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DSM-5 and Psychotic and MoodDisorders

George F. Parker, MD

The criteria for the major psychotic disorders and mood disorders are largely unchanged in the Diagnostic andStatistical Manual of Mental Disorders, Fifth Edition (DSM-5), with a few important exceptions: a new assessmenttool for the psychotic disorders based on dimensional assessment, a new scheme of specifiers for the mooddisorders, the addition of three new depressive disorders, and recognition of catatonia as a separate clinical entity.In addition, subtle changes to the diagnostic criteria for longstanding disorders may have important ramifications.There are forensic implications to these changes in the psychotic and mood disorders, but in most cases, theseimplications should be relatively modest, as the DSM-5 Work Groups ultimately adopted a cautious approach tochanges in the psychotic and mood disorders.

J Am Acad Psychiatry Law 42:18290, 2014

This article will consider the forensic implications ofthe changes in the diagnostic criteria for the psy-chotic and mood disorders contained in the Diag-nostic and Statistical Manual of Mental Disorders,Fifth Edition (DSM-5),1which was published by the

American Psychiatric Association (APA) in May2013. DSM-5 includes modest changes to the crite-ria and descriptive text for nearly every psychotic andmood disorder, some more significant than others.New developments in the psychotic and mood dis-

orders in DSM-5 include the recognition of catato-nia as a clinical state and the addition of three newdisorders: disruptive mood dysregulation disorder,persistent depressive disorder, and premenstrual dys-phoric disorder.

Forensic clinicians routinely encounter psychoticand mood disorders when performing forensic eval-uations and while caring for patients in correctionalsettings. Psychotic disorders are particularly com-mon in criminal forensic evaluations, as they are theprimary reason for requests for evaluation of compe-tence to stand trial2 and sanity at the time of theoffense.3 The psychotic disorders may also be seen incivil forensic evaluations, particularly in civil com-mitment and disability evaluations. Mood disordersare less frequent than psychotic disorders in criminal

forensic evaluations, but may be pertinent to compe-tence-to-stand-trial and insanity evaluations. Theyare more common in civil forensic evaluations, par-ticularly in disability evaluations.

The members of the DSM-5 Task Force andWork Groups reviewed the results of the abundantneuroscience research published over the past twodecades and realized that the boundaries betweenmany disorder categories are more fluid over the lifecourse than DSM-IV recognized (Ref. 1, p 5) and

considered the implementation of a dimensional ap-proach to diagnosis, which would have dramaticallychanged the focus of the DSM. However, the TaskForce recognized that it is premature scientificallyto propose alternative definitions for most disorders(Ref. 1, p 13). DSM-5 thus continues to use thecategorical approach to clinical diagnosis familiar toclinicians and to most consumers of forensic evalua-tions. Forensic clinicians may experience challengesto DSM-5 diagnoses, based on the widely publishedcriticisms by the chair of the DSM-IV Task Force4

and the current Director of the National Institutes ofMental Health (NIMH), who in 2009 launched theresearch domain criteria project to develop, for re-search purposes, new ways of classifying mental dis-orders based on dimensions of observable behaviorand neurobiological measures.5 Familiarity with theextensive review process that led to DSM-5, whichincluded extensive literature reviews, field trials, andpublic and professional review before final publica-

Dr. Parker is Professor of Clinical Psychiatry and Director of ForensicPsychiatry, Indiana University School of Medicine, IU Health Neuro-science Center, 355 West 16th Street, Suite 2800, Indianapolis, IN46202. E-mail: [email protected].

Disclosures of financial or other potential conflicts of interest: None.

182 The Journal of the American Academy of Psychiatry and the Law

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tion (Ref. 1, pp 610), should allow for effectiverebuttal of such challenges.

The Psychotic Disorders

The Psychotic Disorders Workgroup decided thatDSM-IV criteria for the psychotic disorders do not

accurately capture the considerable variability ofsymptom profile, response to treatment, and mostimportantly, social function and outcome; how-ever, despite considerable pressure to move to a di-mensional approach to the diagnosis of psychoticdisorders, the DSM-5 does not represent such aparadigm shift (Ref. 6, p 11).

