Overview of DSM-5
Daniel Castellanos, MD
Medical Director, South Florida Behavioral Health Network
October 16, 2015
No relevant financial disclosures
Castellanos 2014
Broad Changes
Major Changes in Diagnostic Groups













Schizophrenia Spectrum and Other Psychotic Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Trauma- and Stressor Related Disorders
Obsessive-Compulsive and Related Disorders
Somatic Symptom and Related Disorders
Dissociative Disorders
Feeding and Eating Disorders
Disruptive Impulse Control and Conduct Disorders
Substance-Related and Addictive Disorders
Personality Disorders
Paraphilic Disorders
Implications
Castellanos 2014
DSM-I (1952)
DSM-II (1968)
DSM-III (1980):



Reconceptualization of diagnosis
Explicit criteria
Emphasis on reliability rather than validity
DSM-III-R (1987):


Criteria broadened
Most hierarchies Dropped
DSM-IV (1994):

Requires clinically significant distress or impairment
Castellanos 2014
1999-2001
Development of Research Agenda (3 conferences)
2002-2007
APA/WHO/NIMH DSM-5/ICD-11: 13 Research Planning conferences
2006
Appointment of DSM-5 Taskforce
2007
Appointment of 13 Workgroups (Total=168 members)
2007-2011
Literature Review and Data Re-analysis
2010-2012
Field Trials
July 2012
Final Draft of DSM-5 for APA review
July-Oct 2012 Final Round of Reviews (5 Different Committees)
Dec. 2012
Approval by Board of Trustees
May 2013
DSM-5 Published
Castellanos 2014
Task Force
 Initial review
Scientific Review Committee
 Review of validity of recommendations
Clinical and Public Health Committee
 Impact on public health and clinical practice
Forensic Committee
 Clarity of language with regard to forensic implications
Summit Group
 Chairs and Co-Chairs of Various Initial Review Groups
Board of Trustees
 Final Approval
Castellanos 2014
Perceived Shortcomings in DSM-IV
High rates of comorbidity
High use of NOS category
Incredible complexity
Unclear distinctions between several different disorders
Only modestly guide treatment selection
Impeding research progress
Castellanos 2014
Key Objectives for DSM-5
Incorporate research into the revision and evolution of the classification
Improve Validity
Maintain (when possible, improve) Reliability
Continuity with previous editions should be maintained when possible
Improve Clinical Utility:
 Reduce NOS
 Reduce Artificial Comorbidity
 Simplify
 Address different specific challenges
The DSM is above all a manual to be used by clinicians, and changes
made for DSM-5 must be implementable in routine specialty practices.
Castellanos 2014
Overview of Major Changes
Castellanos 2014
The Multi-axial model will be partly replaced by a dimensional
component and adding a severity measure to diagnostic categories.
Will largely eliminate the need for "not otherwise specified (NOS)"
conditions, now termed “other specified…” or “unspecified…"
conditions.
The dimensional diagnostic system also better correlates with treatment
planning.
Changes in Overall Structure:
 20 sections organized to describe inter-relationship
 Developmental lifespan emphasized in each chapter
Castellanos 2014
Discontinue Multi-axial system:
 Move to a non-axial documentation of diagnosis
 Combines Axes 1-3
 Separate notations for psychosocial and contextual
factors (formerly Axis IV). Captured via V codes (Z codes
in ICD-10) or in narrative
 Eliminate GAF (formerly Axis V). Disability now
described separately via optional WHODAS-II measure
and/or in narrative
Castellanos 2014
Validity
 Must define a “Real” entity with distinctive etiology, pathophysiology,
clinical expression, treatment, & outcome
 Antecedent validators, concurrent validators; and predictive validators
Utility
 Must be useful in addressing needs of various constituencies (the
patient, clinician, researcher, treatment payor, society at large …..)
 Must predict treatment response, guide treatment selection, and
predict course and outcome
Reliability
 Different groups of people who need to diagnose this condition must
be able to do so in a consistent manner
Castellanos 2014
A Mental Disorder is a health condition characterized by
significant dysfunction in an individual’s cognitions, emotions,
or behaviors that reflects a disturbance in the psychological,
biological, or developmental processes underlying mental
functioning. Some disorders may not be diagnosable until they
have caused significant distress or impairment of performance.
 Not merely an expected or culturally sanctioned response to a specific
event
 Neither culturally deviant behavior nor a conflict between individual and
society
 Developed for clinical, public health, and research purposes
 Not equivalent to a need for treatment
Castellanos 2014
Section III serves as the location for items that appear to
have initial support in terms of clinical use but require
further research before being officially recommended as
part of the main body of the manual.
Includes emerging measures and models:
 Assessment Measures
 Cultural Formulation
 Alternative DSM-5 Model for Personality Disorders
 Conditions for Further Study
Castellanos 2014
Assess patient characteristics not necessarily included in
diagnostic criteria but of high relevance to prognosis,
treatment planning and outcome
Measures include:
 Level 1 and Level 2 Cross-Cutting Symptom assessments
 Diagnosis-specific Severity ratings
 Disability assessment
May be patient, informant, or clinician completed
Castellanos 2014
Referred to as “cross-cutting” because it calls attention to
symptoms relevant to most, if not all, psychiatric disorders (e.g.,
mood, anxiety, sleep disturbance, substance use, suicide)
 Self-administered by patient
 13 symptom domains for adults
 12 symptoms domains for children 11+, parents of children 6+
 Brief—1-3 questions per symptom domain
 Screen for important symptoms, not for specific diagnoses
(i.e., “cross-cutting”)
Castellanos 2014
Castellanos 2014
Castellanos 2014
Completed when the corresponding Level 1 item is
endorsed at the level of “mild” or greater (for most but not
all items, i.e., psychosis and inattention)
 Gives a more detailed assessment of the symptom
domain
 Largely based on pre-existing, well-validated measures
for attention, substance use, anger, sleep disturbance,
emotional distress)
Castellanos 2014
Castellanos 2014
Severity measures are disorder-specific, corresponding
closely to criteria that constitute the disorder definition.
Can be administered to individuals with:
 A diagnosis meeting full criteria
 A clinically significant syndrome that falls short of
meeting full criteria; such as, an “other specified…”
diagnosis
Some clinician-rated, some self-completed.
Castellanos 2014
Castellanos 2014
Understanding and communicating
Getting around
Self Care
Getting along with people
Life activities:
 household
 work or school
Participation in Society
Castellanos 2014
Castellanos 2014
Castellanos 2014
See www.dsm5.org
“Online Assessment Measures” (right side of page)
Castellanos Jun 2014
Conditions for Further Study:








Attenuated Psychosis Syndrome
Depressive Episodes With Short Duration Hypomania
Persistent Complex Bereavement Disorder
Caffeine Use Disorder
Internet Gaming Disorder
Neurobehavioral Disorder Due to Prenatal Alcohol Exposure
Suicidal Behavior Disorder
Non-suicidal Self-Injury
Castellanos 2014
Includes:
 Highlights of changes from DSM-IV to DSM-5
 Glossary of technical terms
 Glossary of cultural concepts of distress
 Alphabetical listing of DSM-5 diagnoses and codes (ICD9-CM and ICD-10-CM)
 Numerical listing of DSM-5 diagnoses and codes (ICD-9CM)
 Numerical listing of DSM-5 diagnoses and codes (ICD-10CM)
 DSM-5 advisors and other contributors
Castellanos 2014
The DSM-5 groups are:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Neurodevelopmental disorders
Schizophrenia spectrum & other
psychotic disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Trauma and Stressor-Related
Disorders
Obsessive Compulsive and
Related Disorders
Dissociative Disorders
Somatic Symptom and Related
Disorders
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Feeding and Eating Disorders
Sleep-Wake Disorders
Sexual Dysfunction
Elimination Disorders
Disruptive, Impulse-Control,
and Conduct Disorders
Substance-Related and
Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Gender Dysphoria
Other Disorders
Castellanos 2014
Neurodevelopmental Disorders
Castellanos 2014
Renamed:
 Mental Retardation (317-319) renamed Intellectual Disability
 Wording c/w US Law (Rosa’s law, 2010)
Greater emphasis on adaptive functioning deficits rather than IQ scores
alone
 Based on deficits of > 2 sd on an individualized, standardized,
culturally appropriate test
 Coding of severity (mild, moderate, severe, profound) not based on
IQ level, but on adaptive functioning
 Three Domains: Conceptual, Social, Practical
Deleted:
 Borderline intellectual functioning
Castellanos 2014
Intellectual disability (intellectual developmental disorder) is a disorder with
onset during the developmental period that includes both intellectual and
adaptive functioning deficits in conceptual, social, and practical domains. The
following three criteria must be met:
A.Deficits
in intellectual functions, such as reasoning, problem solving, planning, abstract
thinking, judgment, academic learning, and learning from experience, confirmed by both
clinical assessment and individualized, standardized intelligence testing.
B.Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing
support, the adaptive deficits limit functioning in one or more activities of daily life, such as
communication, social participation, and independent living, across multiple
environments, such as home, school, work, and community.
C.Onset of intellectual and adaptive deficits during developmental period.
Castellanos 2014
Coding of Severity:
 Based on adaptive functioning in 3 domains
 Age-relevant descriptors for different severity levels
provided for each domain
 Conceptual: ability to learn; information processing, approach to
problem-solving;
 Social: social interaction, communication, social cues, emotional
regulation, social judgment
 Practical: personal care, daily living tasks, ability to perform ageappropriate roles

Based on degree of needed assistance and support
Castellanos 2014
Replaces DSM-IV’s autistic disorder, Asperger’s disorder,
childhood disintegration disorder, and pervasive
developmental disorder NOS
Extremely poor reliability for distinctions, in part because
clinicians have been applying DSM-IV criteria
inconsistently and incorrectly
Two Dimensions:
 Deficits in social communication and interaction
 Restrictive and repetitive behavior patterns
Castellanos 2014
Specifiers
With or without accompanying intellectual impairment
With or without accompanying structural language impairment
Associated with known medical or genetic condition or
environmental factor (eg., Rett’s)
Associated with another neurodevelopmental, mental, or
behavioral disorder
With catatonia
Three Levels of Severity
 Based on Need for Supportive Services Requiring Support
 Requiring Substantial Support
 Requiring Very Substantial Support
Castellanos 2014
Language Disorder (combines DSM-IV Expressive & Mixed
Receptive-Expressive Language Disorders)
Speech Sound Disorder (replaces Phonological Disorder)
Childhood-Onset Fluency Disorder (replaces Stuttering)
Social (Pragmatic) Communication Disorder:
 Cannot be diagnosed in the presence of restricted repetitive
behaviors, interests, and activities (the other component of
ASD)
Castellanos 2014
Age of onset raised from 7 years to 12 years


Studies indicate later detection/identification
Onset criterion has been changed from “symptoms that caused impairment were
present before age 7 years” to “several inattentive or hyperactive-impulsive
symptoms were present prior to age 12”
Slight modification of criteria to accommodate Adult ADHD

