1. Supervising Candidates on the Transition to DSM 5: Changes and Ethical Concerns Philip R. Budd, Psy.D. Director of Behavioral Health St. Anthony Family Medicine Residency Program

2. Facts First attempt at any diagnostic tracking was 1840 census. One category labeled “idiocy/insanity”First attempt at any diagnostic tracking was 1840 census. One category labeled “idiocy/insanity” 1917 Committee on Statistics which later became APA along with the National Commission on Mental Hygeine developed a guide for mental hospitals titled, “Statistical Manual for the Use of Institutions for the Insane” There were 22 diagnoses.1917 Committee on Statistics which later became APA along with the National Commission on Mental Hygeine developed a guide for mental hospitals titled, “Statistical Manual for the Use of Institutions for the Insane” There were 22 diagnoses. First DSM was in 1952; DSM II in 1968; DSM III 1980; DSM IIIR 1987; DSM IV 1994; DSM IV TR 2000First DSM was in 1952; DSM II in 1968; DSM III 1980; DSM IIIR 1987; DSM IV 1994; DSM IV TR 2000 DSM is in the process of significant revision and the new DSM 5 will be released in May, 2013.DSM is in the process of significant revision and the new DSM 5 will be released in May, 2013. The DSM 5 is dropping the Roman Numerals to allow for easier updates that will be numbered 5.2, 5.3, etc.The DSM 5 is dropping the Roman Numerals to allow for easier updates that will be numbered 5.2, 5.3, etc. There has been much controversy about the this new edition. Some questioning the need for any revision and others clamoring that the process has been shrouded in secrecy and that changes that are being proposed are ill conceived.There has been much controversy about the this new edition. Some questioning the need for any revision and others clamoring that the process has been shrouded in secrecy and that changes that are being proposed are ill conceived. There is no current final draft and so any discussions of what DSM 5 will be in final form carry with it the possibility of revision. In fact, you can monitor this process by logging on to dsm5.orgThere is no current final draft and so any discussions of what DSM 5 will be in final form carry with it the possibility of revision. In fact, you can monitor this process by logging on to dsm5.org

3. Goals of DSM 5 What is working and what is not workingWhat is working and what is not working E.g. how to address the high number of co-occuring disorders and NOS diagnosesE.g. how to address the high number of co-occuring disorders and NOS diagnoses To better specify treatment targets for clinical practiceTo better specify treatment targets for clinical practice To dispense with imprecise criteria and unused/poorly used featuresTo dispense with imprecise criteria and unused/poorly used features Three principles for DSM 5 development according to APA:Three principles for DSM 5 development according to APA: High priority in optimizing for clinical utilityHigh priority in optimizing for clinical utility Research evidence should guide recommendationsResearch evidence should guide recommendations Continuity to previous editions be maintainedContinuity to previous editions be maintained

4. Concerns about DSM 5

5. Groups Concerned about DSM 5 ACAACA American Psychological AssnAmerican Psychological Assn British Psychological AssnBritish Psychological Assn Society of Biological PsychiatrySociety of Biological Psychiatry

6. Allen Frances, MD (Chair of DSM IV Task Force) Reckless expansion of the diagnostic system (through inclusion of untested new diagnoses and reduced thresholds in old ones. It is interesting to not the DSM5.orgReckless expansion of the diagnostic system (through inclusion of untested new diagnoses and reduced thresholds in old ones. It is interesting to not the DSM5.org Lack of scientific rigor and independent reviewLack of scientific rigor and independent review Dimensional proposals that are too complex ever to be used by cliniciansDimensional proposals that are too complex ever to be used by clinicians

7. Ethical Concerns with DSM 5

8. Ethical Concerns with Diagnostic Nomenclature Pejorative labelsPejorative labels Objectifying peopleObjectifying people Labels create self fulfilling prophecyLabels create self fulfilling prophecy May medicalize people’s problems leading to overuse of medication. Lack of categorical differences in mental illness makes this a challenge.May medicalize people’s problems leading to overuse of medication. Lack of categorical differences in mental illness makes this a challenge. Labeling may result in underreporting symptoms and then under treatment of issues.Labeling may result in underreporting symptoms and then under treatment of issues. May treat the disorder instead of the patientMay treat the disorder instead of the patient Abnormal functioning in medicine is indicating pathology, whereas, abnormal in mental functioning is socially derivedAbnormal functioning in medicine is indicating pathology, whereas, abnormal in mental functioning is socially derived

