posttraumatic Stress Disorder and Acute Stress
Disorder are no longer included in the section
on anxiety disorder, but in a new separate
section on Trauma- and Stressor-Related
16
Disorders.
4. New Categories for Children
• Autism Spectrum Disorder (ASD)
is a new DSM-5 disorder that
contains the previous DSM-IV
autistic disorder (autism), Asperger’s
disorder, childhood disintegrative
disorder, and pervasive
developmental disorder not otherwise
specified (PDD-NOS).
17
New Categories for Children
(cont’d)
• Disruptive Mood Dysregulation Disorder
(DMDD) is a new disorder for children up to
age 18 years who exhibit persistent irritability
and frequent episodes of extreme behavioral
control.
• This new category, which is included in DSM5 as a Depressive Disorder, was added to
address concerns about potential overdiagnosis and over-treatment of bipolar
18
disorder in children.
New Categories for Children
(cont’d)
• Social (pragmatic) Communication Disorder
is a new condition involving persistent
difficulties in the social uses of verbal and
nonverbal communication.
• Some individuals previously diagnosed with
Pervasive Developmental Disorder-Not
Otherwise Specified (PDD-NOS) in DSM-IV
may meet criteria for Social Communication
Disorder, provided that they do not also display
restricted behaviors, interests, and activities. 19
5. Changes in Existing
Categories for Children
• The term Intellectual Disability (intellectual
developmental disorder) replaces the term
Mental Retardation that was used in DSM-IV.
• The names of several communication disorders
have been changed (e.g., phonological disorder
has been changed to speech sound disorder).
• A new category of Specific Learning Disorder
combines the diagnoses of Reading Disorder,
Mathematics Disorder, and Disorder of Written
20
Expression.
Changes in Existing Categories
for Children (continued)
• Symptoms of autism spectrum disorder are grouped
into two categories, rather than three:
1. Deficits in social communication and social
interaction; and
2. Restricted, repetitive patterns of behavior, interests,
or activities.
Note: Previously, deficits in communication and social
interaction were view separately. However, research now
indicates that they are best viewed as single factor
(Guthrie et al., 2013).
21
Changes in Existing Categories
for Children (cont’d)
• Selective Mutism and Separation
Anxiety Disorder are now
classified as anxiety disorders
rather than as Disorders Usually
First Diagnosed in Infancy,
Childhood, or Adolescence.
22
Changes in Existing Categories
for Children (cont’d)
• Criteria for Oppositional Defiant Disorder are
now grouped into three types: angry/irritable
mood, argumentative/defiant behavior, and
vindictiveness.
• Conduct disorder features a specifier to indicate
when it occurs with limited prosocial emotions.
This specifier is intended to capture children
with CD who display: lack of remorse or guilt,
callous-lack of empathy, unconcerned about
performance, and shallow or deficient affect. 23
6. Addition of Subtypes and
Specifiers
• DSM-5 provides subtypes and specifiers for
increased specificity of diagnoses.
• Subtypes define mutually exclusive and
jointly exhaustive subgroupings within a
diagnosis (e.g., predominantly inattentive,
predominantly hyperactive/impulsive, or
combined presentation in the case of ADHD),
and are indicated by the instruction: “Specify
whether” in the diagnostic criteria set.
24
Addition of Subtypes and Specifiers
(cont’d)
• Specifiers are used to indicate such things as
course (e.g., in partial remission, in full
remission), associated conditions (e.g., with or
without accompanying intellectual impairment),
severity level of a disorder (e.g., mild, moderate,
or severe), age of onset (e.g., onset before age 10
years), and/or others. In contrast to subtypes,
specifiers are not intended to be mutually
exclusive or jointly exhaustive, which means
that more than one specifier may be given.
25
7. Proposed New Disorders and
Features (Section III)
• DSM-5 includes a new Section III titled “Emerging
Measures and Models.” It presents new disorders
referred to as “Conditions for Further Study.”
• This section was designed to stimulate further
research on less well-studied disorders not yet
sufficiently established to be part of the official DSM5 classification system for routine clinical use.
• Three proposed conditions relevant to children &
adolescents are: “Suicidal Behavior Disorder,”
“Nonsuicidal Self-Injury,” “Neurobehavioral Disorder
Associated with Prenatal Alcohol Exposure.”
26
Proposed New Disorders and Features
(Section III) cont’d
• An alternative DSM-5 model for
personality disorders is included in
Section III. This proposal is a
hybrid model that has both a
categorical and dimensional focus.
27
Proposed New Disorders and Features
(Section III) cont’d
• Section III in DSM-5 includes a
number of emerging measures for
further research and evaluation that,
used over time, are intended to provide
more accurate and flexible clinical
descriptions of individual symptom
presentations and associated disability
during diagnostic assessments.
