DZ
Rhoda Olkin, Ph.D.
Distinguished Professor
California School of Professional Psychology – SF rolkin@alliant.edu
1

7 Facts
DZ
1) DSM 5 (not V) to allow for numbering of revisions (5.1, 5.2, etc).
2) Was targeted for 2009, then 2011, now
May 22, 2013.
3) Am Psychiatric Assoc mtg in SF.
4) 2-year grace period for implementation.
5) Complete interface with ICD-11; codes in parentheses.
6) NIMH
7) Cost: $139 – $199
2

DZ
3

DZ
•
Each DSM has tried to resolve problems in previous versions.
•
Problems in DSM-IV-TR
–
Not very user friendly.
–
9 categories for diagnostic uncertainty.
–
NOS predominated.
–
Insufficient on culture.
–
Index not as good.
4

Guiding Principles for
Changes to DSM

Research evidence should support any addition or substantive modification.

Continuity with the current manual should be maintained when possible.

No restraints should limit the degree of change between DSM-5 and past editions.
(Contradiction)
 Routine clinical practices must be able to implement any changes.
5

1) Structural changes.
2) Shifting criteria.
3) New diagnoses.
4) Reclassification of diagnoses.
5) Deleted diagnoses.
6) Code #s
6

RO
Sections
•
Section 1: Intro to updates, how to use.
•
Section II: The diagnoses (22 chapters)
•
Section III: Conditions requiring further research; cultural formulations; glossary.
7

RO
Overall Structural Changes

What is the order of chapters (chronology?
Relatedness?) .

No axes
 info goes elsewhere.

Ego syntonic / dystonic (insight) specifiers:
–
Good or Fair (dystonic)
–
Poor insight (ambivalent)
–
Absent insight (syntonic)
8

RO
Overall Structural Changes p. 2
•
Some require direct knowledge over 12 mos.
•
Severity indicators (replaces Axis V: GAF).
• Severity level is “over time & circumstances.”
•
Some diagnoses go up to severity level 2, some to 3. Rating scales.
0 = None (>70 GAF)
1 = Mild (>70 GAF)
2 = Severe
3 = Very severe (<31 GAF)
9

RO
Changes
•
Axis III: Part of diagnosis on Axis I.
•
Axis IV: Make notation of psychosocial and contextual factors.
•
What happened to The Big 4 from DSM IV?
–
(GMC, substance use, malingering or factitious, normal)?
10

The Big 4
RO
•
GMC:
–
Not in index.
–
But evident throughout.
–
Often option of X Disorder Due to Another
Medical Condition (e.g., Depressive Disorder
Due to MS).
–
Sometimes not (e.g., Bipolar Dis Due to A.M.C.)
11

The Big 4
•
Malingering

Factitious Disorder
–
In Somatic Symptom & Related Disorders chapter.
–
Factitious Disorder Imposed on Self
– Factitious Disorder Imposed on Another (was “by proxy).
–
Single vs Recurrent Episodes
– “Surreptitious actions to misrepresent, simulate, or cause signs or symptoms of illness or injury in absence of obvious external rewards.” (p. 325)
–
May co-occur with medical condition (e.g., manipulating blood sugar in person with diabetes).
12

The Big 4
•
Substance Abuse: and Suicidality:
–
Elevated status.
–
Will always note the correlation.
–
Some disorders can be:
“Substance/Medication-Induced.
13

The Big 4
•
Normal:
–
Less of a concern?
• Bereavement (V code).
• Disruptive Mood Dysregulation Disorder (new).
• ASD (increased stigma?).
– “Saving normal” (Allen Francis, 2013)
14

RO
Overall Structural Changes p. 3
•
NOS

CNEC (conditions not elsewhere classified) :
–
Only for 6 months.
–
Only for specific reasons:
1) Diagnosis unclear (e.g., psychotic disorder CNEC)
2) Clinician not trained to make the dx.
3) Clinician cannot get info (e.g., client uncooperative; records not available).
4) You do not have enough info.
5) Clinicians needs or is required to take more time of direct observation (e.g., 12 months).
15