There is subtle evidence of the dimensional ap-proach in the chapter entitled Schizophrenia Spec-trum and Other Psychotic Disorders, which begins

with a description of five domains of psychotic

symptoms (Ref. 1, p 87), the names of which areidentical to the five symptoms listed in Criterion Afor the diagnosis of schizophrenia in DSM-IV. Inaddition, the work group developed a rating instru-ment, the Clinician-Rated Dimensions of PsychosisSymptom Severity, to evaluate eight dimensions ofpsychosis, which may help with treatment plan-ning, prognostic decision-making and research(Ref. 1, p 89), but placed it in Section III, EmergingMeasures and Models (Ref. 1, pp 7434). This in-strument is mentioned in the last section of the cri-teria for each of the psychotic disorders, under the

heading Specify Current Severity; clinicians are re-ferred to the instrument after the statement quanti-tative assessment of the primary symptoms of psy-chosis . . . may be rated for its current severity . . . ona 5-point scale (Ref. 1, p 91). This tool appears to beeasy to use, could easily be adapted for inclusion in anelectronic medical record, and may prove valuable incorrectional and other treatment settings where con-tinuity of care is difficult to achieve due to clinicianturnover and movement of patients within the sys-tem. However, each section ends with a note, whichstates diagnosis of [the disorder] can be made with-out using the severity specifier, which certainly im-plies that the use of this instrument is not required. APubMed search of the phrase clinician-rated dimen-sions of psychosis symptom severity returned noitems; thus, this instrument appears not to have beenvalidated, which may make it vulnerable to challengein court.

Overall, the criteria for diagnosis of psychotic dis-orders in DSM-5 are little changed from those in

DSM-IV. All of the psychotic disorders found inDSM-IV are present in DSM-5, and catatonia wasadded, as a semiautonomous clinical entity. Schizo-typal personality disorder is listed at the beginning ofthe section, because this disorder is considered partof the schizophrenia spectrum of disorders (Ref. 1, p

90). However, because only a small proportion(Ref. 1, p 657) of people with schizotypal personalitygo on to develop another psychotic disorder, the di-agnostic criteria and explanatory text for schizotypalpersonality disorder, which are essentially identicalto those in DSM-IV, remain in the section on Per-sonality Disorders. The recognition in DSM-5 ofschizotypal personality as part of the schizophreniaspectrum may have implications for sanity evalua-tions, which typically hinge on the presence or ab-sence of psychosis, even though people with schizo-typal personality do not show persistent symptoms of

psychosis, such as hallucinations or delusions.

Delusional Disorder

In DSM-5, people who show bizarre delusions arenow eligible for the diagnosis of delusional disorder,

which is a significant change. The criteria also in-clude a more modest change, as course specifiers arenow more detailed. The subtypes of delusions areunchanged from DSM-IV, but clinicians may nowalso specify if the persons delusions show bizarrecontent. The addition of bizarre delusions to the

diagnostic criteria may increase slightly the fre-quency of this uncommon diagnosis, which DSM-5estimates has a lifetime prevalence of 0.2 percent(Ref. 1, p 92). In a recent article, bizarre delusions

were rarely (2%) identified as the sole reason for aDSM-IV diagnosis of schizophrenia,7 so the numberof people whose diagnosis would change fromschizophrenia to delusional disorder is likely to below. It is hard to predict how the shift of bizarredelusions to the criteria for delusional disorder willaffect treatment; the small research literature on thetreatment of delusional disorder suggests that long-term treatment with antipsychotic medication maylead to a modest decrease in the intensity of delu-sions.8,9 It is unknown whether people who havedelusional disorder with bizarre content will show asimilar response to antipsychotic medication. Giventhe strong likelihood of persistent symptoms in aperson with delusional disorder, assessment of therisk of violence based on bizarre delusions will re-quire, as always, a careful evaluation of the individual

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and his symptoms, particularly if the delusions in-volve an identifiable individual (e.g., a family mem-ber or neighbor) or a group of people (e.g., policeofficers), thus putting that person or group at risk ofviolence.