28
Proposed New Disorders and Features
(Section III) cont’d
• Among these measures are:
a. A measure of symptom severity across
multiple domains that can be used across all
diagnostic groups.
b. A standard measure of global disability level
(WHO Disability Assessment Scale [WHODAS];
World Health Organization, 2001) that replaces
the more limited Global Assessment of
Functioning Scale presented in DSM-IV.
29
Proposed New Disorders and Features
(Section III) cont’d
 A variety of tools, techniques, and measures are
presented that are designed to enhance clinical
decision making with children, adolescents, and
adults and to better understand the cultural context
in which mental disorders occur.
 These “emerging measures” appear in Section III
of the DSM-5 manual and, along with others, at
the following website:
http://www.psychiatry.org/practice/dsm/dsm5/onli
30
ne-assessment-measures.
ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER: Changes from DSM-IV to DSM-5
• Attention-deficit/Hyperactivity disorder
(ADHD) is now included in the DSM-5’s
Neurodevelopmental Disorders chapter
instead of the Attention-Deficit and Disruptive
Behavior Disorders Section in the Disorders
Usually First Diagnosed in Infancy,
Childhood, or Adolescence chapter (which
was eliminated entirely in DSM-5).
• Why was this done?
31
ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER:
Changes from DSM-IV to DSM-5 (cont’d)
Two main reasons:
1. ADHD shares with these other disorders an
early onset and persistent course.
2. ADHD is often associated with disruptions in
neurodevelopment and other developmental
problems in language, motor, and social
development that overlap with the other
neurodevelopmental disorders (Nigg &
32
Barkley, in press).
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER:
Changes from DSM-IV to DSM-5 (cont’d)
• The DSM-5 diagnostic criteria for Attention
Deficit/Hyperactivity Disorder (ADHD) have been
revised to better allow the diagnosis of adults with
ADHD. Research has shown that although ADHD
begins in childhood, it can continue into adulthood for
some individuals.
• To assist in its application across the life span, DSM5 includes examples to illustrate the types of behavior
children, older adolescents, and adults with ADHD
might exhibit.
33
ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER: Changes from DSM-IV to DSM-5
(cont’d)
• A symptom threshold change for adults has been made
with the cutoff for ADHD of five symptoms, instead of
six required for younger individuals, for both
inattention and for hyperactivity/impulsivity.
• Onset of impairing symptoms before age 7 has been
changed to onset of symptoms before age 12. Support
for this change comes from research showing no
clinical differences between children identified prior to
7 years versus later with respect to severity, course,
outcome, or response to treatment (Barkley, 2010). 34
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER:
Changes from DSM-IV to DSM-5 (cont’d)
• A comorbid diagnosis with Autism
Spectrum Disorders is now allowed in the
DSM-5, since research has found that
symptoms of both disorders can and do cooccur.*
*Kotte et al., in press, Pediatrics.
35
Neurodevelopmental Disorder:
ADHD
DSM-IV-TR
DSM-5
Attention-Deficit/Hyperactivity
Disordera
Attention-Deficit/Hyperactivity
Disorder
• Inattention (6/9)
• Hyperactivity-impulsivity (6/9)
• Inattention (6/9)
• Hyperactivity and impulsivity (6/9)
• Age of onset: before age 7
• Age of onset: before age 12
• Symptoms described so as to better
able to diagnose adolescents and
adults
aClassified
as a disorder Usually First Diagnosed in Infancy, Childhood, or
Adolescence
36
DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT
DISORDERS, and ANTISOCIAL PERSONALITY DISORDER:
Changes from DSM-IV to DSM-5
• Oppositional defiant disorder
• Conduct Disorder
• Antisocial Personality Disorder
37
Oppositional Defiant Disorder:
Changes from DSM-IV to DSM-5
• DSM-5 groups symptoms of Oppositional
Defiant Disorder into three types, in order
to reflect that the disorder includes
emotional and behavioral components:
1. angry/irritable mood
2. argumentative/defiant behavior
3. vindictiveness (spiteful)
38
Oppositional Defiant Disorder (ODD):
Changes from DSM-IV to DSM-5 (cont’d)
• DSM-5 has removed the exclusionary
criterion of conduct disorder and
antisocial personality disorder (in
individuals age 18 years or older) from
the oppositional defiant disorder
diagnosis, since these disorders can
and do co-occur.
39
Oppositional Defiant Disorder (ODD):
Changes from DSM-IV to DSM-5 (cont’d)
• DSM-5 provides additional guidance regarding
the frequency typically needed for a behavior
to be considered symptomatic of the disorder.