Implications?
•
Positives:
–
More reliability?
–
Better treatment planning?
–
Longer therapy authorized?
•
More work & time in the diagnostic process.
RO
•
Demand for outcome studies; clinicians to validate their treatments (Dept of Corrections)
•
Responsibilities of diagnostician.
–
Severity index.
–
Symptom scales for some disorders.
16

The Chapters
• 22 chapters.
•
New order (?).
•
Some split (e.g., anxiety disorders).
•
Some renamed (e.g., neurodevelopmental disorders).
RO
•
Some new (e.g., Trauma- & Stressor-
Related Disorders)
17

22 Chapters:
RO
1. Neurodevelopmental
Disorders
2. Schizophrenia Spectrum &
Other Psychotic Disorders
3. Bipolar & Related Disorders
4. Depressive Disorders
5. Anxiety Disorders
6. Obs-Compulsive & Related
7. Trauma- & Stressor-Related
8. Dissociative Disorders
9. Somatic Symptom Disorders
10.Feeding & Eating Disorders
11.Elimination Disorders
12.Sleep/Wake Disorders
13. Sexual Dysfunctions
14. Gender Dysphoria
15. Disruptive, Impulse-Control
& Conduct Disorders
16. Substance Related &
Addictive Disorders
17. Neurocognitive Disorders
18. Personality Disorders
19. Paraphilic Disorders
20. Other Mental Disorders
21. Medication-induced
Movement…Med Effects
22. Other Conditions (v codes)
18

Neurodevelopmental
RO
•
Not just a rename –
–
Etiology important; p. 31
–
Disorders here are considered genetic/biochemical;
–
Not responses to environment.
•
Eliminated Rett’s Disorder (genetic).
•
Includes: ADHD, ID, ASD, Communication
Disorders, Global Developmental Delay,
Motor (Tic) Disorders, Specific LD.
•
May include specifier : “associated with known med/genetic condition or environmental factor.”
•
NO: Sensory Processing Disorder (SID)
19

Neurodevelopmental
MR

Intellectual Disability (ICD-11: Int Dev Dis.)
–
PL 111-256, 2010, “ID.”
–
3 criteria: Deficits in (a) intellectual functions, (b) adaptive functioning, (c) onset during develop. period.
–
Code
319 with severity specifier: Mild (F70), Moderate
(F71), Severe (F72), Profound (F73). (Table for severity)
–
Severity is based on adaptive functioning, not IQ scores.
–
Functioning in Conceptual Domain, Social Domain,
Practical Domain.
–
Usually IQ scores 70 + 5 (Mean = 100; s.d. = 15).
– Requires testing with instruments “normed for individual’s sociocultural background and native language.” (p. 37)
20

Neurodevelopmental
RO
Autism Spectrum Disorder
(ASD):
(p. 50)
–
Now included as ASD: Autism, Aspergers,
PDD NOS, Disintegrative Disorder.
– 2 areas of disturbance:
• Social Communication & Social Interaction;
• Restricted repetitive patterns of behavior.
– Diagnostic criteria are “illustrative, not exhaustive.”
–
Table for severity level, requiring: 1-support; 2substantial support; 3-very substantial support.
–
M:F = 4:1
21

Neurodevelopmental
RO
Communication Disorders:
•
Social Communication Disorder ( new ):
•
Language Disorders
•
Speech Disorders
•
Unspecified Communication Disorder
•
All of the following DSM IV disorders are subsumed under above: Language Emergence;
Specific Language Impairment; Social
Communication Disorder; Voice Disorder; Speech-
Sound Disorder; Motor Speech Disorder; Child
Onset Fluency Disorder.
22

Neurodevelopmental
Social Communication Disorder:
•
Must have all of A.
• A.
Persistent difficulties in social use of verbal and nonverbal communication:
–
Social purposes: (greeting, sharing info).
–
Changing communication to match listener or context.
–
Difficulties following rules for conversation or storytelling (taking turns).
–
Difficulties understanding what is not explicitly stated, and nonliteral or ambiguous meanings (idioms, humor, metaphors).
23

Autism
DSM-IV-TR
Overlap Aspergers
DSM 5
RO
Autism Spectrum Disorder
Social
Communication
Disorder
24