Brief Psychotic DisorderThe core diagnostic criteria for brief psychotic dis-

order are essentially unchanged: the symptoms mustpersist for one month or less, and the person mustrecover fully after the psychosis ends. The criterianow require the acute onset of at least one symptom:delusions, hallucinations, or disorganized speech.Grossly disorganized or catatonic behavior remainsas a fourth possible symptom but is not sufficientalone to make the diagnosis. The impact of this mi-nor revision on forensic psychiatry is likely to beminimal.

Schizophreniform Disorder

The diagnosis of schizophreniform disorder is lit-tle changed. The A, B, C, and D criteria are identicalto those in DSM-IV. The text for the specifier withgood prognostic features has been slightly revised(Ref. 1, p 97). Schizophreniform disorder remainsintermediate in symptom duration between briefpsychotic disorder and schizophrenia. It has no cor-ollary in the International Classification of Diseases(ICD) scheme,10 in which a diagnosis of schizophre-

nia may be made after one month of symptoms ofpsychosis. The forensic impact of the minor changesin the criteria for schizophreniform disorder inDSM-5 should be minimal.

Schizophrenia

Critics have described the DSM-5 criteria forschizophrenia as an evolution, not a break-through.11,12 The DSM-IV criteria for schizophre-nia were quite reliable and diagnoses made with thesecriterion were stable over time, so only modestchanges were made in DSM-5.13 The five symptomsof the A criterion, which are familiar to clinicians,have been retained, but one of the two symptomsneeded to diagnose schizophrenia must be delusions,hallucinations, or disorganized thinking and speech.Schneiderian first-rank symptoms (i.e., bizarre delu-sions or auditory hallucinations, either conversingamong themselves or providing a running commen-tary) are no longer sufficient to qualify a person for adiagnosis of schizophrenia. Research on these symp-

toms found that they had no prognostic relevanceand were not linked to a family history of schizophre-nia; removing the Schneiderian symptoms from the

A criteria was estimated to affect fewer than 2 percentof diagnoses.11 In another change based on recentresearch, the negative symptoms have been limited to

two choices: diminished emotional expression oravolition (Ref. 1, p 99). Negative symptoms areoften overlooked in criminal forensic evaluations,

which typically focus on the link between positivesymptoms of psychosis and behavior, but a lack ofvolition may have important implications for decid-ing whether a defendant possessedmens rea at thetime of the alleged offense. In civil forensic evalua-tions, negative symptoms are well known as a pri-mary cause of disability in schizophrenia.14

DSM-5 does not identify any subtypes of schizo-phrenia (e.g., paranoid or disorganized), due to thefrequent comorbidity among the DSM-IV subtypesand their poor reliability, low stability, and limitedprognostic value.13 In contrast, the course specifiersfor schizophrenia in DSM-5 are almost completelynew. There are two main categories of course speci-fiers, first episode and multiple episodes, each of

which may be described as acute, in partial remission,or in full remission; the specifier continuous is theonly holdover from DSM-IV (Ref. 1, pp 99100).These specifiers should allow clinicians to describeaccurately the present clinical status of a person with

schizophrenia. The specifiers are likely to see regularuse in correctional psychiatry, where ongoing treat-ment is the norm, and in civil forensic evaluations,

where the specifiers may be helpful in commitmentand disability evaluations. The course specifiers arenot as likely to be a factor in criminal evaluations ofcompetence or sanity.

The connection between a given mental disorderand a risk of violence is not prominent in the psycho-sis and mood disorders sections of DSM-5. The clos-est DSM-5 comes to this topic is in the description ofassociated features supporting diagnosis of schizo-phrenia, which includes the observation that hostil-ity and aggression can be associated with schizophre-nia, although spontaneous and random assault isuncommon. Aggression is more frequent for youngermales and for individuals with a history of violence,non-adherence with treatment, substance abuse andimpulsivity (Ref. 1, p 101). Beyond this statement,DSM-5 has little to say about the risk of violenceassociated with psychosis. The Cautionary State-

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ment for Forensic Use of DSM-5, which precedesthe sections of diagnostic criteria, does not mentionrisk of violence.