• Since many symptoms of ODD occur
commonly in normally developing children and
adolescents, this information is intended to
help differentiate ODD from normal
oppositional behavior.
40
Oppositional Defiant Disorder (ODD):
Changes from DSM-IV to DSM-5 (cont’d)
• DSM-5 adds a severity rating to the
criteria for oppositional defiant
disorder to reflect research showing
that the extent of pervasiveness of
symptoms across settings is a
significant indicator of severity.
41
Conduct Disorder (CD):
Changes from DSM-IV to DSM-5
• The diagnostic criteria for conduct
disorder in DSM-5 are mostly unchanged
from DSM-IV.
• DSM-5 adds a descriptive features
specifier for individuals meeting full
criteria for conduct disorder and also
presenting “with limited prosocial
emotions.”
42
Conduct Disorder (CD):
Changes from DSM-IV to DSM-5 (cont’d)
• To qualify for the “limited prosocial emotions” (LPE) specifier
the individual must persistently display at least two of the
following four characteristics:
1. lack of remorse or guilt
2. callous-lack of empathy
3. unconcerned about performance
4. shallow or deficient affect
• Limited prosocial emotions applies to individuals with CD who
show a callous and unemotional interpersonal style persistently
and across multiple settings and relationships.
• This specifier is based on research showing that individuals with
CD who meet criteria for LPE tend to have a relatively more
severe form of the disorder and a different treatment response43
(Frick, Ray, Thornton, & Kahn, 2013).
Disruptive, Impulse Control, and Conduct Disorders
DSM-IV-TR
DSM-5
Oppositional Defiant Disorder (4/8)a
Oppositional Defiant Disorder (4/8)
•Angry/Irritable Mood
•Argumentative/Defiant Behavior
•Vindictiveness
Conduct Disorder (3/15)a
•Aggression to people and animals
•Destruction of property
•Deceitfulness or theft
•Serious violation of rules
Conduct Disorder (3/15)
•Aggression to people and animals
•Destruction of property
•Deceitfulness or Theft
•Serious violation of rules
Specifiers
•Childhood-onset type
•Adolescent-onset type
Specifiers (with limited prosocial
emotions)
•Lack of remorse or guilt
•Callous—lack of empathy
•Unconcerned about performance
•Shallow or deficient affect
aClassified
as a disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence 44
Antisocial Personality Disorder (APD):
Changes from DSM-IV to DSM-5
• DSM-5 diagnostic criteria for all personality disorders,
including Antisocial Personality Disorder are identical to those
found in DSM-IV.
• During the development of the DSM-5, some professionals
working on the DSM-5 personality disorders criteria proposed
an alternative model for conceptualizing personality disorders.
• Following this model, all personality disorders, including
Antisocial Personality Disorder, would be described using
standardized criteria that described impaired personality
functioning related to self and others, and pathological
45
personality traits.
Antisocial Personality Disorder (APD):
Changes from DSM-IV to DSM-5 (cont’d)
• In the case of Antisocial Personality Disorder, the proposed
pathological personality traits include Antagonism
(manipulativeness, callousness, deceitfulness, hostility), and
Disinhibition (risk taking, impulsivity, and irresponsibility).
• Although the alternative model was not officially adopted, it is
included in the DSM-5 (Section III), separate from diagnostic
criteria. The table immediately after the Diagnostic Criteria for
Antisocial Personality Disorder presented below, outlines the
proposed diagnostic structure of personality disorders. This
structure provides a useful way of thinking about personality
functioning, because it highlights areas that are problematic
46
across all personality disorders.
Personality Disorders
DSM-IV-TR
Paranoid
Schizoid
Schizotypal
Antisocial
Borderline
Histrionic
Narcissistic
Avoidant
Dependent
Obsessive-Compulsive
NOS
DSM-5
Unchanged
47
Personality Disorders
DSM-IV Personality Disorders
Paranoid
Schizoid
Schizotypal
Antisocial
Borderline
Histrionic
Narcissistic
Avoidant
Dependent
Obsessive-Compulsive
NOS
Section III: Alternative DSM-5 Model
for Personality Disorders
----Schizotypal
Antisocial
Borderline
--Narcissistic
Avoidant
--Obsessive-Compulsive
48
Personality Disorders
Section III: Alternative DSM-5
Model for Personality
Disorders
• General Criteria for
Personality Disorder
• Criterion A: Level of
Personality Functioning
• Criterion B: Pathological
Personality Traits
• Personality Disorder-Trait
Specified
7 features
Self (Identity, Self-direction)
and Interpersonal (Empathy,
Intimacy)
2 of 4 of Criterion A
1 of 4 trait domains: Negative
affectivity, detachment,
antagonism, disinhibition,
psychoticism (30+ facets)
49
Anxiety Disorders:
Changes from DSM-IV to DSM-5
• Note: In DSM-5, the DSM-IV category Anxiety Disorders
has been subdivided into three categories: anxiety disorders,
trauma- and stressor-related disorders, and obsessivecompulsive and related disorders.