Neurodevelopmental
RO
ADHD
(p. 59)
•
Inattention (>6/9) and/or hyperactivity-impulsivity
(>6/9) that interferes with functioning or development.
•
Prior to age 12 (instead of 7).
•
2 or more settings.
•
Specify: Combined (314.01), Predominantly inattentive presentation (314.00), Predominantly hyper/impulsive presentation (314.01). (Typo?)
•
Specify: Mild, moderate, Severe.
•
Prevalence: About 5% of children, 2.5% of adults.
•
M:F 2:1
25

Neurodevelopmental
Specific Learning Disorder:
(p. 66)
– Difficulties despite “provision of interventions” in:
– A.
6 areas (no specified # to be met).
–
Specify and code: Reading; Written expression;
Mathematics.
–
Specify: Mild, Moderate, Severe.
26

Neurodevelopmental
Motor Disorders
(p. 74)
–
Developmental Coordination Disorder.
–
Stereotypic Movement Disorder.
– Tic Disorders (specify: Tourette’s; Persistent
Motor or Vocal Tic disorder; Provisional Tic
Disorder.)
Other childhood disorders:
–
See other chapters.
27

Anxiety Disorders
DZ
Split into
3 chapters:
–
Anxiety Disorders:
• Fight or flight system (Amygdala).
–
Trauma- & Stressor-Related Disorders.
• Greater focus on affective response to external stressors.
–
OCD & Related Disorders.
• Based on imaging and genetic studies, and treatment response.
• Basal ganglia – movement circuit – focus on urge and behavior, less on anxiety.
28

Anxiety Disorders
•
Fear (fight or flight) + Anxiety (hyper-vigilance) +
Behavior (avoidance).
•
Separation Anxiety.
•
Selective Mutism.
•
Specific Phobias (more specifiers).
•
Social Anxiety Dis. (in chldrn, not just w adults).
•
Panic Disorder (4/12 symptoms + worry + behav.).
•
Agoraphobia.
•
GAD (3/6 sxs for adults, 1/6 for children).
•
Substance/medication induced; Anxiety due to AMC
•
Also Panic Attack Specifier
(p. 214) p. 189 29

DZ

OCD.

Hoarding Disorder.

Excoriation (Skin
Picking Disorder).

Hair Pulling Disorder.

Substance/Medication Induced.

Due to Another Medical Condition. p. 235 30

Obsessions vs
Compulsions

Obsessions: Recurrent & persistent thoughts, urges, or images that are experiences as intrusive and unwanted.

Compulsions: Repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be rigidly applied.
31

DZ

Exposure to traumatic or stressful event. p. 265

New grouping of disorders from various places in DSM

Adjustment Disorder.

Acute Stress Disorder.

PTSD .
– 4 clusters of symptoms: Intrusion, Avoidance, Negative mood/cognitions, Arousal & reactivity.
–
Children: expanded definition; section for < 6 yo.
–
Specifiers: (a) dissociative sxs (depersonalization or derealization); (b) delayed expression.

Attachment disorders (next slide).
32

Attachment related disorders:

Common etiology: Absence of adequate caregiving during childhood.

Reactive Attachment Disorder:
 Internalizing disorder: depression, withdrawal.
 New criteria (4/5 sxs; onset between 9 mos. & 5 yrs.)

Disinhibited Social Engagement: (NEW).
 Externalizing disorder: disinhibition, externalizing behavior.
 2/4 sxs; onset > 9 mos.
33

RO
Some disorders are considered to arise from one or more of five pathogenic realms. This distinguishes them from disorders that are thought to be biochemical (e.g., bipolar disorder).
1. Persistent disregard of child’s emotional needs; &/or
2. Persistent disregard of child’s physical needs; &/or
3. Repeated changes in primary caregivers; &/or
4. Raised in settings with limited opportunities for stable attachments; &/or
5. Persistent harsh punishment or other types of grossly inept parenting.
34

Bipolar Disorders
•
1974: Increased focus on distinguishing BP from schizophrenia.
•
Mid-1980s: Broadening the “BP spectrum”
–
Avoid antidepressant-induced mania
–
Treat the spectrum properly
DZ
•
Mid-1990s: Pediatric BD
–
Catch it early, avoid kindling p. 123
35