Schizoaffective Disorder

Schizoaffective disorder was considered for re-

moval from DSM-5, in favor of a dimensional ap-proach to the diagnosis of the psychotic disorders.This proposal was based on the low reliability of thisdiagnosis compared with other psychotic disorders,recent research that suggested that schizoaffectivedisorder is intermediate between schizophrenia andbipolar disorder and may not be a separate diagnosticentity, and the limited clinical utility of a diagnosisthat practitioners make without adhering to crite-ria.15 However, because the available research find-ings are not yet compelling enough to justify a moveto a more neurodevelopmentally continuous modelof psychosis (Ref. 16, p 131), schizoaffective disor-der was retained, with revised criteria. In particular,the requirement for the presence of a mood episode

was strengthened, such that mood symptoms suffi-cient to meet criteria for a mood episode must bepresent for at least half of the total duration of theillness from the onset of the first psychosis to makea diagnosis of schizoaffective disorder (Ref. 15, pp234). Schizoaffective disorder diagnosed withDSM-IV criteria has been shown to be an unstablediagnosis.17 Field trials of the DSM-5 criteria for

schizoaffective disorder showed good test-retest reli-ability when rigorously applied,18 so it is possible thenew criteria will also lead to a more stable diagnosticentity.

The forensic implications of the changes in thecriteria for schizoaffective disorder in DSM-5 are notclear. A proper diagnosis of schizoaffective disorderrequires that a person meet all of the criteria forschizophrenia and all of the criteria for an episode ofbipolar disorder or depression, with the exception ofimpaired function. DSM-5 estimates the prevalenceof schizoaffective disorder to be one-third that ofschizophrenia (Ref. 1, p 107), so it should be anuncommon disorder. Although it is important tomake as accurate a diagnosis as possible to treat effec-tively, the alternatives to schizoaffective disorder(i.e., schizophrenia with a mood component or amood disorder with psychosis), should also lead cli-nicians to treat with appropriate classes of medica-tion. Otherwise, the forensic implications of thechanges to schizoaffective disorder should be modest;

the main concern will continue to be appropriate andconsistent use of the criteria.

Catatonia

In DSM-5, catatonia is recognized as a separateclinical entity, though not as an independent disor-

der. It can be diagnosed whenever it is present, butonly in the context of a mental disorder, a medicaldisorder, or an unspecified condition. If a personmeets 3 of the 12 criteria, the specifier with catato-nia should be added to diagnoses of most of theserious mental disorders in DSM-5 (Ref. 1, pp 119120), to facilitate its appropriate recognition andspecific treatment.19 Catatonia was once considereda common presentation of schizophrenia, but its re-ported prevalence in schizophrenia declined over thecourse of the 20th century20,21; in recent research,though, catatonia was found in up to 10 percent of

people with an acute psychiatric disorder, nearly halfof whom had a mood disorder and only a quarter of

whom had a psychotic disorder.22 Improved aware-ness of catatonia could have implications for forensicpractice. In the criminal realm, catatonia could cer-tainly contribute to a finding of incompetence tostand trial, but it is unlikely to be an element of aninsanity defense, as only one of the 12 symptoms,agitation, might be a precursor to illegal activity. Theprimary outcome of recognition of catatonia,though, would be the impact on the person withcatatonia, as this condition can be treatedeffectively.22

Attenuated Psychosis Syndrome and SharedPsychotic Disorder

The Psychotic Disorders Work Group consideredadding attenuated psychosis syndrome as a new di-agnosis to DSM-5, but instead decided to place it inSection III as a condition for further study, after fieldtrial data showed that it was not diagnosed reliably byclinicians.23 Attenuated psychosis syndrome ismeant to describe people who show recent onset ofmodest, psychotic-like symptoms and clinically rele-vant distress and disability (Ref. 23, p 32). In addi-tion, the person who experiences the symptoms mustrecognize them as unusual and experience sufficientdistress or disability to seek clinical evaluation. De-spite the clear guidance in the DSM-5 that condi-tions in Section III are not intended for clinical use,this syndrome is not just in Section III, but is alsospecifically identified in Other Specified Schizo-phrenic Spectrum and Other Psychotic Disorder as

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one of four examples of alternative presentations of apsychotic disorder; where it is labeled other psy-chotic disorder, attenuated psychosis syndrome(Ref. 1, p 122).