• General changes to DSM-5 anxiety disorders:
• Selective Mutism and Separation Anxiety Disorder are
newly classified as anxiety disorders. They were previously
classified as Disorders Usually First Diagnosed in Infancy,
Childhood or Adolescence.
• In DSM-5, Separation Anxiety Disorder may be diagnosed
50
in adults.
Anxiety Disorders:
Changes from DSM-IV to DSM-5 (cont’d)
• For several disorders, the individual no longer needs
to recognize that his or her anxiety is excessive.
• Agoraphobia is now a disorder in its own right,
instead of being classified in the context of other
disorders. In addition, it is now diagnosed
separately from panic disorder.
• Social anxiety disorder is no longer conceptualized
as generalized versus non-generalized; instead, a
new specifier performance-only has been added.51
Anxiety Disorders
DSM-IV-TR
DSM-5
Separation Anxiety Disordera
Separation Anxiety Disorder
Selective Mutisma
Selective Mutism
Specific Phobia
Specific Phobia
Social Phobia (Social Anxiety Disorder)
Social Anxiety Disorder (Social
Phobia)
Panic Disorder Without Agoraphobia
Panic Disorder
Panic Disorder With Agoraphobia
Agoraphobia
Generalized Anxiety Disorder
Generalized Anxiety Disorder
aClassified
as a disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence
52
Obsessive Compulsive and Related Disorders:
Changes from DSM-IV to DSM-5
• In DSM-IV, these disorders were classified as
anxiety disorders. The new DSM-5 category
Obsessive-Compulsive and Related Disorders
highlights the importance of obsessive thoughts
and compulsive behavior in these disorders.
• Body dysmorphic disorder is newly classified
among obsessive-compulsive and related
disorders, having been classified as a somatic
53
symptom disorder in DSM-IV.
Obsessive Compulsive and Related Disorders:
Changes from DSM-IV to DSM-5 (cont’d)
• Trichotillomania (hair-pulling disorder) is newly
classified among obsessive-compulsive and related
disorders, having been classified as an impulse control
disorder in DSM-IV.
• There are two new disorders in this category:
– Excoriation (skin-picking disorder), previously
classified as an example of impulse control
disorders.
– Hoarding disorder, previously described as one
manifestation of obsessive-compulsive disorder. 54
Obsessive-Compulsive and Related Disorders
DSM-IV-TR
DSM-5
Obsessive-Compulsive Disordera Obsessive-Compulsive Disorder
Body Dysmorphic Disorderb
Body Dysmorphic Disorder
Hoarding Disorder
Trichotillomaniac
Trichotillomania (Hair-Pulling)
Disorder
Excoriation (Skin-Picking) Disorder
aClassified
as an Anxiety Disorder
bClassified as a Somatoform Disorder
cClassified as an Impulsive-Control Disorder NEC
55
Trauma and Stressor Related Disorders:
Changes from DSM-IV to DSM-5
• In DSM-IV, these disorders were classified as anxiety
disorders. The new category of Trauma- and StressorRelated disorders emphasizes that these disorders
follow exposure to an acute or chronic stressor (e.g.,
assault, combat, abuse during childhood).
• There are two new disorders in this category: Reactive
Attachment Disorder and Disinhibited Social
Engagement Disorder. These respectively reflect the
inhibited and disinhibited subtypes of DSM-IV
Reactive Attachment Disorder.
56
Trauma and Stressor Related Disorders:
Changes from DSM-IV to DSM-5 (cont’d)
• Separate criteria are provided for diagnosing
Posttraumatic Stress Disorder in children age 6
years and younger, reflecting the differential
presentation of the disorder in young children.
• Diagnostic criteria for the nature of “traumatic
event(s)” have become slightly more inclusive.
• Trauma exposure is now conceptualized as
possibly involving multiple traumatic events.57
Trauma- and Stressor-Related Disorders
DSM-IV-TR
DSM-5
Reactive Attachment Disorder of Infancy
or Early Childhooda
•Inhibited type
•Disinhibited type
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorderb
Posttraumatic Stress Disorder
(separate criteria for children 6 and younger)
Acute Stress Disorderb
Acute Stress Disorder (9/14)
•experienced directly
•witnessed
•experienced indirectly
•subjective reaction to the event eliminated in
Criterion A in DSM-IV
Adjustment Disorders
Adjustment Disorders
aClassified
as a disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence
bClassified as an Anxiety Disorder
58
Depressive Disorders:
Changes from DSM-IV to DSM-5
• The DSM-IV chapter on Mood Disorders, which
included both depressive and bipolar diagnoses,
has been replaced by two separate chapters, one
on Depressive Disorders and the second on
Bipolar and Related Disorders.
