What has changed in the DSM-5? JESSICA SHELTON, M.S.ED., LPC, LMFT JUNE 4, 2015.

What has changed in the DSM-5?JESSICA SHELTON, M.S.ED., LPC, LMFT

JUNE 4, 2015

Why were there changes in the first place?

The new ICD-10 codes will be required in the U.S. as of 10/1/15 The DSM-IV used ICD-9 codes

The DSM-5 includes both ICD-9 and ICD-10 codes to help with the transition period

Increased call for standardization in diagnostic and research terminology Criteria is more objective to help bring consistency

There have been many advances in research, especially in area of neuroscience, since the previous edition. Changes in understanding led to changes in diagnostic criteria

So what’s different?

The title includes a numeral instead of a Roman numeral to facilitate more frequent updates instead of huge overhauls (i.e., DSM-5.1)

The multi-axial system is different (Not everyone has converted to this yet) Axis I, II, and III are now combined The former Axis IV (psychosocial or environmental factors)

may still be noted The former Axis V Global Assessment of Functioning (GAF)

scale is gone; the World Health Organization Disability Assessment Schedule (WHODAS) is to be used instead


Section I of the DSM-5 contains overview information and instructions on using the manual

Section II includes the diagnoses and their criteria Section III of the DSM-5 includes assessments to be used by

clinicians, including the WHODAS Not all assessments were included. More can be found online,

along with supplemental diagnostic information This section also contains information on cultural

considerations in diagnosing mental illness and a list of possible future disorders (Internet Gaming Disorder, Nonsuicidal Self-Injury, etc.)


Many chapters have a Dx for “Substance/Medication-Induced ______ Disorder” and “______ Disorder Due to Another Medical Condition,” rather than these disorders being listed in their own chapter

“Not Otherwise Specified” is no longer an option: “Other Specified Disorder” – when the client does not meet full

criteria for the disorder, the clinician can specify with this Dx and the reason the full Dx is not met

“Unspecified Disorder” – when the client does not meet the full criteria and the clinician does not want to specify why the Dx is not met


Diagnoses were added, deleted, reorganized, or had diagnostic criteria changed

Subtypes – used to differentiate among mutually exclusive Dx Ex. – AD/HD predominantly inattentive, predominantly

hyperactive/impulsive, or combined

Specifiers – used to describe the Dx further (not mutually exclusive) Ex. – In partial remission

Note: many codes for subtypes and specifiers are not coded in ICD 9 or 10

DSM-IV Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

Chapter is now called Neurodevelopmental Disorders Includes Intellectual Disabilities, Communication Disorders, ASD,

AD/HD, Specific Learning Disorder, and Motor Disorders

Mental Retardation is now called Intellectual Disability Expressive Language Disorder and Mixed Receptive-Expressive

Language Disorder have been combined into Language Disorder

Phonological Disorder is now called Speech Sound Disorder Stuttering is now called Childhood-Onset Fluency Disorder


New Dx: Social Communication Disorder May encompass many of those formerly diagnosed with

Pervasive Developmental Delay NOS

Autism, Childhood Disintegrative Disorder, Asperger’s, and PDD NOS have been combined into Autism Spectrum Disorder (ASD) Biological causes such as Down Syndrome or Rett Syndrome

are specifiers

AD/HD criteria have changed slightly


Reading, Mathematics, Written Expression, and Learning Disorders are now all called Specific Learning Disorder Type is listed as a specifier

Motor Disorder still includes Developmental Coordination Disorder but now also includes Stereotypic Movement Disorder and Tic Disorders (Tourette’s, Persistent Motor or Vocal Tic Disorder, and Provisional Tic Disorder)

DSM-IV Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence Conduct Disorder and Oppositional Defiant Disorder moved

to a new chapter called Disruptive, Impulse-Control, and Conduct Disorders

Joins with some of the disorders from the DSM-IV chapter called Impulse-Control Disorders Not Elsewhere Classified: Intermittent Explosive Disorder, Pyromania, and Kleptomania Pathological Gambling is now called Gambling Disorder and

was moved from this DSM-IV chapter to the chapter now called Substance-Related and Addictive Disorders

Trichotillomania is in a new chapter called Obsessive-Compulsive and Related Disorders, along with OCD, Body Dysmorphic Disorder, Hoarding Disorder, and Excoriation


Elimination Disorders (encopresis and enuresis) moved to their own chapter

Pica, Rumination Disorder, and Feeding Disorder of Infancy or Childhood (now called Avoidant/Restrictive Food Intake Disorder) joined Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder in the chapter now called Feeding and Eating Disorders


Separation Anxiety Disorder and Selective Mutism moved to the Anxiety Disorders chapter, along with Specific Phobias, Social Anxiety Disorder, Panic Disorder, Agoraphobia (now its own Dx), and Generalized Anxiety Disorder