9. Conflict of Interest between DSM 5 workgroup and Pharmaceutical Companies Center for Science in the Public Interest found that more than half of the 28 members of the DSM5 task force have ties to the drug industry.Center for Science in the Public Interest found that more than half of the 28 members of the DSM5 task force have ties to the drug industry. Of the 170 panel members who contributed to the diagnostic criteria produced for DSM IV and DSM IV TR, 56% had 1 or more financial associations with pharmaceutical companies.. In 6 of 18 panels, more than 80% of the panel members had financial ties to pharmaceutical companiesOf the 170 panel members who contributed to the diagnostic criteria produced for DSM IV and DSM IV TR, 56% had 1 or more financial associations with pharmaceutical companies.. In 6 of 18 panels, more than 80% of the panel members had financial ties to pharmaceutical companies Dr. William Carpenter, Jr. has worked as a consultant for 13 drug companies over the past 5 years.Dr. William Carpenter, Jr. has worked as a consultant for 13 drug companies over the past 5 years.

10. Dimensional Assessment A significant change is the use of dimensional assessments to reconceptualize psychopathology. The goal is more measurement based approach to patient care that will improve clinician tracking of symptom threshold, severity and treatment outcomesA significant change is the use of dimensional assessments to reconceptualize psychopathology. The goal is more measurement based approach to patient care that will improve clinician tracking of symptom threshold, severity and treatment outcomes

11. Confidentiality Agreements DSM 5 participants were required to sign confidentiality agreements making full disclosure of the process and total transparency regarding Task Force minutes and work group meetings impossible.DSM 5 participants were required to sign confidentiality agreements making full disclosure of the process and total transparency regarding Task Force minutes and work group meetings impossible. This has improved by posting work group progress reports, but is not total transparencyThis has improved by posting work group progress reports, but is not total transparency APA has countered that developing the DSM 5 has been more open and inclusive than any previous edition. Citing the 13 NIH supported international rsearch conferences that included more than 400 scientists and clinicians and the DSM 5 workgroups that have 150 experts in various specialties. In addition, over 200 advisors have shared their expertise. APA cites the confidentiality agreements as protecting intellectual property and the work product of the various Work Groups. They believe that the scientific process is supported by the literature reviews, secondary data analyses and the field trials.APA has countered that developing the DSM 5 has been more open and inclusive than any previous edition. Citing the 13 NIH supported international rsearch conferences that included more than 400 scientists and clinicians and the DSM 5 workgroups that have 150 experts in various specialties. In addition, over 200 advisors have shared their expertise. APA cites the confidentiality agreements as protecting intellectual property and the work product of the various Work Groups. They believe that the scientific process is supported by the literature reviews, secondary data analyses and the field trials.

12. Inclusion of new disorders Many see the inclusion of new disorders as a pretext for prescribing profitable drugsMany see the inclusion of new disorders as a pretext for prescribing profitable drugs One controversy has been the elimination of the exclusion of bereavement from MDD. Instead of waiting 2 months for complications with grief for MDD to be diagnosed, one can diagnose MDD after the 2 week requirement for MDD. A proposal exists for adding, “Adjustment Disorder, Greif Related”One controversy has been the elimination of the exclusion of bereavement from MDD. Instead of waiting 2 months for complications with grief for MDD to be diagnosed, one can diagnose MDD after the 2 week requirement for MDD. A proposal exists for adding, “Adjustment Disorder, Greif Related”

13. Risk Syndromes (Oliver Matthes, 2011) Categories of disorders which are not fully developed but practitioner believes the person is at risk of developing. E.g., with Schizophrenia, someone at risk of developing Schizophrenia would suffer from “Attenuated Psychotic Syndrome” Purpose appears to be early detection of serious disorders. Some argue that it is like identifying risks for cardio vascular diseases. The risk is that you increase the risk of false negatives being identified with the result for the patient of: 1.Unnecessary treatment with medications that have significant side effects 2.Stigma of the labels. The label itself may create negative impact on the patient 3.Impact on obtaining health and life insurance 4.The iatrogenic impact could be severe. 5.Only 30% of patients with “Attenuated Psychosis” will develop schizophrenia