• DSM-IV diagnoses of “Dysthymia and Major
Depressive Disorder – Chronic” have been
combined in the DSM-5 diagnosis “Persistent
59
Depressive Disorder.”
Depressive Disorders:
Changes from DSM-IV to DSM-5 (cont’d)
• There is a new depressive disorder in DSM-5
with special relevance for diagnosing children.
• Disruptive Mood Dysregulation Disorder is a
new disorder that reflects persistent irritability
and frequent episodes of extreme behavioral
dyscontrol in the form of temper tantrums in
children, who in the past would have been (often
erroneously) diagnosed with bipolar disorder.
60
DISRUPTIVE MOOD DYSREGULATION
DISORDER
Criterion A - Temper outbursts
• Severe recurrent temper outburst manifested verbally
(e.g., verbal rages) and/or behaviorally (e.g., physical
aggression toward people or property) that are grossly
out of proportion in intensity or duration to the
situation or provocation.
Criterion B - Inconsistency with developmental level
• The temper outbursts are inconsistent with
developmental level.
Criterion C - Frequency of outbursts
• The temper outbursts occur, on average, three or more
61
times per week.
DISRUPTIVE MOOD DYSREGULATION
DISORDER (cont’d)
Criterion D - Mood between outbursts
• The mood between temper outbursts is
persistently irritable or angry most of the day,
nearly every day, and is observable by others
(e.g., parents, teachers, peers).
Criterion E - Duration and chronicity
• Criteria A-D have been present for 12 or more
months. Throughout that time, the individual has
not ahd a period lasting 3 or more consecutive
months without all of the symptoms in Criteria62
A-D.
DISRUPTIVE MOOD DYSREGULATION
DISORDER (cont’d)
Criterion F - Context and severity
• Criteria A and D are present in at least two of
three settings (i.e., at home, at school, with
peers) and are severe in at least one of these.
Criterion G - Age of diagnosis
• The diagnosis should not be made for the first
time before age 6 years or after age 18 years.
Criterion H - Age of onset
• By history or observation, the age at onset of
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Criteria A-E is before 10 years.
DISRUPTIVE MOOD DYSREGULATION
DISORDER (con’t)
Criterion I - Absence of mania
• There has never been a distinct period lasting
more than 1 day during which the full
symptom criteria, except duration, for a manic
or hypomanic episode have been met.
• Note: Developmentally appropriate mood
elevation, such as occurs in the context of a
highly positive event or its anticipation, should
not be considered as a symptom of mania or
hypomania.
64
DISRUPTIVE MOOD DYSREGULATION
DISORDER (con’t)
Criterion J - Distinction from other mental disorders
•The behaviors do not occur exclusively during an
episode of major depressive disorder and are not
better explained by another mental disorder (e.g.,
autism spectrum disorder, posttraumatic stress
disorder, separation anxiety disorder, persistent
depressive disorder [dysthymia]).
Criterion K - Distinction from other conditions
•The symptoms are not attributable to the
physiological effects of a substance or to another
65
medical or neurological condition.
Depressive Disorders:
Changes from DSM-IV to DSM-5 (cont’d)
• The DSM-IV Bereavement Exclusion, which
suggested that depressive symptoms cannot
be diagnosed as a depressive disorder in the
context of bereavement lasting less than two
months after a major loss (e.g., death of a
loved one), has been removed. This highlights
the fact that grief and major depression are
related yet independent conditions.
66
Depressive Disorders:
Changes from DSM-IV to DSM-5 (cont’d)
• With mixed features is a new specifier that
reflects experiencing depressive symptoms
during a manic or hypomanic episode, or
manic symptoms during a depressive
episode.
• With anxious distress is a new specifier
that reflects experiencing anxiety during a
depressive, manic or hypomanic episode.
67
Depressive Disorders:
Changes from DSM-IV to DSM-5 (cont’d)
• Note: Athough they are not designated as
disorders in DSM-5, “Suicidal Behavior
Disorder” and “Non-Suicidal Self-Injury”
have been added to the “Conditions for
Further Study” section of DSM-5.
Suicidal behavior and non-suicidal selfinjury are related to mood disorders in
young people.