Five or more of 9 inattention and/or >5/9 hyperactivity symptoms (instead of
>6/9)
Cross-situational requirement has been strengthened to “several”
symptoms in each setting
Castellanos 2014
Specifiers:
 Subtypes have been replaced with presentation specifiers
that map directly to the prior subtypes:
 Combined
 Predominantly Inattentive
 Predominantly Hyperactive
 Severity: based on # and severity of symptoms, and
impact on function: mild/moderate/severe
 If in partial remission
A comorbid diagnosis with autism spectrum disorder is now
allowed
Castellanos 2014
Now presented as a single disorder with coded specifiers for
specific deficits in reading, writing, and mathematics
 Clinical reality does not support 3 distinct conditions
Specifiers:
 With impairment in Reading
 With impairment in Written Expression
 With impairment in Mathematics
 Severity
Castellanos 2014
Schizophrenia Spectrum
and
Other Psychotic Disorders
Castellanos 2014
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophrenia
Schizoaffective Disorder
Substance/Medication-Induced Psychotic Disorder
Psychotic Disorder Due to Another Medical Condition
Catatonia Associated with Another Mental Disorder
Catatonia Due to Another Medical Condition
Other Specified Schizophrenia Spectrum & Other Psychotic Disorder
Unspecified Schizophrenia Spectrum & Other Psychotic Disorder
Castellanos 2014
What Have we Learned Since DSM-IV?
Schizophrenia
 Marked heterogeneity in need of explanation
 Multiple psychopathological dimensions
 Ability to identify individuals at high risk in context of
need for early intervention
 Mood symptoms can be prominent
 Subtypes not stable
These observations are the basis of recommended changes
in criteria, boundaries, and specifiers
Castellanos 2014
Definition of Psychosis
Core Features:



Delusions
Hallucinations
Disorganized speech (thought disorder)
Accompanying Features:




Catatonia
Disorganized behavior
Negative symptoms
Mood Symptoms
Castellanos 2014
Precision in measurement-based care
Specific targeting of distinct dimensions of schizophrenia
and other psychotic disorders
Individualizing treatment with more precise responsebased treatment adjustments
Clinician education about utility
Castellanos 2014
Changes were made to the primary symptom criteria:
 Elimination of special attribution of bizarre delusions and
Schneiderian first-rank auditory hallucinations (e.g., two or
more voices conversing).
 This special attribution was removed due to the nonspecificity of
Schneiderian symptoms and the poor reliability in
distinguishing bizarre from nonbizarre delusions.
 In DSM-IV, only one such symptom was needed to meet the
diagnostic requirement for Criterion A, instead of two of the
other listed symptoms.
Castellanos 2014
Must have at least one of three “positive” symptoms:

Delusions

Hallucinations

Disorganized speech
Castellanos 2014
Eliminate current subtypes of schizophrenia
 Limited diagnostic stability, low reliability, and poor validity
 Didn’t help with providing better targeted treatment, or
predicting treatment response
Add dimensional measures to assessment:
 Rating severity for the core symptoms of schizophrenia is
included to capture the important heterogeneity in
symptom type and severity expressed across individuals with
psychotic disorders
Treat catatonia uniformly across the manual
“Attenuated Psychosis Syndrome” as condition for further study
Castellanos 2014
Name:
Age:
Sex: [
] Male
[
] Female
Date:
Instructions: Based on al l the i nformati on you have on the i ndi vi dual and usi ng your cl i ni cal judgment, pl ease rate (wi th checkmark) the
presence and severi ty of the fol l owi ng symptoms as experi enced by the i ndi vi dual i n the past seven (7) days.
Domain
0
1
2
I. Hal l uci nati ons
II. Del usi ons
III. Di sorgani zed speech
IV. Abnormal psychomotor
behavi or
V. Negati ve symptoms
(restri cted emoti onal
expressi on or avol i ti on)
VI. Impai red cogni ti on
VII. Depressi on
VIII. Mani a
 Not present
 Not present
 Not present
 Not present
 Not present
 Not present
 Not present
 Not present
 Equi vocal (severi ty or durati on not
suffi ci ent to be consi dered psychosi s)
 Equi vocal (severi ty or durati on not
suffi ci ent to be consi dered psychosi s)
 Equi vocal (severi ty or durati on not
suffi ci ent to be consi dered
di sorgani zati on)
