DSM – 5:A Brief Overview

Chuck Pistorio, Ph.D.Laura Tejada, Ph.D.Shedeh Tavakoli, Ph.D.

Overview

Outline significant changes

Chapter organizations

New categories

New Diagnoses

Eliminated diagnoses

Review specific changes for some of the most commonly diagnosed disorders

Changes in Philosophy

Greater emphasis on cultureCultural Formulation Inventory (CFI)Awareness of international use

ICD, WHO

Validity rather than reliability More emphasis on client’s experiences and reported symptoms/needs

Changes to Chapters

Chapters reorganized

Organized by common etiologiesMore dimensional approachDiagnosis is ongoing

Reflects developmental lifespanRemoved Disorders Usually Diagnosed in Infancy, Childhood & AdolescenceIndividual chapters organized developmentally

Changes to Five-Axis SystemDSM-IV Five-Axis

System DSM-5 Equivalent

Axis I: Mental Health Disorders Record on diagnosis lineList primary reason for visit first

Axis II: Personality Disorders & Mental Retardation

Record on diagnosis lineList primary reason for visit first

Axis III: General Medical Conditions

Record on diagnosis lineList those most important to understanding mental health first

Axis IV: Psychosocial & EnvironmentalProblems

Record on diagnosis lineV, Z, or T codes from chapter “Other Conditions that May be of Clinical Attention” (p. 715)

Axis V: Global Assessment of Functioning [GAF]

Optional use of World Health Organization Disability Schedule [WHODAS] (p. 745)

Changes to Five-Axis System

DSM-IV Five-Axis System DSM-5 Equivalent

Axis I: 309.81 PTSD, with delayed onset; 296.32 Major Depressive Disorder, recurrent, moderate, with mild anxious distress

Axis II: No diagnosisAxis III: No diagnosis

Axis IV: V.15.41 Personal history of spouse or partner violence, physicalV60.1 Inadequate housing;V60.2 Extreme poverty

Axis V: GAF score

1. 309.81 PTSD, with delayed onset

2. 296.32 Major Depressive Disorder, recurrent, moderate, with mild anxious distress

3. V15.41 Personal history of spouse or partner violence, physical

4. V60.1 Inadequate housing

5. V60.2 Extreme poverty

Changes to NOS

Not Elsewhere Classified [NEC]Specific symptoms with code

Other Specified Allows documentation of why client does not meet specific diagnostic criteria

UnspecifiedSignificant distress but does not meet criteriaInsufficient information (crisis, ER)

Organization & Content

Section IOrientationHistorical back groundDevelopment of DSM-5 How to use it

Section II Diagnostic Criteria and codes“Medication-induced Movement Disorders”“Other Conditions That May be a Focus of Clinical Attention.”

Organization & ContentSection III

Emerging Measures and ModelsAssessment measures http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measuresCultural formulationAlternative DSM-5 model for personality disorders“Criteria Sets for Conditions for Further Study”

AppendixHighlights of changes from DSM-IV to DSM-5

Glossary of technical terms

Glossary of cultural terms

Alpha & numeric listings of diagnoses and codes

List of advisors and contributors

Structure for Each Diagnosis

Diagnostic Criteria

Subtypes and/or specifiers

Severity

Codes and recording procedures

Explanatory text (new or expanded)

Structure for Each Diagnosis

Diagnostic and associated features

Prevalence

Development and course

Risk and prognosis

Culture- and gender-related factors

Diagnostic markers

Functional consequences

Differential diagnosis

Comorbidity

Social (Pragmatic) Communication Disorder

Disruptive Mood Dysregulation Disorder

Premenstrual Dysphoric Disorder

Hoarding Disorder

Excoriation (Skin‐Picking) Disorder

Disinhibited Social Engagement Disorder (split from Reactive Attachment Disorder)

Binge Eating Disorder

New Disorders

New DisordersCentral Sleep Apnea

Sleep-Related Hypoventilation

Rapid Eye Movement Sleep Behavior Disorder

Restless Legs Syndrome

Caffeine Withdrawal

Cannabis WithdrawalMajor Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other Medical Conditions)

Mild Neurocognitive Disorder

Eliminated

 

Sexual Aversion Disorder

Polysubstance-Related Disorder

Diagnostic Changes

New categories:

Obsessive-Compulsive and Related Disorders

Trauma- and Stressor-Related Disorders

Transformed:

Neurodevelopmental Disorders

(Infancy, adolescence, childhood)

Somatic Symptom and Related Disorders

Combined:

Language disorders

Autism spectrum

Specific Learning Disorder

Delusional disorder

Panic Disorder

Dissociative Amnesia

Somatic Symptom

Insomnia Disorder

Alcohol use disorder

Cannabis use disorder

Stimulant Intoxication

Stimulant withdrawal

Substance/medication-induced disorders

Examples of Changes

Trauma and Stress-Related Disorders

New chapter in DSM-5 brings together anxiety disorders that are preceded by a distressing or traumatic event