68
Depressive Disorders
DSM-IV-TR
DSM-5
Disruptive Mood Dysregulation Disorder
(11 criteria)
Major Depressive Episode (5/9)
Major Depressive Disorder (Single,
Recurrent)
Major Depressive Disorder (5/9)
•Bereavement as an exclusion criterion
deleted
Dysthymic Disorder (2/6)
Persistent Depressive Disorder
(Dysthymia) (2/6)
Premenstrual Dysphoric Disordera
Premenstrual Dysphoric Disorder (5/11)
Mood Disorder NOS
Other Specified Depressive Disorder
Unspecified Depressive Disorder
aClassified
in Appendix B (Criteria Sets and Axes Provided for Further Study)
69
Neurodevelopmental Disorders:
Intellectual Disability
• DSM-5 substitutes the category
Intellectual Disability (intellectual
developmental disorder) for the
category previously referred to as
Mental Retardation in DSM-IV.
70
Neurodevelopmental Disorders:
Intellectual Disability (cont’d)
• Intellectual Disability is the term formally
adopted by the American Association on
Intellectual and Developmental Disabilities
and is the term most commonly used in
research journals, and by medical,
educational, other professionals, and the
lay public.
71
Neurodevelopmental Disorders:
Intellectual Disability (cont’d)
• DSM-5 replaces the DSM-IV category of “Mental Retardation,
Severity Unspecified” with the diagnosis of Global
Developmental Delay.
• The Global Developmental Delay diagnosis is reserved for
children under the age of 5 when clinical severity level cannot be
reliably assessed during early childhood.
• The diagnosis applies to children who fail to meet developmental
milestones in several areas of intellectual functioning but who are
unable or too young to participate in systematic/standardized
assessments of intellectual functioning.
• This diagnosis requires reassessment following a period of time.
72
Neurodevelopmental Disorders:
Intellectual Disability (cont’d)
• The DSM-5 defines the various levels of severity
for Intellectual Disability (using the Mild,
Moderate, Severe, and Profound specifiers) on
the basis of adaptive functioning, and not IQ
scores.
• This change was made since it is adaptive
functioning that determines what levels of
support are required. Also, IQ scores are less
73
valid in the lower end of the IQ range.
Neurodevelopmental Disorders:
Autism Spectrum Disorder
• The DSM-5 combines four previous diagnoses
into Autism Spectrum Disorder, reflecting a
general consensus among scientists that Autistic
Disorder, Asperger’s Disorder, Childhood
Disintegrative Disorder, and Pervasive
Developmental Disorder Not Otherwise
Specified are actually one condition with
different levels of severity.
74
Neurodevelopmental Disorders:
Autism Spectrum Disorder (cont’d)
• DSM-5 no longer includes the overarching
category of Pervasive Developmental
Disorders.
• The genetic syndrome of Rett’s disorder has
been removed from DSM-5 but, when
present, can be specified as an associated
known genetic disorder when a diagnosis of
autism spectrum disorder has been made. 75
Neurodevelopmental Disorders:
Autism Spectrum Disorder (cont’d)
• The DSM-5 specifies three levels of severity for
Autism Spectrum Disorder symptoms in relation to
the amount of required support in each the two
component areas of Social Communication and
Restricted, Repetitive Behaviors. This change was
made to provide a compact and precise description
of the severity of the individual’s current symptoms
while recognizing that symptom severity and
required support may vary across situations and
76
over time.
Neurodevelopmental Disorders:
Autism Spectrum Disorder
DSM-IV-TR
Autistic Disordera
Rett’s Disordera
Childhood Disintegrative Disordera
Asperger’s Disordera
Pervasive Developmental Disorder NOSa
DSM-5
Autism Spectrum Disorder
Social (Pragmatic) Communication
Disorder
aClassified
as a disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence
77
Neurodevelopmental Disorders:
Communication Disorders
• The DSM-5 combines two previous diagnoses
into Language Disorder, integrating the often cooccurring Expressive Language Disorder and
Mixed Receptive-Expressive Language
Disorder.
• DSM-IV’s Phonological Disorder was renamed
Speech Sound Disorder in DSM-5.
• DSM-IV’s Stuttering was renamed Childhood78
Onset Fluency Disorder (Stuttering) in DSM-5.
Neurodevelopmental Disorders:
Communication Disorders (cont’d)
• The DSM-5 adds a new communication disorder,
Social (Pragmatic) Communication Disorder, which
involves persistent difficulties in using verbal and
nonverbal communication socially.
• Some individuals previously diagnosed with PDDNOS (Pervasive Developmental Disorder-Not
Otherwise Specified in DSM-IV may meet criteria
for Social Communication Disorder, provided that
they do not also display restricted behaviors, 79
interests, and activities.
Diagnostic Criteria for Social
(Pragmatic) Communication Disorder
Criterion A - Persistent difficulties in the social use of
verbal and nonverbal communication as manifested by all of
the following:
• Deficits in using communication for social purposes, such
as greeting and sharing information, in a manner that is
appropriate for the social context.