The diagnosis of attenuated psychosis syndromemay contribute to a finding of incompetence to stand

trial, as young adults are at highest risk for this dis-order and are at highest risk for arrest, but it is un-likely to be the single reason for such a finding, giventhe absence of overt psychosis. Attenuated psychosisis also unlikely to be a precursor to an insanity ver-dict, as this syndrome is meant to identify people

with symptoms that are psychosis-like but below thethreshold for a full psychiatric disorder (Ref. 1, p783). Attenuated psychosis may appear more fre-quently in civil forensic evaluations, in the context ofemployment and disability assessments.

Shared psychotic disorder (folie a deux), which was

present in DSM-IV as a separate disorder, exists inDSM-5 only in the section on other specified schizo-phrenic spectrum and other psychotic disorders, asdelusional symptoms in partner of individual withdelusional disorder (Ref. 1, p 122). The presence ofshared psychotic disorder in DSM-5 will allow con-tinued recognition of this disorder, which, althoughrare, is occasionally seen in forensic cases, both crim-inal and civil.

Mood Disorders

The DSM-IV section on Mood Disorders hasbeen replaced in DSM-5 with separate sections forthe Bipolar Disorders and the Depressive Disorders.The section on Bipolar Disorders is placed betweenthe Psychotic Disorders and the Depressive Disor-ders in DSM-5, in recognition of their place as abridge between the two diagnostic classes in terms ofsymptomatology, family history and genetics (Ref.1, p 123). Three new depressive disorders are in-cluded in DSM-5: disruptive mood dysregulationdisorder, persistent depressive disorder, and premen-strual dysphoric disorder; the first of these will not bediscussed in this article but will be considered in thereview of Neurodevelopmental and Other Disor-ders of Childhood and Adolescence.24 The numberof bipolar disorders is unchanged; they consist ofbipolar I, bipolar II, and cyclothymic disorders, as

well as bipolar disorder due to medications, drugs, ora medical condition. The criteria for episodes of ma-nia, hypomania, and major depression are generallyunchanged from DSM-IV, with a few important ex-

ceptions, which are discussed below. Missing fromDSM-5 is the DSM-IV entity of mood disorderNOS, which has been replaced with unspecified bi-polar disorder and unspecified depressive disorder;people who present with an unclear pattern will haveto be designated as one or the other.

Specifiers for Mood Disorders

DSM-5 includes multiple specifiers to describethe Bipolar and Depressive Disorders (Ref. 1, pp14954, 1848), as part of a mixed categorical-dimensional approach.25 The specifiers are meantto define a more homogeneous subgrouping of in-dividuals with the disorder who share certain charac-teristics . . . and to convey information that is rele-vant to the management of the individuals disorder(Ref. 1, pp 212). The presence of new and moredetailed descriptive specifiers for the bipolar and de-pressive disorders may have some impact on forensicpsychiatry. The specifiers are intended to be used todescribe the course of a persons disorder and shouldnot affect the frequency of the underlying diagnosis,but some specifiers may have implications for suiciderisk. In addition, these specifiers may be useful inforensic contexts where a prediction of future coursemay be helpful, such as sentencing, civil commit-ment, and child custody.

The specifier of with anxious distress (Ref. 1, p149) is the only entirely new one. It was added to

account for the high prevalence of symptoms of anx-iety in both manic and depressed states and becausea substantial body of research conducted over thepast two decades points to the importance of anxietyas relevant to prognosis and treatment decision-mak-ing in bipolar and depressive disorders.26 The addi-tion of this specifier should encourage the identifica-tion of anxiety in people who have a bipolar ordepressive disorder, which should lead to improvedmanagement of suicide risk, as anxiety is a risk factorfor suicide.27 Conversely, a lack of recognition ofanxiety in the medical record or treatment plan couldhave implications for malpractice liability in cases ofattempted or completed suicide.