Bipolar Disorders
•
Late 1990s: Increased use of 2 nd generation antipsychotics for BD.
•
Now: Narrowing the gate on Pediatric
BD.
36

Bipolar Disorders
DZ
•
Bipolar I: no change (> 1 episode mania).
(NB: suicide risk 15 x’s greater)
•
Bipolar II: no change (hypomania & MDD)
(Lethality of suicide methods greater than
Bipolar I)
•
Cyclothymia: (hypomanic episodes below criteria for hypomania + depression below threshold for MD); (minimum of 2 years for adults, 1 year in children/adolescents).
37

Bipolar Disorders
Specifiers: o Anxious distress (mild, moderate, moderate-severe, severe).
o Mixed features.
o Rapid cycling (4 mood episodes in 12/ months. o With melancholic features.
o With atypical features.
38

DZ
•
Increasing diagnosis, over-diagnosis, wrong medication interventions, inaccurate prediction, heterogenous disorder.
•
There may be two types of currently diagnosed PBD:
– a narrow definition that looks like adult BD > still BD.
– a different form that includes explosive emotional outbursts that don’t look like mania (no grandiosity, delusions) and are not so cyclical.
• Looks a little like ADHD, but there may be more aggression.
Looks like disruptive behavior disorder, but more emotional lability.
• Believed that they will not grow up with BD and should perhaps be treated with antidepressants and/or Ritalin.
• Many will now be diagnosed with Disruptive Mood
Dysregulation Disorder (under Depression).
39

RO
Disruptive Mood Dysregulation Disorder:
–
New disorder.
–
Older than
5 yrs;
–
Persistent irritability;
–
Frequent episodes of behavior outbursts >
3 a week for more than
1 year;
–
Intended to address concerns about potential overdx & over-trmnt of bipolar disorder in children;
–
First diagnosis between ages
6-18
;onset <
10
.
–
Cannot coexist with ODD or bipolar disorder.
–
Children with this dx typically develop unipolar depression or anxiety, not bipolar disorder.
40 p. 155

RO
Major Depressive Episode
–
–
Need 5/9 symptoms.
–
In children/adol mood may be irritable.
–
Table of codes for severity and single vs recurrent
Dysthymia  Persistent Depressive Disorder
–
Still 2 years (adults); 1 yr children/adol
–
Five specifiers. (p. 169) o Nixed Mixed Anxiety Depression

Section 3.

Premenstrual Dysphoric Disorder
•
5 sxs in week before menses.
•
Improvement few days after onset of menses.
•
A: 1/4 mood symptoms + B: 1/7 behavior symptoms = combined to equal 5 sxs.
42

Bereavement
“Responses to a significant loss (e.g., bereavement…) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in the Criterion A [for MDE], which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a
MDE in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and cultural norms for the expression of distress in the context of loss.” (p. 125-126) {V Code}
• See footnote p. 126; same footnote p. 161 43

Schizophrenia & Other
Psychotic Disorders
RO p. 87
•
Schizophrenia:
–
Eliminated subtypes (paranoid, hebephrenic, disorganized, residual, catatonic).
–
2/5 sxs (a. delusions, b. hallucinations, c. disorganized speech, d. disorganized or catatonic behavior, e. negative symptoms); 1 sx must be a, b, or c;
1 month.
–
What are negative sxs? “diminished emotional expression or avolition”).
–
Functional impairment.
–
Disturbance persist for >
6 months.
44

Schizophrenia & Other
Psychotic Disorders
RO
Delusional Disorders: Few changes.
•
Subtypes: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified.
•
Specifier: w. bizarre content (implausible, not within ordinary experience).
Brief Psychotic Disorder:
–
1 day to 1 month.
–
Specifiers: w./w-o stressors; postpartum; with catatonia, severity (0-4 for each symptom).
45

Schizophrenia & Other
Psychotic Disorders
•
Schizophreniform Disorder.
– 1 to
6 months.
–
Specifiers: good/w-o good prognostic features, with catatonia, each sxs severity 0-4
•
Schizoaffective Disorder:
•
Major Mood Episode + Criterion A of schizophrenia.
•
>
2 weeks of delusions or hallucinations w-o mood.
•
Some discussion of Schizotypal PD here.
46