 Equi vocal (severi ty or durati on not
suffi ci ent to be consi dered abnormal
psychomotor behavi or)
 Equi vocal decrease i n faci al
expressi vi ty, prosody, gestures, or sel fi ni ti ated behavi or
 Equi vocal (cogni ti ve functi on not
cl earl y outsi de the range expected for age
or SES; i .e., wi thi n 0.5 SD of mean)
 Equi vocal (occasi onal l y feel s sad,
down, depressed, or hopel ess; concerned
about havi ng fai l ed someone or at
somethi ng but not preoccupi ed)
 Equi vocal (occasi onal el evated,
expansi ve, or i rri tabl e mood or some
restl essness)
3
4
Score
 Present, but mi l d (l i ttl e pressure to  Present and moderate (some pressure to
act upon voi ces, not very bothered by respond to voi ces, or i s somewhat bothered
voi ces)
by voi ces)
 Present and severe (severe pressure
to respond to voi ces, or i s very bothered
by voi ces)
 Present, but mi l d (l i ttl e pressure to  Present and moderate (some pressure to
act upon del usi onal bel i efs, not very act upon bel i efs, or i s somewhat bothered by
bothered by bel i efs)
bel i efs)
 Present and severe (severe pressure
to act upon bel i efs, or i s very bothered
by bel i efs)
 Present, but mi l d (some di ffi cul ty
fol l owi ng speech)
 Present, but mi l d (occasi onal
abnormal or bi zarre motor behavi or
or catatoni a)
 Present, but mi l d decrease i n
faci al expressi vi ty, prosody, gestures,
or
sel f-i ni ti ated behavi or
 Present, but mi l d (some reducti on
i n cogni ti ve functi on; bel ow expected
for age and SES, 0.5–1 SD from mean)
 Present, but mi l d (frequent peri ods
of feel i ng very sad, down, moderatel y
depressed, or hopel ess; concerned
about havi ng fai l ed someone or at
somethi ng, wi th some preoccupati on)
 Present and moderate (speech often
di ffi cul t to fol l ow)
 Present and moderate (frequent abnormal
or bi zarre motor behavi or
or catatoni a)
 Present and severe (speech al most
i mpossi bl e to fol l ow)
 Present and severe (abnormal or
bi zarre motor behavi or or catatoni a
al most constant)
 Present and moderate decrease i n faci al
expressi vi ty, prosody, gestures, or sel fi ni ti ated behavi or
 Present and severe decrease i n faci al
expressi vi ty, prosody, gestures, or
sel f-i ni ti ated behavi or
 Present and moderate (cl ear reducti on i n
cogni ti ve functi on;
bel ow expected for age and SES, 1–2 SD from
mean)
 Present and severe (severe reducti on
i n cogni ti ve functi on; bel ow expected
for age and SES, > 2 SD from mean)
 Present and moderate
(frequent peri ods of deep depressi on or
hopel essness; preoccupati on wi th gui l t,
havi ng done wrong)
 Present, but mi l d (frequent peri ods  Present and moderate (frequent peri ods of
of somewhat el evated, expansi ve, or
extensi vel y el evated, expansi ve, or i rri tabl e
i rri tabl e mood or restl essness)
mood or restl essness)
 Present and severe (deepl y depressed
or hopel ess dai l y; del usi onal gui l t or
unreasonabl e
sel f-reproach grossl y
out of proporti on to ci rcumstances)
 Present and severe (dai l y and
extensi vel y el evated, expansi ve, or
i rri tabl e mood or restl essness)
Note. SD = standard deviation; SES = socioeconomic status.
Co pyright © 2013 A merican P sychiatric A sso ciatio n. A ll Rights Reserved.
This material can be repro duced witho ut permissio n by researchers and by clinicians fo r use with their patients.
Castellanos 2014
Signs of disturbance for ≥6 months
≥1 mo. of ≥2 active-phase symptoms*
Signs of disturbance for ≥6 months
≥1 mo. of ≥2 active-phase symptoms
Symptoms:
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
Symptoms:
Delusions*
Hallucinations*
Disorganized speech*
Grossly disorganized or catatonic behavior
Negative symptoms
Subtypes
disorganized,
catatonic,
paranoid,
undifferentiated,
Residual
Subtypes
Eliminated
* Only 1 is required if delusions are bizarre or for specific types
of verbal auditory hallucinations (e.g., command
hallucinations)
* At least one of these 3 core positive symptoms is required
for diagnosis
Castellanos 2014
Other Specified Schizophrenia Spectrum & Other Psychotic
Disorder (298.8):
Sxs of schizophrenia or other psychotic disorders
present but are subthreshold for full Dx
 Clinician chooses to communicate the reason the
presentation does not meet full criteria
 Must specify the reason (eg, persistent auditory
hallucinations)