The DSM-IV specifier of postpartum onset hasbeen replaced in DSM-5 by with peri-partum on-set, which may be applied if the mood episode oc-curs during pregnancy or within four weeks of deliv-ery. The explanatory note for this specifier makes itclear that it was added to improve the recognition ofbipolar and depressive episodes during pregnancy, in




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order to prevent postpartum psychosis, which is of-ten linked to a mood disorder and is a major riskfactor for infanticide (Ref. 1, pp 1523). The addi-tion of peri-partum onset will thus have forensic im-plications, both for the management of bipolar anddepressive disorders in pregnancy and for the review

of cases of infanticide.The DSM-IV entity of a mixed episode of bipolar

disorder has been replaced with the specifier withmixed features (Ref. 1, p 14950), which can beapplied to bipolar I, bipolar II, major depressive, andpersistent depressive disorders. Thus, a person withhypomania or mania who shows some symptoms ofdepression and a person with depression who showssome symptoms consistent with hypomania or ma-nia should be designated as with mixed features.

Although the mixed-features specifier will better ac-

count for the highly prevalent subsyndromal presen-tations (Ref. 28, p 30) of both manic and depressedstates, its addition does not solve the problems of theoverlap between unipolar and bipolar depression orthe gray zone of the boundary between bipolar dis-order and schizoaffective disorder.28 As a result, de-bate on the applicability of this specifier to a partic-ular person could be vigorous. The DSM-5 criteriafor the specifier of mixed features have also beencriticized for including euphoria and excluding agi-tation and irritability, thus moving away from Kra-epelins original concept of mixed depression as afairly common clinical entity.29 Overall, the impactthis specifier will have on forensic practice is unclear.

The specifier with seasonal pattern now includesall mood episodes (mania, hypomania, and depres-sion) in the introduction and the criteria, instead ofbeing limited, as in DSM-IV, only to episodes ofdepression. However, the explanatory note makes itclear that the essential feature is the onset and re-mission of major depressive episodes at characteristictimes of the year (Ref. 1, p 153), which retains theintent of the DSM-IV criteria.

The criteria for the specifiers with melancholicfeatures and with atypical features are largely un-changed from DSM-IV, but a detailed note on theuse of each specifier has been added to the text foreach. The criteria for the specifier with psychoticfeatures are essentially unchanged and have no ex-planatory note. The criteria for with rapid cyclingare also unchanged, but a second explanatory note

was added to clarify that each of the four episodes

needed in one year to qualify for this diagnosis mustbe marked by full remission or a switch of polarity.

Bipolar I Disorder

The Mood Disorders Work Group introduced thecriteria for the bipolar disorders by noting the bipo-

lar I disorder criteria represent the modern under-standing of the classic manic-depressive disorder(Ref. 1, p 123). There are two changes in the criteriafor bipolar I disorder in DSM-5. First, a person withmania must show elated or irritable mood or bothand increased energy or activity, which modestlytightens the criteria for a manic episode. Second,excessive involvement in activities no longer re-quires these activities to be pleasurable, just to have ahigh potential for painful consequences (Ref. 1,p.134), which can be seen as a modest loosening of

the criteria. The work group also clarified that maniainduced by treatment with antidepressant medica-tion counts as a manic episode for the purpose ofdiagnosing bipolar I disorder. The DSM-5 criteriafor bipolar disorder are unlikely to have a significantimpact on forensic psychiatry and are unlikely tosolve the debate over whether bipolar disorder isoverdiagnosed30 or underdiagnosed.31