Substance-Related &
Addictive Disorders
• No “abuse” or “dependence”; now “ use
.”
•
Chapter reorganized by substance.
–
10 classes of drugs:
Alcohol; Caffeine; Cannabis; Hallucinogens;
Inhalants; Opioids; Sedatives, hypnotics & anxiolytics; Stimulants; Tobacco; Other.
•
Two groups of disorders: (a) Substance use disorders, (b) Substance-induced disorders.
47 p. 481

Substance-Related &
Addictive Disorders
•
Substance use disorder: continued use of substance despite significant substancerelated problems.
4 sets of criteria:
–
Impaired control (4 criteria).
–
Social impairment (3 criteria).
–
Risky use (2 criteria).
–
Pharmacological criteria (2 criteria: tolerance & withdrawal).
48

Substance-Related &
Addictive Disorders
•
Severity levels:
–
Mild (2-3 symptoms)
–
Moderate (4-5 symptoms)
–
Severe (> 6 symptoms)
•
Remission:
–
Early vs Sustained;
–
Maintenance therapy
–
Controlled environment
Example:
Moderate
Valium use disorder; Mild alcohol use disorder;
Secobarbital withdrawal.
49

Substance-Related &
Addictive Disorders
•
New language:
“All drugs that are taken in excess have in common direct activation of the brain reward system….
Individuals with lower levels of self-control, which may reflect impairments of brain inhibitory mechanisms, may be particularly predisposed to develop substance use disorders, suggesting that the roots of substance use disorders for some persons can be seen in behaviors long before the onset of actual substance use itself .”
(p. 481)
50

Substance-Related &
Addictive Disorders
• “This chapter also includes gambling disorder , reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse, and produce some behavioral symptoms that appear comparable to those produced by the substance use disorders.”
(p. 481)
51

Substance-Related &
Addictive Disorders
•
Controversy about other behavioral
“addictions” to be included here/elsewhere.
–
Gambling is here.
–
Other behavioral patterns are not: Internet gaming, shopping, sex, exercise addiction.
52

Disruptive, Impulse Control,
& Conduct Disorders
•
Some childhood disorders went here.
•
These disorders share symptom of problems of self-control of emotions and behaviors.
•
Unique in that they violate the rights of others or brings person into conflict with authority.
•
Typical onset is in childhood or adolescence.
53 p. 461

RO
Disruptive, Impulse Control,
& Conduct Disorders
•
Oppositional defiant disorder.
•
Intermittent explosive disorder.
•
Conduct disorder.
•
Antisocial PD (see PD chapter)
•
Pyromania.
•
Kleptomania.
•
Other.
54

Disruptive, Impulse Control,
& Conduct Disorders
Conceptualizing the relationship across
ODD, CD, & Antisocial PD:
CD
APD
ANXIETY
DEPRESSION
55
ODD

RO
Disruptive, Impulse Control,
& Conduct Disorders
Oppositional Defiant Disorder: o 4
/7 symptoms
• Angry/Irritable Mood (3)
• Argumentative/Defiant Behavior (4) o Plus has been spiteful or vindictive > x2 in past 6 months. o 6 months; not just with sibling.
o Mild (1 setting); Moderate (2 settings); Severe (>3 settings)
56

RO
Disruptive, Impulse Control,
& Conduct Disorders
Intermittent Explosive Disorder
–
Either verbal aggression 2/week for
3 mos., or behavioral outbursts resulting in damage of property or assault on animals or person, 3 xs in
12 mos.
–
Minimum age of
6
. (For ages 6-18 is not part of Adjustment Disorder.)
57

RO
Disruptive, Impulse Control,
& Conduct Disorders
Conduct Disorder (minor wording changes) o 3/15 criteria in 12 mos, from any category:
•
Aggression to people and animals (7)
•
Destruction of property (2)
•
Deceitfulness or theft (3)
•
Serious violation of rules (3) o Subtypes: Age of onset (<10, >10, unspecified) o Specifier: With limited prosocial emotions (use multiple sources of information).
(see p. 470)
58

RO
Disruptive, Impulse Control,
& Conduct Disorders
•
Pyromania and Kleptomania remained.
•
All disorders in this chapter:

Are correlated with substance abuse.