• Impairment of the ability to change communication to
match context or the needs of the listener, such as
speaking differently in a classroom than on a playground,
talking differently to a child than to an adult, and
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avoiding use of overly formal language.
Diagnostic Criteria for Social (Pragmatic)
Communication Disorder (cont’d)
• Difficulties following rules for language and
storytelling, such as taking turns in conversation,
rephrasing when misunderstood, and knowing how
to use verbal and nonverbal signals to regulate
interaction.
• Difficulties understanding what is not explicitly
stated (e.g., making inferences) and nonliteral or
ambiguous meanings of language (e.g., idioms,
humor, metaphors, multiple meanings that depend
81
on the context for interpretation).
Diagnostic Criteria for Social (Pragmatic)
Communication Disorder (cont’d)
Criterion B - Impairment
• The deficits result in functional limitations in effective
communication, social participation, social
relationships, academic achievement, or occupational
performance, individually or in combination.
Criterion C - Onset
• The onset of the symptoms is early in the
developmental period (but deficits may not become
fully manifest until social communication demands
82
exceed limited capacities).
Diagnostic Criteria for Social (Pragmatic)
Communication Disorder (cont’d)
Criterion D - Exclusionary conditions and
diagnoses
•The symptoms are not attributable to another
medical or neurological condition or to low
abilities in the domains of word structure and
grammar, and are not better explained by autism
spectrum disorder, intellectual disability
(intellectual developmental disorder), global
83
developmental delay, or another mental disorder.
Neurodevelopmental Disorders:
Specific Learning Disorder
• The DSM-5 combines four DSM-IV diagnoses
(Reading Disorder, Mathematics Disorder,
Disorder Of Written Expression, and Learning
Disorder Not Otherwise Specified diagnoses) in
a single Specific Learning Disorder category. By
doing so, the DSM-5 integrates DSM-IV’s
frequently co-occurring Reading Disorder,
Mathematics Disorder, and Disorder Of Written
84
Expression.
Neurodevelopmental Disorders:
Specific Learning Disorder (con’t)
• However, within the Specific Learning
Disorder diagnosis, DSM-5 uses
specifiers to designate whether the
impairments are in reading, written
expression, mathematics or more than
one of these areas, and provides
examples of types of deficits for each
area.
85
Neurodevelopmental Disorders:
Motor Disorders
• Stereotypic movement disorder has been more
clearly differentiated from body-focused
repetitive behavior disorders that are in the
DSM-5 obsessive-compulsive disorder chapter.
• The DSM-5 Tic Disorders category was changed
to include Tourette’s Disorder, Persistent
(Chronic) Motor or Vocal Tic Disorder, and
Provisional Tic Disorder. The tic criteria have
86
been standardized across all of these disorders.
Schizophrenia Spectrum and
Other Psychotic Disorders
DSM-IV-TR
DSM-5
Delusional Disorder
Shared Psychotic Disorder (Folie a
Deux)
Delusional Disorder
•requirement that the delusions be
“nonbizarre” has been eliminated
Brief Psychotic Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophreniform Disorder
Schizophrenia (2/5)
Schizophrenia (2/5)
•Requirements for Criterion A
modified
•subtypes eliminated
Schizoaffective Disorder
Schizoaffective Disorder
87
Substance Related and Addictive
Disorders
• The distinction between Substance Abuse Disorder and
Substance Dependence Disorder has been eliminated in
DSM-5. Now, these two previously separate disorders
are replaced by a combined Substance Use Disorder,
which includes symptoms of both Substance Abuse and
Substance Dependence
• Diagnostic criteria for substance intoxication are now
specified for each group of substances, and there is no
longer a general Substance Intoxication diagnosis in the
DSM-5.
88
Substance Related and Addictive
Disorders (cont’d)
• Additional diagnoses have been added, including,
notably Gambling Disorder and Tobacco Use
Disorder
• There is a move to characterize substance-related
disorders by severity instead of only by diagnostic
cut-off. For the general diagnosis of Substance Use
Disorder, there is a severity rating in DSM-5 based
on the number of symptoms endorsed: mild (2 to 3),
moderate (4 to 5), severe (6 or more)
89
Substance-Related and Addictive Disorders
DSM-IV-TR
Substance Dependence (3/7)
Substance Abuse (1/4)
DSM-5
Substance Use Disorders
• Alcohol Use Disorder (2/11)
• Cannabis Use Disorder
(2/11)
• Opioid Use Disorder (2/11)
• Stimulant Use Disorder
(2/11)
• Tobacco Use Disorder (2/11)
Substance-Induced Disorders
Substance-Induced Disorders
Impulse-Control Disorders NEC Non-Substance-Related
•Pathological Gambling (5/10)
Disorders
•Gambling Disorder (4/9)
90
Sleep-Wake Disorders
• Generally, sleep disorders’ diagnoses have been
revised to better reflect scientific understanding
of their pathophysiology.