Castellanos 2014
Unspecified Schizophrenia Spectrum & Other Psychotic
Disorder(298.9):



Sxs of schizophrenia or other psychotic disorders present but
are subthreshold for full Dx
Clinician chooses NOT to communicate the reason the
presentation does not meet full criteria
Includes presentations in which there is insufficient
information to make a more specific diagnosis (eg,
Emergency Depts)
Castellanos 2014
Poor reliability
Poor validity
Low diagnostic stability
Low utility
Castellanos 2014
Biggest change is that a major mood episode must be present for a
majority of the disorder.
Now based on the lifetime (rather than episodic) duration of illness in
which the mood and psychotic symptoms described in Criterion A
occur.
It makes schizoaffective disorder a longitudinal instead of a crosssectional diagnosis — more comparable to schizophrenia, bipolar
disorder, and major depressive disorder, which are bridged by this
condition.
The change was also made to improve the reliability, diagnostic
stability, and validity of this disorder, while recognizing that the
characterization of patients with both psychotic and mood symptoms,
either concurrently or at different points in their illness, has been a
clinical challenge.
Castellanos 2014
.
DSM-IV-TR Criteria
Schizoaffective Disorder
A. Uninterrupted period of illness during which there
is a major mood episode [major depressive, manic, or
mixed] concurrent with criterion A of schizophrenia.
DSM-5 Criteria
Schizoaffective Disorder
A. An uninterrupted period of illness during which there
is a major mood disorder (major depressive or manic)
concurrent with Criterion A symptoms of schizophrenia.
B. Delusions and hallucinations for 2 or more weeks in
absence of prominent mood symptoms.
B. Delusions and/or hallucinations are present at least
for 2 weeks in the absence of a major mood episode
during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood
episode are present for a substantial portion of the total
duration of the active and residual portion of the
illness.
C. A major mood episode is present for the majority of
the total duration of the illness. (Note periods of
successfully treated mood symptoms count towards the
cumulative duration of the major mood episode).
D. Disturbance not due to direct physiological effects of
a substance or a general medical condition.
D. Disturbance not due to direct physiological effects of
a substance or a general medical condition.
Castellanos 2014
Psychotic
Mood
Mood disorder with psychotic features
Psychosis with superimposed mood disorder
Psychotic
Mood
Schizoaffective Disorder
Psychotic
Mood
Castellanos 2014
The same criteria are used to diagnose catatonia whether the context
is a psychotic, bipolar, depressive, or other medical disorder, or an
unidentified medical condition.
Coded as a specifier for neurodevelopmental, psychotic, mood and
other mental disorders; as well as for other medical disorders
(catatonia due to another medical condition).
In DSM-IV, two out of five symptom clusters were required if the
context was a psychotic or mood disorder, whereas only one symptom
cluster was needed if the context was a general medical condition.
In DSM-5, all contexts require three catatonic symptoms (from a total
of 12 characteristic symptoms).
Castellanos 2014
.
Castellanos 2014
Mood Disorder section eliminated
Now separated into 2 sections:
 Bipolar & Related Disorders
 Depressive Disorders
Castellanos 2014
Bipolar disorder now a free standing category.
Taken out of the broad mood disorder category
The primary criteria for manic and hypomanic episodes
(Criterion A) now includes an emphasis on changes in
activity and energy — not just mood.
Will enhance the accuracy of diagnosis and facilitate earlier
detection in clinical settings,
Castellanos 2014
.
DSM-IV diagnosis of bipolar I disorder, mixed episode, required
individuals simultaneously meet full criteria for both mania and
major depressive episode.
“Mixed episode” has been removed from the DSM-5.
New specifier, “with mixed features,” has been added.
Can be applied to episodes of mania or hypomania when
depressive features are present.
It can also be applied to episodes of depression — such as in the
context of major depressive disorder or bipolar disorder — when
features of mania/hypomania are present.
Castellanos 2014
“With anxious distress” also added as a specifier for bipolar
disorders
This specifier is intended to identify patients with anxiety
symptoms that are not part of the bipolar diagnostic criteria.
Will reduce artificial comorbidity.
May be meaningful for treatment planning.
Castellanos 2014
Mania
Hypomania
Euthymia/Baseline
Maintenance
Bipolar Depression
Psychotropic Medications Training 2014
62
Castellanos 2014
Added:
 Persistent Depressive Disorder
 Premenstrual Dysphoric Disorder
 Disruptive Mood Deregulation Disorder
 Specifiers:
 “With mixed features”
 “With anxious distress”
Renamed:
 Dysthymic Disorder (now Persistent Depressive Disorder)
Castellanos 2014
Major Depressive Disorder:
 Essentially unchanged except removal of the
“bereavement exclusion.”
 Allows clinicians to now exercise their professional
judgment as to whether someone with a major depressive
disorder and grieving should be diagnosed with MDD.
 The 2-month timeframe required by DSM-IV suggests an
arbitrary time course to bereavement that is inaccurate.
 Individuals experiencing both conditions can benefit
from treatment but are excluded from diagnosis under
DSM-IV.
Castellanos 2014
Persistent Depressive Disorder (300.4):
 Includes both chronic major depressive disorder and
the previous dysthymic disorder.
 “An inability to find scientifically meaningful
differences between these two conditions led to their
combination with specifiers included to identify
different pathways to the diagnosis and to provide
continuity with DSM-IV.”
Premenstrual Dysphoric Disorder (625.4):
 Moved from DSM-IV Appendix to main body of text
now.
Castellanos 2014
Other Specified Depressive Disorder (311):
 Symptoms characteristic of a depressive disorder that cause
clinically significant distress or impairment…but do not meet
the full criteria of any depressive disorder.
 Used in situations in which the clinician chooses to
communicate the specific reason the presentation does not
meet the criteria for a specific depressive disorder.
Unspecified Depressive Disorder (311):
 Used in situations in which the clinician chooses not to
specify the reason the criteria are not met for a specific
depressive disorder.
Castellanos 2014
Addresses symptoms that have been incorrectly considered as
“childhood bipolar disorder” by some.
Diagnosed in children up to age 18 years who exhibit persistent
irritability and frequent episodes of extreme, out-of-control
behavior.
Reduces the likelihood of such children being inappropriately
prescribed antipsychotic medication.
DMDD does not allow a dual diagnosis with oppositional-defiant
disorder (ODD) or intermittent explosive disorder (IED), but it
can be diagnosed with conduct disorder (CD).
Children who meet criteria for DMDD and ODD would be
diagnosed with DMDD only.
Castellanos 2014
Mania
DMDD
Hypomania
Euthymia/Baseline
Maintenance
Bipolar Depression
Castellanos & Cohen 2014
Castellanos 2014
PTSD and OCD no longer included in this category
Social Phobia renamed Social Anxiety Disorder
 “Generalized” specifier has been deleted and replaced
with a “performance only” specifier.
Separation Anxiety Disorder and Selective Mutism are
included here
Panic disorder and agoraphobia are unlinked
Minor changes in criteria for various conditions
Castellanos 2014
Agoraphobia, Specific Phobia, and Social Anxiety Disorder
(Social Phobia)
 Changes in criteria for agoraphobia, specific phobia,
and social anxiety disorder (social phobia) include
deletion of the requirement that individuals over age 18
years recognize that their anxiety is excessive or
unreasonable.
Castellanos 2014
Panic Attack
 The essential features of panic attacks remain
unchanged, although the complicated DSM-IV
terminology for describing different types of panic
attacks (i.e., situationally bound/cued, situationally
predisposed, and unexpected/uncued) is replaced with
the terms unexpected and expected panic attacks.
 Panic attack can
be listed as a specifier that is
applicable to all DSM-5 disorders.
Castellanos 2014
Trauma & Stressor
Related Disorders
Castellanos 2014
Trauma related disorders are now a stand alone category
Added:
 PSTD in Preschool Children
Moved here:
 Reactive Attachment Disorder (313.89)
 Acute Stress Disorder (308.3)
New disorders:
 Disinhibited Social Engagement Disorder (313.89)
Castellanos 2014
Adjustment Disorders are now listed here:

Reconceptualized as a heterogeneous array of stressresponse syndromes that occur after exposure to a
distressing (traumatic or nontraumatic) event, rather
than as a residual category for individuals who exhibit
clinically significant distress without meeting criteria
for a more discrete disorder (as in DSM-IV )
Castellanos 2014
Stressor criterion (Criterion A) is more explicit with regard
to how an individual experienced “traumatic” events.
Criterion A2 (subjective reaction) has been eliminated.
Diminished emphasis on dissociative symptoms
Major symptom clusters:
 DSM-IV: 1)re-experiencing, 2) avoidance/numbing, 3)
arousal
 DSM-5: 1) re-experiencing, 2) avoidance, 3)persistent
negative alterations in cognitions and mood, 4) arousal.
Castellanos 2014
Criterion A: stressor
The person was exposed to: death, threatened death, actual or threatened serious
injury, or actual or threatened sexual violence, as follows: (one required)
1.
Direct exposure.
2.
Witnessing, in person.
3.
Indirectly, by learning that a close relative or close friend was exposed to
trauma. If the event involved actual or threatened death, it must have been
violent or accidental.
4.
Repeated or extreme indirect exposure to aversive details of the event(s),
usually in the course of professional duties (e.g., first responders, collecting
body parts; professionals repeatedly exposed to details of child abuse). This
does not include indirect non-professional exposure through electronic
media, television, movies, or pictures
Castellanos & Cohen 2014
Criterion B: intrusion symptoms (Re-experiencing)
The traumatic event is persistently re-experienced in the following way(s):
(one required)
1.
Recurrent, involuntary, and intrusive memories. Note: Children older
than six may express this symptom in repetitive play.
2.
Traumatic nightmares. Note: Children may have frightening dreams
without content related to the trauma(s).
3.
Dissociative reactions (e.g., flashbacks) which may occur on a
continuum from brief episodes to complete loss of consciousness.
Note: Children may reenact the event in play.
4.
Intense or prolonged distress after exposure to traumatic reminders.
5.
Marked physiologic reactivity after exposure to trauma-related stimuli
Castellanos & Cohen 2014
Criterion C: avoidance
Persistent effortful avoidance of distressing trauma-related
stimuli after the event: (one required)
1.
2.
Trauma-related thoughts or feelings.
Trauma-related external reminders (e.g., people, places,
conversations, activities, objects, or situations).
Castellanos & Cohen 2014
Criterion D: negative alterations in cognitions and mood
Negative alterations in cognitions and mood that began or worsened after the
traumatic event: (two required)
1.
2.
3.
4.
5.
6.
7.
Inability to recall key features of the traumatic event (usually dissociative amnesia;
not due to head injury, alcohol, or drugs).
Persistent (and often distorted) negative beliefs and expectations about oneself or
the world (e.g., "I am bad," "The world is completely dangerous").
Persistent distorted blame of self or others for causing the traumatic event or for
resulting consequences.
Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or
shame).
Markedly diminished interest in (pre-traumatic) significant activities.
Feeling alienated from others (e.g., detachment or estrangement).
Constricted affect: persistent inability to experience positive emotions.
Castellanos & Cohen 2014
Criterion E: alterations in arousal and reactivity
Trauma-related alterations in arousal and reactivity that began or worsened after
the traumatic event: (two required)
1.
Irritable or aggressive behavior
2.
Self-destructive or reckless behavior
3.
Hypervigilance
4.
Exaggerated startle response
5.
Problems in concentration
6.
Sleep disturbance
Castellanos & Cohen 2014
DSM-IV’s reactive attachment disorder (RAD) subtypes are now
two distinct disorders: RAD and disinhibited social engagement
disorder (DSED).
These appear to be two distinct conditions that are characterized
by different attachment behaviors.
DSED is more similar to ADHD and disruptive behavior disorders
and reflects poorly formed or absent attachments to others.
RAD is more similar to depression and other internalizing
disorders but occurs in children with both insecure and more
secure attachments
Castellanos 2014
Castellanos 2014
OCD is now a stand alone category
Moved:
 Body Dysmorphic Disorder (300.7) listed under OCD.
Renamed:
 Trichotillomania now called Hair-Pulling Disorder
(312.39)
New disorders:
 Hoarding Disorder (300.3)
 Excoriation (skin-picking) Disorder (698.4)
 Substance-/medication-induced obsessive-compulsive &
related disorder
 Obsessive-compulsive and related disorder due to
another medical condition (294.8).
Castellanos 2014
The “with poor insight” specifier refined. Now 3 levels of insight:
 Good
 Poor
 Absent-delusional
Analogous “insight” specifiers have been included for body
dysmorphic disorder and hoarding disorder.
These specifiers are intended to improve differential diagnosis.
This change also emphasizes that the presence of absent
insight/delusional beliefs warrants a diagnosis of the relevant
obsessive-compulsive or related disorder, rather than a
schizophrenia spectrum and other psychotic disorder.
Castellanos 2014
Castellanos 2014
Depersonalization Disorder now called
Depersonalization/Derealization Disorder
Dissociative Fugue has been removed from this category
(only a specifier for dissociative amnesia)
Dissociative Identity Disorder modified (modestly expanded)
Castellanos 2014
Criterion A:
 Expanded to include certain possession-form phenomena and
functional neurological symptoms to account for more diverse
presentations of the disorder.
 Specifically states that transitions in identity may be
observable by others or self-reported.
Criterion B:
 Individuals with dissociative identity disorder may have
recurrent gaps in recall for everyday events, not just for
traumatic experiences.
Castellanos 2014
Now includes a dissociative fugue specifier, which was
previously an independent disorder
Revision was implemented due to a lack of clinical and
epidemiological data supporting dissociative fugue as an
independent disorder and due to the low validity of DSM-IV
dissociative fugue criteria.
Castellanos 2014
Somatic Symptom
&
Related Disorders
Castellanos 2014
Replaced:
 Somatoform Disorders with this category
Eliminated:



Somatization Disorder
Pain Disorder
Hypochondriasis
Added:



Complex Somatic Symptom Disorder
Simple Somatic Symptom Disorder
Illness Anxiety Disorder
Renamed:

Conversion Disorder renamed Functional Neurological Symptom
Disorder
Castellanos 2014
These disorders are primarily seen in medical settings, and
nonpsychiatric physicians found the DSM-IV somatoform
diagnoses problematic to use.
The DSM-5 classification reduces the number of these
disorders and subcategories to avoid problematic overlap.
Emphasize presence of maladaptive thoughts, feelings, and
behaviors more than “Medically Unexplained Symptoms”
Castellanos 2014
DSM-IV criteria overemphasized the importance of an absence of a medical
explanation for the somatic symptoms. Unexplained symptoms are present to
various degrees, particularly in conversion disorder, but somatic symptom
disorders can also accompany diagnosed medical disorders.
The reliability of medically unexplained symptoms is limited, and grounding a
diagnosis on the absence of an explanation is problematic and reinforces mind body dualism.
The DSM-5 classification defines disorders on the basis of positive symptoms
(i.e., distressing somatic symptoms plus abnormal thoughts, feelings, and
behaviors in response to these symptoms).
Medically unexplained symptoms do remain a key feature in conversion disorder
and pseudocyesis because it is possible to demonstrate definitively in such
disorders that the symptoms are not consistent with medical pathophysiology.
Castellanos 2014
Replaces somatoform disorder, undifferentiated somatoform
disorder, hypochondriasis, and the pain disorders.
Individuals with somatic symptoms plus abnormal thoughts,
feelings, and behaviors may or may not have a diagnosed medical
condition.
The diagnosis of somatization disorder was essentially based on a
long and complex symptom count of medically unexplained
symptoms.
Individuals previously diagnosed with somatization disorder will
usually meet DSM-5 criteria for somatic symptom disorder, but only
if they have the maladaptive thoughts, feelings, and behaviors that
define the disorder, in addition to their somatic symptoms.
Castellanos 2014
.
Hypochondriasis has been eliminated as a disorder.
Most individuals who would previously have been diagnosed
with hypochondriasis have significant somatic symptoms in
addition to their high health anxiety, and would now receive a
DSM-5 diagnosis of somatic symptom disorder.
In DSM-5, individuals with high health anxiety without somatic
symptoms would receive a diagnosis of illness anxiety disorder
(unless their health anxiety was better explained by a primary
anxiety disorder, such as generalized anxiety disorder).
Castellanos 2014
Feeding & Eating Disorders
Castellanos 2014
Moved to this category:
 Pica
 Rumination Disorder
Added:
 Binge Eating Disorder
 Avoidant/Restrictive Food Intake Disorder
No significant change:
 Anorexia nervosa or bulimia nervosa
Castellanos 2014
Binge Eating Disorder:
 Minimum average frequency of binge eating required for
diagnosis has been changed from at least twice weekly for 6
months to at least once weekly over the last 3 months, which is
identical to the DSM-5 frequency criterion for BN.
 Meant to reduce frequency of Eating Disorder NOS
Anorexia Nervosa:
 Diagnosis no longer requires amenorrhea
 Other core diagnostic criteria for anorexia nervosa are
conceptually unchanged from DSM-IV.
Castellanos 2014
Disruptive Impulse Control
&
Conduct Disorders
Castellanos 2014
Moved here:
 Oppositional Defiant Disorder
Removed from category:
 Trichotillomania
 Gambling
Dual listing:
 Antisocial Personality Disorder
Castellanos 2014
Symptoms grouped into three types:
 angry/irritable mood
 argumentative/defiant behavior
 vindictiveness.
Exclusion criterion for conduct disorder has been removed.
Behaviors associated with symptoms of ODD occur commonly in normally
developing children/adolescents, a note has been added to the criteria to
provide guidance on the frequency typically needed for a behavior to be
considered symptomatic of the disorder.
Severity rating has been added to the criteria to reflect research showing
that the degree of pervasiveness of symptoms across settings is an
important indicator of severity.
Castellanos 2014
The criteria for conduct disorder are largely unchanged from
DSM-IV.
Addition of a conduct disorder specifier called “with limited
prosocial emotions”
 Applies to those with conduct disorder who show a callous
and unemotional interpersonal style across multiple
settings and relationships.
 Based on research showing that individuals with conduct
disorder with limited prosocial emotions tend to have a
relatively more severe form of the disorder and a different
treatment response.
Castellanos 2014
Primary change is the type of aggressive outbursts that
should be considered:

Physical aggression towards individuals was required in DSMIV, whereas verbal aggression and physical aggression towards
animals or property also meet criteria in DSM-5.
DSM-5 also provides more specific criteria to define types of
outbursts and the frequency needed to meet threshold.
Further, diagnosis is now limited to children at least 6 years
of age.
Castellanos 2014
Substance-Related &
Addictive Disorders
(Substance Use Disorders/SUDs)
Castellanos 2014
Renamed:
 Nicotine Related renamed Tobacco Use Disorder
Added:
 Caffeine Withdrawal
 Cannabis Withdrawal
 Gambling Disorder: “reflects the increasing and consistent evidence
that some behaviors, such as gambling, activate the brain reward
system with effects similar to those of drugs of abuse and that
gambling disorder symptoms resemble substance use disorders to a
certain extent.”
Discontinued:
 Polysubstance Abuse categories
Castellanos 2014
Consolidate substance abuse with substance dependence
into a single disorder called substance use disorder
Studies from clinical and general populations indicate
DSM-IV substance abuse and dependence criteria represent
a singular phenomenon but encompassing different levels
of severity.
Castellanos 2014
There are two major changes to the new DSM-5 criteria for
substance use disorder:
“Recurrent legal problems” criterion for substance abuse
has been deleted from DSM-5
 A new criterion has been added: craving or a strong
desire or urge to use a substance