Prognosis guarded.
•
Not included: Nonsuicidal self-injury (see proposed criteria in Section 3).
59

p. 451
Gender Dysphoria
•
Different criteria for children, & adoles. & adults.
• 6
/8 symptoms over
6 mos (must include strong desire to be other gender)
•
Language:
–
Sex = biology; Gender = social role/identity;
–
Transgender = identify with other gender;
–
Transexual = seeks/has undergone social transition to other gender.
–
Gender dysphoria = distress that may accompany the incongruience between assigned and expressed gender.
–
Thus dysphoria , not identity , is key to this diagnosis.
•
Specifier: With disorder of sex development (for children & adults); post-transition (adolescents & adults).
60

RO
Gender Dysphoria
•
Less pathologizing term than Disorder.
•
Balancing Needs:
–
Not a Mental Disorder per se.
–
How to get insurance coverage?
• Imperfect compromise.
•
Other dysphorias?
•
Keeping pathology in gender identity?
• No “Discrimination Disorder” 
A new V code?
61

Other Disorders:
V codes!
p. 715

Relational problems (7) [uncomplicated bereavement]

Abuse & Neglect (approximately 48)
 Educational Problems (1)

Occupational Problems (2)
 Housing & Economic Problems (9)

Other problems related to social environment (6) [discrimination]
 Problems related to crime or interaction w legal system (5)

Other health srvc encounters for counseling & medical advice (2)

Problems related to other psychosocial, personal, & environmental circumstances (7)

Other circumstances of personal history (7)
RO
 Problems related to access to medical & other health care (2)

Nonadherence to medical treatment (5) [malingering]
62

Re Suicidal Behaviors
•
Kapusta, N. (2012). Non-suicidal selfinjury and suicide risk assessment, quo vadis DSM-V? Suicidology Online, 3, 1-3.
63

RO
What is a “personality” and how can it be “disordered”?
64

RO
Where Are We?
Where were we?
Where did we go wrong?
Where should we go?
65

Personality Traits
RO
Previously:
Gordon Allport: 4,000 personality traits
Unmanageable.
Raymond Cattell: 16 personality factors
Still too complex.
Hans Eysenck: 3-factor theory
Too simplistic.
Then:
D. W. Fiske (1949); Norman (1967); Smith
(1967); Goldberg (1981); and McCrae & Costa
(1987): THE BIG FIVE
–
Studied in over 50 cultures; remarkably consistent.
66

The Big Five
(OCEAN)

Openness: This trait features characteristics such as imagination and insight, and those high in this trait also tend to have a broad range of interests.

Conscientiousness: Common features of this dimension include high levels of thoughtfulness, with good impulse control and goaldirected behaviors. Those high in conscientiousness tend to be organized and mindful of details.

Extraversion: This trait includes characteristics such as excitability, sociability, talkativeness, assertiveness and high amounts of emotional expressiveness.

Agreeableness: This personality dimension includes attributes such as trust, altruism, kindness, affection, & other pro-social behaviors.
RO
•
 Neuroticism: Individuals high in this trait tend to experience emotional instability, anxiety, moodiness, irritability, and sadness.
67

RO
Dimensional Scale
Based on Big Five
68

RO
Big 5 vs DSM-IV
 The five personality dimensions were not the building blocks for the personality disorders in DSM-IV.