14. Some Current Changes from DSM IV to DSM 5

15. DSM 5 Organizational Structure and Disorder names Change attempts to better reflect scientific advancesChange attempts to better reflect scientific advances It attempts to address the change since DSM III in understanding etiology and systematizing disorders to avoid overlapping comorbidities (e.g., internalizing disorders vs. externalizing disorders).It attempts to address the change since DSM III in understanding etiology and systematizing disorders to avoid overlapping comorbidities (e.g., internalizing disorders vs. externalizing disorders). Attempts to address the frequency of NOS diagnoses due to prior narrowing of disorder criteria to increase reliabilityAttempts to address the frequency of NOS diagnoses due to prior narrowing of disorder criteria to increase reliability Some DSM IV categories do not fit with genetic mapping and don’t appear fixable by tweaking existing categories. Broader categories seem to be more helpfulSome DSM IV categories do not fit with genetic mapping and don’t appear fixable by tweaking existing categories. Broader categories seem to be more helpful Attempt to make diagnosis easier and more clinician friendlyAttempt to make diagnosis easier and more clinician friendly Chapters are organized in developmental lifespan fashion starting with Neurodevelopmental disorders and progress through disorders commonly diagnosed in adulthood such as Sleep-Wake disordersChapters are organized in developmental lifespan fashion starting with Neurodevelopmental disorders and progress through disorders commonly diagnosed in adulthood such as Sleep-Wake disorders Within each diagnostic category, the individual disorders are similarly arranged so that those more commonly diagnosed in children appear first.Within each diagnostic category, the individual disorders are similarly arranged so that those more commonly diagnosed in children appear first. Grouping of similar diagnostic categories close to one another.Grouping of similar diagnostic categories close to one another.

16. Neurodevelopmental Disorders Intellectual DisordersIntellectual Disorders Communication DisordersCommunication Disorders Autism Spectrum DisorderAutism Spectrum Disorder Attention Deficit/Hyperactivity DisorderAttention Deficit/Hyperactivity Disorder Specific Learning DisorderSpecific Learning Disorder Motor DisordersMotor Disorders

17. Intellectual Developmental Disorders Intellectual Developmental Disorder includes both a current intellectual deficit and a deficit in adaptive functioning with onset during the developmental period: CriteriaIntellectual Developmental Disorder includes both a current intellectual deficit and a deficit in adaptive functioning with onset during the developmental period: Criteria 1.Characterized by deficits in general mental abilities such as reasoning, problem-solving, planning, abstract thinking, judgment, academic learning and learning from experience 2.Impairment in adaptive functioning for the individual’s age and sociocultural background. Adaptive functioning refers to how well a person meets the stanadards of personal independence and social responsibility in one or more aspects of daily life activities, such as communication, social participation, functioning at school or at work, or personal independence at home or in community settings. The limitations result in the need for ongoing support at school, work, or independent life. 3.All symptoms must have an onset during the developmental period 1.Intellectual or Global Developmental Delay Not Elsewhere Classified

18. Rationale Name change is to harmonize with other classifications such as WHO International Classification of Functioning (ICF) and International Classification of Diseases (ICD).Name change is to harmonize with other classifications such as WHO International Classification of Functioning (ICF) and International Classification of Diseases (ICD). It reflects a failure of brain developmentIt reflects a failure of brain development IQ test score discussion is in the text of the diagnosis rather than the criteria. IQ score and adaptive functioning are important in this diagnosis.IQ test score discussion is in the text of the diagnosis rather than the criteria. IQ score and adaptive functioning are important in this diagnosis. This eliminates subtypes of mild, moderate, severe and profound subtypes. Instead, it lists mild, moderate and severe levels. Severity level is focused more on adaptive functioning than IQ score. There is a chart describing the three levels regarding their conceptual domain, social domain and practical domainThis eliminates subtypes of mild, moderate, severe and profound subtypes. Instead, it lists mild, moderate and severe levels. Severity level is focused more on adaptive functioning than IQ score. There is a chart describing the three levels regarding their conceptual domain, social domain and practical domain

19. Communication Disorders Language DisorderLanguage Disorder Speech DisorderSpeech Disorder Social Communication DisorderSocial Communication Disorder