The prevalence of self-reported bipolar disorder incorrectional populations is likely to remain high solong as people who report mood swings are given aprescription for a mood-stabilizing medication and adiagnosis of some form of bipolar disorder by clini-cians. If the DSM-5 criteria for the diagnosis of bi-polar disorder are used appropriately, the frequencyof this phenomenon should decrease. However, eventhough the DSM-IV diagnosis of bipolar disorderNOS has been removed, DSM-5 has added otherspecified bipolar and related disorders (Ref. 1,p 148) and unspecified bipolar disorder (Ref. 1,p 149), which are likely to be used to describe people

who report subjective mood instability that does notmeet criteria for bipolar I or bipolar II disorder. In

particular, the choices under other specified bipolarand related disorder include four variant presenta-tions, including one that is also listed in Section III(depressive episodes with short-duration mania),

which could account for several bipolar presentationsthat do not include a true manic or hypomanic epi-sode. The report of a prior diagnosis of bipolar dis-order in a forensic evaluation should prompt thor-ough, open-ended questioning of the persons

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psychiatric history, searching for evidence of truemanic or hypomanic episodes.

Bipolar II Disorder

The DSM-5 diagnosis of bipolar II continues torequire at least one episode of current or past hypo-

mania and at least one episode of current or pastmajor depression, with no history of an episode ofmania. There is a new focus in the criteria on thefunctional impact of the symptoms of depression inbipolar II, as the section on the diagnostic featuresnotes that this disorder often presents with majordepression and urges clinicians to ask for a history ofhypomania in people who are depressed (Ref. 1, p135). In addition, because people who have bipolarII disorder often experience repeated or prolongedepisodes of depression, DSM-5 makes a point of de-scribing bipolar II disorder as not less severe thanbipolar I disorder. The observations made above re-garding the prevalence of diagnoses of bipolar I dis-order also apply to bipolar II disorder.

Cyclothymic Disorder

The diagnosis of cyclothymic disorder requires atwo-year history of many episodes of not-quite hy-pomania and not-quite major depression. DSM-IVpermitted this diagnosis to remain active if an epi-sode of mania, hypomania, or major depression oc-curred after the first two years of subsyndromal

symptoms. The DSM-5 criteria hold that criteriafor a major depressive, manic or hypomanic episodehave never been met. In addition, the DSM-5 cri-teria clarify that hypomanic or depressive symptomsmust be present at least half of the time during therequired two-year period (Ref. 1, pp 139 40). Thesechanges in the criteria will further restrict the preva-lence of this relatively rare disorder, but their impacton forensic practice is likely to be minimal, as thisdisorder is uncommon in criminal forensic evalua-tions and is not a major cause of disability.

Major Depressive Disorder

The primary criteria for the diagnosis of majordepression in DSM-5 are largely unchanged fromDSM-IV, with one potentially significant exception.DSM-IV permitted a diagnosis of depression in abereaved person only if the symptoms had been pres-ent for more than two months or if they had causedmarked functional impairment. However, researchon bereavement and depression found little reason

for such a distinction. The Mood Disorders WorkGroup therefore proposed that symptoms of depres-sion in the context of bereavement or other signifi-cant loss would qualify for a diagnosis of major de-pression, which would have removed the normalbereavement exception for depression found in

DSM-IV and present in the ICD.32

This proposalwas met with strong criticism by many clinicians andthe public, who felt that the new disorders inappro-priately turned a normal psychological reaction toloss into a form of psychopathology.

The Mood Disorders Work Group did not rein-state the bereavement exception, but instead added anote to the depression criteria to explain that re-sponses to a significant loss . . . may include the feel-ings of intense sadness, rumination about the loss,insomnia, poor appetite, and weight loss noted in

Criterion A, which may resemble a depressive epi-sode. Although such symptoms may be understand-able or considered appropriate to the loss, the pres-ence of a major depressive episode . . . should also becarefully considered (Ref. 1, p 161). This change tothe criteria for major depression could have an im-pact on civil forensic psychiatric evaluations. If be-reavement is no longer a barrier to a diagnosis ofdepression, this diagnosis can be made in survivors of

wrongful or negligent deaths, which could increaseclaims for damages.