Instead, 10 PD were put into three clusters.
 The characterization of the clusters did not coincide with the Big 5.
69

RO
DSM-IV-TR Clusters
•
Cluster A : Odd or eccentric
–
Schizoid, Paranoid, Schizotypal
• Cluster B : Dramatic, emotional or erratic
–
Antisocial, Borderline, Narcissistic, Histrionic
•
Cluster C : Anxious, fearful
–
Avoidant, Dependent, Obsessive-Compulsive
70

The Categorical System
71

Personality Disorders
RO
Study on clients diagnosed with PD who were in treatment, conducted by DSM TF, 1999-2007:
–
Rediagnosed using RDC on 5,000 clients  75% false positives.
– Those with “BPD” 
85% false positives.
–
After 1 yr most no longer meet criteria.
Therefore, workgroup considered:
–
Eliminating some PD.
–
Elevating criteria for PD.
–
Making process of dx more daunting.
72

From DSM-IV to DSM 5
•
Erase all PD?
•
Recluster?
DZ
•
Redefine?
73

RO
Could Redefine “Personality”
•
DSM-IV: A pervasive pattern of thinking/ behaving/emotionality.
•
Perhaps?
A personality disorder reflects
" adaptive failure " involving:
–
"Impaired sense of self-identity" or
–
"Failure to develop effective interpersonal functioning."
74

RO
Personality Disorders –
The way it almost was
•
Personality types defined by personality domains and facets:
–
Negative affect (facets: lability,anxiety/ insecurity, hostility)
–
Detachment (facets: withdrawal/depression, suspicion)
–
Antagonism (facets: difficult to get along with: manipulative, deceitful, hostile)
–
Disinhibition (facets: impulsive/irresponsible)
–
Psychoticism (facets: unusual/bizarre experiences, eccentric)
75

Personality Disorders –
The way it almost was
More emphasis on process of PD diagnosis:
1. Does person have a personality problem (self, interpersonal)
2. Determine if it matches 1 of the 6 personality types
(former PD’s)
3. If it does, describe using domains and their facets
4. If it doesn’t PD-trait specified (PDTS) category: you can describe people even if they don’t have a trait diagnosis.
5. Would require knowing more about a client, increase involvement of psychotherapist in diagnosis, reduce use of PD diagnosis.
6. Sequestered to Section 3 as of December 2012
76

Personality Disorders
RO
Suggested process of diagnosis:
1.
Documented observations over 12 months of impairments in core functioning (self, interpersonal, empathy, intimacy).
2.
Personally observed pathological traits over 12 months.
3.
Recognized overall severity level of 3 over
12 months.
77

RO
Personality Disorders
Pathological traits seen in
5 realms, as seen in relationship with therapist over
12 months:
1.
Negative affectivity:
Lability, anxiety, separation insecurity, hostility, perseveration, submissiveness, suspiciousness, dysphoric attitudes, emotional dysregulation.
2.
Detachment:
Emotional constriction, anhedonia, withdrawal, intimacy avoidance.
78

Personality Disorders
RO
3.
Antagonism:
Manipulative, deceitful, attention seeking, grandiose, callous.
4.
Disinhibition or compulsivity:
Perfectionism, controlling, impulsive, risk taking, distancing, emotionally inaccessible.
5.
Psychoticism:
Unusual beliefs, eccentric, cognitive dysregulation.
79

RO
Personality Disorders
•
Considered eliminating:
–
Schizotypal (to be moved to Schiz.)
–
Schizoid (to be moved to Schiz.)
–
Histrionic PD
–
Dependent PD
80

RO
Personality Disorders
Instead, retained:
All 10 PDs
The cluster system
What did they change?
Removed lower age limit (except
Antisocial PD).

See also Section 3
81

RO
Culture

DSM-IV: Culture bound syndromes.

APA Multicultural Guidelines: How social, cultural, political, and historical contexts manifest in clinical presentations.

DSM 5: More in text; Cultural formulation chapter (p. 749-759) w CF
Interview (16 Qs).
82

Good Article re Culture:
Dadlani, Overtree, & Perry-Jenkins
(2012). Culture at the center: A reformulation of diagnostic assessment. Professional Psychology:
Research & Practice, 43(3), 175-182.
83

Good Books re Diagnosis

Beach, Wamboldt, Kaslow, Heyman, First, Underwood,
& Reiss (Eds.) (2006). Relational processes and DSM-V:
Neuroscience, assessment, prevention, and treatment.
Arlington, VA: American Psychiatric Association.

Garcia, B., & Petrovich, A. (2011). Strengthening the
DSM: Incorporating resilience and cultural competence.
NY: Springer Publishing Co.

Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM 5, big pharma, & the medicalization of ordinary life.
NY:
William Morrow.
84

85