The two subtypes of Reactive Attachment Disorder were made separate diagnoses (RAD and Disinhibited Social Engagement Disorder); they moved to a new chapter called Trauma- and Stressor-Related Disorders, along with PTSD, Acute Stress Disorder, and Adjustment Disorders

DSM-IV Delirium, Dementia, and Amnestic and Other Cognitive Disorders

Now called Neurocognitive Disorders, and is one of the last chapters instead of one of the first

Delirium criteria have been mildly updated Dementia and Amnestic Disorder are now together as Major

or Mild Neurocognitive Disorder There are criteria for the specifiers (Alzheimer’s, Vascular,

Parkinson’s, etc.)

DSM-IV Substance-Related Disorders

This chapter is now called Substance-Related and Addictive Disorders Includes Gambling Disorder (with more non-substance

addictions likely to follow as research grows)

Polysubstance Dx has been removed; diagnose multiple substances separately

Physiological specifier has been removed Can specify if client is in a controlled environment, or if they

are on maintenance therapy


The DSM-IV diagnoses of Substance Abuse and Substance Dependence are gone; the new Dx is Substance Use Disorder Depending on the number of criteria endorsed, Dx is listed as

mild, moderate, or severe Criteria groups include impaired control, social impairment,

risky use, and pharmacological criteria (tolerance and withdrawal)

At least 2 criteria are now required instead of 1 Recurrent legal trouble was removed; craving was added


Covers 10 classes of drugs: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives/hypnotics/anxiolytics, stimulants, tobacco, and other (or unknown) The diagnoses are made depending on class of drugs (i.e.,

Alcohol Use Disorder, Caffeine Withdrawal, etc.) Use the specific substance in the name of the Dx, not the class

name (i.e., Secobarbital Use Disorder, not Sedatives/Hypnotics/Anxiolytics Use Disorder)

Not all substance classes have each Dx (i.e., no Tobacco Intoxication)

DSM-IV Schizophrenia and Other Psychotic Disorders

This chapter is now titled Schizophrenia Spectrum and Other Psychotic Disorders

Schneiderian symptoms were removed due to the level of discrepancy in diagnosing, so now there must be at least two Category A symptoms, and one must be delusions, hallucinations, or disorganized speech

The subtypes from DSM-IV have been removed; severity is to be listed and other specifiers (including catatonia) are available

DSM-IV Schizophrenia and Other Psychotic Disorders

The other disorders in this chapter had some minor changes to diagnostic criteria: Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizoaffective Disorder Catatonia

DSM-IV Mood Disorders

This chapter has been divided into two: 1. Bipolar and Related Disorders

Bipolar I Disorder

Bipolar II Disorder

Cyclothymic Disorder

The DSM-IV diagnosis of Bipolar Disorder with Mixed Features is gone; now “mixed features” is a specifier

DSM-IV Mood Disorders

2. Depressive Disorders Disruptive Mood Dysregulation Disorder (new Dx)

Major Depressive Disorder

Persistent Depressive Disorder (formerly Dysthymia)

Premenstrual Dysphoric Disorder (new Dx)

The Bereavement exclusion has been removed There are specifiers for these diagnoses as well

DSM-IV Anxiety Disorders

OCD, PTSD, and Acute Stress Disorder moved to other chapters

Some of the diagnostic criteria have changed slightly Criteria that adult recognizes the anxiety as unreasonable or

excessive has been removed

Agoraphobia is now separate from Panic Disorder Panic attack categories have been simplified to “expected”

or “unexpected” Selective Mutism and Separation Anxiety are in this chapter

now

DSM-IV Somatoform Disorders

New chapter is called Somatic Symptom and Related Disorders

The number of diagnoses has been reduced to avoid overlap and erroneous diagnosis Somatization Disorder, Hypochondriasis, and Pain Disorder

were removed

Somatic Symptom Disorder is similar to Somatization Disorder, but there must be maladaptive thoughts, feelings, or behaviors related to the physical symptoms

DSM-IV Somatoform Disorders

Those with previous Dx of Hypochondriasis would likely qualify for Illness Anxiety Disorder Dx

Factitious Disorder went from being its own chapter to being included in Somatic Symptoms and Related Disorders

New Dx: Psychological Factors Affecting Other Medical Conditions Ex. Anxiety affects course of asthma

Conversion Disorder criteria only changed slightly Body Dysmorphic Disorder moved to Obsessive-Compulsive

and Related Disorders chapter

DSM-IV Dissociative Disorders

Dissociative Identity Disorder and Dissociative Amnesia had minor changes to their criteria DID includes that behaviors can be reported instead of just

observed, and it discusses cultural relevance

Dissociative Fugue is no longer a separate disorder but is a specifier for Dissociative Amnesia

