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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