Castellanos 2014
DSM-5 threshold for SUD diagnosis is set at 2 or more
criteria. In DSM-IV, abuse required a threshold of one or
more criteria be met and 3 or more for substance
dependence.
Severity specifiers of the SUDs is based on the number
of criteria endorsed:
 2–3 criteria = mild disorder
 4–5 criteria = moderate disorder
 6 or more
= severe disorder
Castellanos 2014
Qualifiers used in the category:
 Use replaces both abuse and dependence
 Intoxication remains same
 Withdrawal remains same
SUDs will be coded with DSM-IV substance dependence
codes.
Castellanos 2014
Alcohol
Opioid
Sedative, Hypnotic or Anxiolytic
Cocaine
Cannabis
Other Hallucinogen
Inhalant
Tobacco
Amphetamine
Phencyclidine
Use Disorder
Castellanos 2014
1.
2.
3.
4.
5.
6.
Taking the substance in larger amounts or for longer than the you
meant to
Wanting to cut down or stop using the substance but not
managing to
Spending a lot of time getting, using, or recovering from use of
the substance
Cravings and urges to use the substance
Not managing to do what you should at work, home or school,
because of substance use
Continuing to use, even when it causes problems in relationships
Castellanos 2014
.
7.
8.
9.
10.
11.
Giving up important social, occupational or recreational activities
because of substance use
Using substances again and again, even when it puts the you in
danger
Continuing to use, even when the you know you have a physical or
psychological problem that could have been caused or made
worse by the substance
Needing more of the substance to get the effect you want
(tolerance)
Development of withdrawal symptoms, which can be relieved by
taking more of the substance.
Castellanos 2014
.
Neurocognitive Disorders
(NCD)
Castellanos 2014
Use of the term major neurocognitive disorder rather than
dementia
Distinguishes between Major and Mild Disorders
Elevation of DSM-IV etiological subtypes (e.g.,
frontotemporal dementia, dementia with Lewy Bodies) to
separate, independent disorders.
Castellanos 2014
Replaces:
 Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Category
 Wording of “Dementia due to ...” with “Major or Mild Neurocognitive
Disorder Due to…” for all conditions listed
Added:
 Mild NCD
 Fronto-Temporal Lobar Degeneration
 Traumatic Brain Injury
 Lewy Body Disease
Renamed:
 Head Trauma as Traumatic Brain Injury
 Renamed Creutzfeldt-Jakob Disease as Prion Disease
Castellanos 2014
Personality Disorders
Castellanos 2014
The criteria for personality disorders in Section II of
DSM-5 have not changed from those in DSM-IV.
Ten Personality Disorders:










Borderline
Obsessive-Compulsive
Avoidant
Schizotypal
Antisocial
Narcissistic
Histrionic
Schizoid
Paranoid
Dependent
Castellanos 2014
No longer stands alone as another AXIS (II). Move to a monoaxial
system that removes the arbitrary boundaries between
personality disorders and other mental disorders.
Despite the required enduring and impairing nature of
personality disorder symptoms and traits, in the field trials, only
borderline personality disorder had good interrater reliability.
In contrast, obsessive-compulsive personality disorder and
antisocial personality disorder were in the questionable reliability
range, and too few patients with other personality disorders were
included to test their reliability.
Castellanos 2014
New Trait-specific based typology (hybrid model with both
dimensional and categorical approaches) included in
Section 3.
Schizotypal Personality Disorder also listed under
Schizophrenia and Other Psychotic Disorders.
Antisocial Personality Disorder also listed under Disruptive
Impulse Control & Conduct Disorders.
Castellanos 2014
Paraphilic Disorders
Castellanos 2014
Diagnostic criteria remain unchanged.
In DSM-5, paraphilias are not de facto mental disorders.
There is a distinction between paraphilias and paraphilic
disorders.
A paraphilic disorder is a paraphilia that is currently causing
distress or impairment to the individual or a paraphilia
whose satisfaction has entailed personal harm, or risk of
harm, to others.
A paraphilia is a necessary but not a sufficient condition for
having a paraphilic disorder.
Castellanos 2014
.
Implications:
 The new approach to paraphilias demedicalizes and
destigmatizes unusual sexual preferences and behaviors,
provided they are not distressing or detrimental to one's
self or others (e.g., transvestism).
 Clinicians are tasked with determining whether a behavior
qualifies as a disorder, based on a thorough history
provided by both the patient and qualified informants.
 A paraphilia by itself does not automatically justify or
require clinical intervention (vs paraphilic disorder).
Castellanos 2014
.
Addition of the course specifiers “in a controlled environment” and “in
remission” to the diagnostic criteria sets for all the paraphilic disorders.
There is no expert consensus about whether a long-standing paraphilia can
entirely remit, but there is less argument that consequent psychological
distress, psychosocial impairment, or the propensity to do harm to others
can be reduced to acceptable levels.
Therefore, the “in remission” specifier has been added to indicate
remission from a paraphilic disorder. The specifier is silent with regard to
changes in the presence of the paraphilic interest per se.
The other course specifier, “in a controlled environment,” is included
because the propensity of an individual to act on paraphilic urges may be
more difficult to assess objectively when the individual has no opportunity
to act on such urges.
Castellanos 2014
They all carry over with new DSM-5 names
Exhibitionistic Disorder
Fetishistic Disorder
Froteuristic Disorder
Pedophilic Disorder
Sexual Masochism Disorder
Sexual Sadism Disorder
Transvestic Disorder
Voyeuristic Disorder
Castellanos 2014
No More Multi-axial diagnoses
Addition of dimensions to diagnosis
Addition of Section 3 with a lot of clinically useful materials
that are not yet part of the official DSM nomenclature
Diagnosis now includes three levels: Category, Specifiers, and
Severity
Castellanos 2014
Substantial changes in treatment of some
groups of disorders
Modest changes in treatment of
schizophrenia, major mood disorders,
substance-use disorders, somatoform
disorders.
More substantial changes in the treatment of
neurodevelopmental disorders, anxiety
disorders, and neurocognitive disorders.
Castellanos 2014