A more subtle change in the criteria for depressionin DSM-5 can be found in the description of de-pressed mood, where a person who is depressed issad, empty or hopeless; in DSM-IV the phrase wassad or empty. Thus, a feeling of hopelessness aloneis enough to meet the criterion for depressed mood,

which could increase the frequency of the diagnosisof depression.32 Hopelessness has long been recog-nized as a risk factor for suicide,33,34 so the recogni-tion of this symptom as characteristic of depressionshould encourage clinicians to inquire about hope-lessness and then to take it into account in their

suicide risk assessment.A major concern for all clinicians who use the

DSM is the reliability of the disorders described inthe manual. Major depression does not fare well inthis regard; the inter-rater reliability of DSM-5 ma-

jor depression showed a coefficient of 0.28, wellbelow the coefficients for the DSM-III35 (between0.60 and 0.80) and DSM-IV (between 0.40 and0.80) criteria.32




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Persistent Depressive Disorder (Dysthymia)

The diagnosis of persistent depressive disorder isnew to DSM-5 and is meant to combine theDSM-IV disorders of dysthymia and chronic majordepression, defined as two or more years of continu-ous major depression. The decision to merge these

diagnostic concepts was based on research that sug-gested that chronic depression was prevalent in thecommunity and could be distinguished from non-chronic depression.36 The A, B, and C criteria forpersistent depressive disorder are unchanged fromthe DSM-IV criteria for dysthymia, but the D crite-rion now reads criteria for a major depressive disor-der may be continuously present for two years (Ref.1, p 168). The relationship between persistent de-pressive disorder and major depression in DSM-5 issomewhat confusing and leads to conflicting recom-mendations. For example, a person whose symp-toms meet major depressive disorder criteria for twoyears should be given a diagnosis of persistent depres-sive disorder as well as major depressive disorder(Ref. 1, p 169), whereas for a person who meetscriteria for persistent depressive disorder, if thesymptom criteria are sufficient for a diagnosis of amajor depressive episode at any time during this pe-riod, then the diagnosis of major depression shouldbe noted, but it is not coded as a separate diagnosisbut rather as a specifier (Ref. 1, pp 1701). Theproper diagnosis of a person with chronic depression

may thus become a fruitful area for cross-examina-tion, given the multiple ways a person with chronicsymptoms of depression could be coded. The impactof persistent depressive disorder in clinical practicemay be modest, outside of the possible confusion ofproper diagnosis, as people who have dysthymia orchronic depression respond to similar treatment.

Premenstrual Dysphoric Disorder

This disorder was in Appendix B of DSM-IV (Ref.37, pp 71518) but has been moved to the main textin DSM-5. The research criteria laid out in DSM-IVhave been modified for DSM-5. This diagnosis isbased on the presence of specific symptoms in the

week before onset of menses followed by resolutionof the symptoms after onset. The symptoms mustinclude one or more of marked affective lability, ir-ritability or anger, depressed mood or hopelessness,and anxiety or tension, as well as one or more of anadditional seven symptoms, with a total of at leastfive symptoms. The criteria specifically note that

Criterion A should be confirmed by prospectivedaily ratings during at least two symptomatic cycles(Ref. 1, p 172), which means it will be difficult tomake this diagnosis on the basis of a single evalua-tion; although two cycles of daily ratings are techni-cally not required, it will be easy to challenge a diag-

nosis made without these data. The addition ofpremenstrual dysphoric disorder to DSM-5 mayopen up new avenues in civil forensic evaluations,most likely in the area of disability evaluations, andmay make an appearance in criminal evaluations ifaffective instability and anger due to this disordercontribute to an individuals violent behavior.

Conclusion

Overall, because many of the changes in the crite-ria for these disorders are minor, the forensic impli-cations of the DSM-5 criteria for the diagnoses of

psychotic and mood disorders appear to be modest,with a few exceptions. Forensic clinicians should re-view the DSM-5 criteria for the mood and psychoticdisorders carefully and consider how the new criteriamay affect their evaluations and practice.

References

1. American Psychiatric Association: Diagnostic and StatisticalManual of Mental Disorders, Fifth Edition. Arlington, VA:American Psychiatric Association, 2013

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