Reactive Attachment Disorder

Disinhibited Social Engagement Disorder (new)

PTSD (includes PTSD for children

6 years and younger)

Acute Stress Disorder

Adjustment Disorders

Posttraumatic Stress Disorder (PTSD)

There are 8 criterion

Criteria (A)- Exposure to actual or threatened death, serious injury, or sexual violence

Four symptom clusters, rather than threeRe-experiencing (B)

Avoidance (C)

Persistent negative alterations in mood and cognition (D)

Arousal- describes behavioral symptoms (E)

Duration of B, C, D, and E is more than 1 month

Causes clinically significant distress

Not attributed to substance use or medical condition

PTSDDSM 5 more clearly defines what constitutes traumatic event

Sexual assault is specifically included

Recurring exposure, that could apply to first responders

Recognition of PTSD in young children

Developmentally sensitive:Criteria have been modified for children 6 and younger

Thresholds- number of symptoms in each cluster have been lowered

Risk and Prognostic actors:Pretraumatic factors

Per traumatic factors

Posttraumatic factors

Substance-Related and Addictive Disorders

DSM-5 consolidates substance abuse and dependence into one disorder:

substance use disorder accompanied by criteria for: intoxication, withdrawal, substance-induced disorders, and unspecified related disorders.

Criteria are nearly identical to DSM-IV w/ exception of:

-Recurrent substance-related legal problems criterion has been deleted from DSM-5.

-And new criterion: craving, or a strong desire or urge to use a substance added.

The threshold is set at 2 or more criteria vs. 1 or more for abuse and 3 or more for dependence in the DSM-IV.

Substance-Related and Addictive Disorders

New disorders in substance-related & addictive disorders chapter of DSM-5:

Gambling Disorder (non-substance related disorder)

Cannabis Withdrawal

Caffeine Withdrawal

* The dx of polysubstance dependence has been eliminated.

Substance-Related and Addictive Disorders

Specifiers:

In DSM-5 severity for substance use disorders is based on the number of criteria endorsed:

-mild= 2-3 criteria

-moderate = 4-5 criteria

-Severe= 6 or more criteria

The DSM-IV specifier for psychological subtype has been eliminated.

Substance-Related and Addictive Disorders

In DSM-5 early remission is defined as at least 3 but less then 12 months without substance use disorder criteria (except craving).

Sustained remission is defined as at least 12 months without criteria (except craving).

New specifiers include:

-in a controlled environment

-on maintenance therapy

Neurodevelopmental Disorders

DSM-IV TR – “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”

Intellectual Disability (vs mental retardation) – Rosa’s Law

Assess cognitive capacity (IQ) and adaptive functioning (the primary determinant of severity).

Autism Spectrum Disorder (gone – Asperger’s, childhood disintegrative disorder, pervasive developmental disorder)

Addition – Social (Pragmatic) Communication Disorder

Neurodevelopmental Disorders

Attention-Deficit/Hyperactive Disorder (prior to age 12 vs age 7, less symptoms for adults, option for comorbid with ASD)

Specific Learning Disorder (DSM-IV TR = Academic Skills Disorders; greater detail in diagnosis, e.g., word reading, fluency, comprehension; clarify requirements for Low Achievement criterion)

Specifiers – greater detail on severity (e.g., ID – mild, moderate, severe, profound; ASD – Levels 1, 2, 3)

Removed – Separation Anxiety Disorder, Pica and Rumination Disorder, Feeding Disorder of Infancy or Early Childhood, Oppositional Defiant Disorder, Conduct Disorder

Personality Disorders

Criteria for PD’s in Section II of DSM-5 not changed from DSM-IV

No longer exist as an Axis II disorder (i.e., dropped multiaxial evaluation system)

PD now coded at same level as other mental disorders

No longer marginalized and treated differently

Personality Disorders

NOS dropped in favor of: (1) Other specified PD and (2) Unspecified PD

New, alternative approach to diagnosing PD developed for further study and included in separate section (Section III)

Personality Change Due to Another Medical Condition included in PD chapter (vs. DSM-IV’s Mental Disorders Due to a General Medical Condition)

Alternative DSM-5 Model for Personality Disorders

New model for assessment of personality disorders and traits

Includes Categorical and Dimensional approaches

Model not accepted by APA for inclusion in Section II

Decision –include in Section III as the “Alternative DSM-5 Model for Personality Disorders”

Rationale: the model “preserve(s) continuity with current clinical practice, while also introducing a new approach that aims to address numerous shortcomings of the current approach to personality disorders.”

Six PDs (vs. ten) – antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal)

Alternative DSM-5 Model for Personality Disorders

Based on Five Factor model of personality (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness)

PD Model (Negative affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism)

Negative Affectivity Neuroticism

Detachment Introversion

Antagonism Antagonism

Disinhibition Low Conscientiousness

Psychoticism Openness

25 Facets (traits): e.g., Anxiousness, Attention Seeking, Depressivity, Emotional Lability, Hostility, Impulsivity, Separation Insecurity, Withdrawal

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