• To reflect better biological understanding of
breathing-related sleep disorders, they are
divided into three separate diagnoses in the
DSM-5: obstructive sleep apnea hypopnea,
central sleep apnea, and sleep-related
91
hypoventilation.
Sleep-Wake Disorders (cont’d)
• Evidence has supported Restless Leg Syndrome and REM
Sleep Behavior Disorder to have full disorder status in DSM-5.
This will reduce the use of the “not otherwise specified”
diagnosis used in DSM-IV.
• Sleep disorder related to another mental disorder or medical
condition has been removed as a diagnosis. Instead, coexisting
conditions/substances can be better specified within each
diagnosis. This change is meant to emphasize that diagnosed
sleep disorders warrant clinical attention beyond that given to
coexisting conditions, and to acknowledge the interactive
effects between sleep and comorbid disorders.
92
Somatic Symptom and Health
Related Disorders
• In DSM-IV, somatic symptom disorders were called
somatoform disorders.
• DSM-5 reflects efforts to consolidate and rearrange
DSM-IV diagnoses that were overlapping and poorly
defined.
• The following DSM-IV Diagnoses are not present in
DSM-5: Hypochondriasis, Somatization Disorder, Pain
Disorder, Undifferentiated Somatoform Disorder.
However, some have been altered to become one or
93
more new DSM-5 diagnoses.
Somatic Symptom and Health
Related Disorders (cont’d)
• There are a number of new disorders in DSM-5. These
include Illness Anxiety Disorder and Somatic Symptom
Disorder.
• Psychological Factors Affecting Other Medical
Conditions is another new disorder in DSM-5, although
the DSM-IV noted that concerns of this nature may be
important to identify. This disorder occurs when there is
both a diagnosed medical condition and a psychological
or behavioral factor that is making that condition worse
(e.g., the anxiety in panic disorder might worsen a 94
person’s asthma).
Somatic Symptom and Health
Related Disorders (cont’d)
• Pain Disorder is now classified as “Somatic
Symptom Disorder with predominant pain.”
• Conversion Disorder is now known as
“Conversion Disorder (Functional
Neurological Symptom Disorder).” This term
is more acceptable to patients and doctors, and
it reflects the importance of taking neurological
data into account when making a diagnosis.
95
Somatic Symptom and Health
Related Disorders (cont’d)
• Factitious Disorder has been retained in DSM-5,
although its subtypes (e.g., distinguishing between
psychological vs. physical symptoms) have been
removed.
• Body Dysmorphic Disorder is now classified among
Obsessive-Compulsive and Related Disorders.
While this disorder does involve significant somatic
concerns, the new classification reflects the
important role played by obsessive and compulsive
96
symptoms.
Somatic Symptom and Related Disorders
DSM-IV-TR (Somatoform
Disorders)
DSM-5
Somatization Disorder
Undifferentiated Somatoform
Disorder
Pain Disorder
Somatic Symptom Disorder
•Requirement that the symptoms
“cannot be fully explained by a
known general medical condition”
has been removed
Hypochondriasis
Illness Anxiety Disorder
Conversion Disorder
Conversion Disorder (Functional
Neurological Symptom Disorder)
Factitious Disordera
Factitious Disorder
aClassified
in a separate chapter in DSM-IV
97
Feeding and Eating Disorders
• In DSM-5, this diagnostic category includes several
disorders previously included in DSM-IV as feeding
and eating disorders of infancy or early childhood
(i.e., pica, rumination disorder, avoidant/restrictive
food intake disorder).
• Binge-eating disorder became an official diagnosis
in the DSM-5.
• Overall, eating disorders’ definitions have not
changed conceptually from the DSM-IV to DSM-5.
98
Feeding and Eating Disorders
DSM-IV-TR
DSM-5
Picaa
Pica
Rumination Disordera
Rumination Disorder
Feeding Disorder of Infancy or Early
Childhooda
Avoidant/Restrictive Food Intake Disorder
(extended criteria)
Anorexia Nervosa
Anorexia Nervosa
•Amenorrhea deleted for postmenarcheal
females
•<85% of expected body weight criterion
deleted
•Severity criteria based on BMI
Bulimia Nervosa
Bulimia Nervosa
Binge-Eating Disorderb
Binge-Eating Disorder
aClassified
as a disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence
bClassified in Appendix B (Criteria Sets and Axes Provided for Further Study)