Depersonalization Disorder is now called Depersonalization/Derealization Disorder

DSM-IV Sexual and Gender Identity Disorders

The three main sections of this chapter are now three separate chapters: Sexual Dysfunctions Paraphilic Disorders Gender Dysphoria


Sexual Dysfunctions Gender-specific disorders have been added and

subtypes/specifiers have changed Sexual Desire Disorder and Arousal Disorder in females in now

called Female Sexual Interest/Arousal Disorder Vaginismus and Dyspareunia have been combined into Genito-

Pelvic Pain/Penetration Disorder

Gender Dysphoria is different from Gender Identity Disorder in that it’s not the mere incongruence in gender identity that is the Dx; it’s the dysphoria the person may experience


Paraphilic Disorders DSM-5 makes a distinction between a paraphilia (an erotic

preference that is consensual and does not cause distress) and a Paraphilic Disorder (either it causes distress for the individual or their partner or includes risk or harm, including breaking the law)

The diagnosis names are now different (i.e. Fetishistic Disorder vs. Fetishism)

All Paraphilic Disorders have the specifiers of “in a controlled environment” and “in remission”

DSM-IV Eating Disorders

The chapter is now called Feeding and Eating Disorders Includes Pica, Rumination Disorder, and Feeding Disorder of

Infancy or Childhood (now called Avoidant/Restrictive Food Intake Disorder) from Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapter in DSM-IV

For Anorexia Nervosa, requirement of amenorrhea has been eliminated

Binge Eating Disorder is now a full Dx For BED and Bulimia Nervosa, binge criteria changed from

2x/week over 6 months to 1x/week over 3 months

DSM-IV Sleep Disorders

Now called Sleep-Wake Disorders Sleep disorders related to medical or mental conditions have been

removed Ten diagnoses in this chapter:

Insomnia Disorder Hypersomnolence Disorder

Narcolepsy Breathing-Related Sleep Disorders

Nightmare Disorder Circadian Rhythm Sleep-Wake Disorders

Restless Leg Syndrome Non-REM Sleep Arousal Disorders

REM Sleep Behavior Disorder Substance/Medication Induced Sleep

Disorder

DSM-IV Impulse-Control Disorders

Intermittent Explosive Disorder, Kleptomania, and Pyromania are in the new chapter called Disruptive, Impulse-Control and Conduct Disorders

Conduct Disorder and Oppositional Defiant Disorder from Childhood/Infancy chapter moved here as well Criteria have been revised to be clearer

Pathological Gambling is now Gambling Disorder in the Substance-Related and Addictive Disorders chapter

Trichotillomania is in the Obsessive-Compulsive and Related Disorders chapter

DSM-IV Adjustment Disorders

Adjustment Disorder is now found in the new Trauma and Stressor-Related Disorders chapter

This new chapter also includes PTSD and Acute Stress Disorder from the former Anxiety Disorders chapter, as well as Reactive Attachment Disorder from the former Childhood chapter

Disinhibited Social Engagement Disorder is a new Dx; was a subtype of Reactive Attachment Disorder in DSM-IV

DSM-IV Adjustment Disorders

In both PTSD and Acute Stress Disorder, diagnostic criteria look at how the person experienced the trauma (directly, witness, etc.)

In PTSD the diagnostic criteria went from 3 categories to 4 The subjective criteria in A2 has been removed

DSM-IV Personality Disorders

Criteria for the disorders have not changed Some Personality Disorders are cross-listed

Antisocial PD is also in the Disruptive, Impulse-Control, and Conduct Disorders chapter

Schizotypal PD is also in the Schizophrenia Spectrum and Other Psychotic Disorders chapter

New DSM-5 Chapters Not Yet Covered

Obsessive-Compulsive and Related Disorders Specifiers focus on insight, since that has implications for

other diagnoses Tic-related specifier is also added due to high comorbidity

Body Dysmorphic Disorder moved from Somatoform Disorders chapter

Trichotillomania moved from Impulse Control Disorders Hoarding Disorder and Excoriation are new Dx

PHEW!

Now we can see why people are dragging their heels to implement changes!

What questions do you have?

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Washington, D.C.: Author. American Psychiatric Association. (2013). Highlights of

changes from DSM-IV-TR to DSM-5. Retrieved from http://www.psychiatry.org/dsm5

American Psychiatric Association DSM-5 Development. (n.d.). Retrieved May 30, 2015, from

http://www.dsm5.org/Pages/Default.aspx

What has changed in the DSM-5? JESSICA SHELTON, M.S.ED., LPC, LMFT JUNE 4, 2015.

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