20. Language Disorder Persistent difficulties in the acquisition and use of spoken language (sound, word, sentence and discourse level comprehension, production and awareness), written language (reading decoding and comprehension; spelling and written formulation), and other modalities of language (e.g., sign language) that are likely to endure into adolescence and adulthood, although the symptoms, domains and modalities involved may shift with age. Symptoms may include the domains of vocabulary; grammar; narrative, expository and conversational discourse; and other pragmatic language abilities individually or in combinationPersistent difficulties in the acquisition and use of spoken language (sound, word, sentence and discourse level comprehension, production and awareness), written language (reading decoding and comprehension; spelling and written formulation), and other modalities of language (e.g., sign language) that are likely to endure into adolescence and adulthood, although the symptoms, domains and modalities involved may shift with age. Symptoms may include the domains of vocabulary; grammar; narrative, expository and conversational discourse; and other pragmatic language abilities individually or in combination Language abilities that are below age expectations in one or more language domain and that manifest persistent difficulties evident by multiple sources of information, including naturalistic observation and individualized, standardized, culturally and linguistically appropriate psychometric measures. A regional, social or cultural/ethnic variation (e.g., dialect) of language is not a Language Disorder.Language abilities that are below age expectations in one or more language domain and that manifest persistent difficulties evident by multiple sources of information, including naturalistic observation and individualized, standardized, culturally and linguistically appropriate psychometric measures. A regional, social or cultural/ethnic variation (e.g., dialect) of language is not a Language Disorder. Language disorders occur as primary impairment or co-exist with other disorders (e.g., Autism Spectrum Disorder, Learning Disorder, Selective Mutism)Language disorders occur as primary impairment or co-exist with other disorders (e.g., Autism Spectrum Disorder, Learning Disorder, Selective Mutism) Symptoms must be present in early childhood (but may not become fully manifest until speech, language, or communication demands exceed limited capabilities)Symptoms must be present in early childhood (but may not become fully manifest until speech, language, or communication demands exceed limited capabilities) The difficulties with language result in functional limitations in effective communication, social participation, academic achievement, and occupational performance, individually or in any combination.The difficulties with language result in functional limitations in effective communication, social participation, academic achievement, and occupational performance, individually or in any combination. Note that rationale for changes are being developedNote that rationale for changes are being developed

21. Speech Disorder Persistent difficulties in speech production that can affect the domains of speech sound production (involving phonological knowledge, neuromotor control, and articulatory skill), speech fluency (involving the ability to speak with normal fluency and time patterning or prosody), voice (involving respiratory control and laryngeal adequacy) or resonance (involving structural and functional adequacy of the hard and soft palate to connect and disconnect the oral and nasal cavaties).Persistent difficulties in speech production that can affect the domains of speech sound production (involving phonological knowledge, neuromotor control, and articulatory skill), speech fluency (involving the ability to speak with normal fluency and time patterning or prosody), voice (involving respiratory control and laryngeal adequacy) or resonance (involving structural and functional adequacy of the hard and soft palate to connect and disconnect the oral and nasal cavaties). Speech production that is atypical for the child’s age or symptomatic of abnormal oral-motor structure or function, based on multiple sources of information, including speech samples gathered in naturalistic and structured contexts, accompanied by examination of oral-motor structures and functions and individualized, standardized, culturally and linguistically appropriate psychometric measures. A regional, social, or cultural/ethnic variation (e.g., dialect) of language is not a Speech disorderSpeech production that is atypical for the child’s age or symptomatic of abnormal oral-motor structure or function, based on multiple sources of information, including speech samples gathered in naturalistic and structured contexts, accompanied by examination of oral-motor structures and functions and individualized, standardized, culturally and linguistically appropriate psychometric measures. A regional, social, or cultural/ethnic variation (e.g., dialect) of language is not a Speech disorder Speech disorders occcur as a primary impairment or co-exist with other disorders (e.g., Language Disorders, IDD, Autism Spectrum, Specific learning disorder) or congenital or acquired conditions (e.g., Cerebral Palsy, Down syndrome, deafness or hearing loss, Pediatric TBI).Speech disorders occcur as a primary impairment or co-exist with other disorders (e.g., Language Disorders, IDD, Autism Spectrum, Specific learning disorder) or congenital or acquired conditions (e.g., Cerebral Palsy, Down syndrome, deafness or hearing loss, Pediatric TBI). Symptoms must be present in childhoodSymptoms must be present in childhood Difficulties with speech production result in functional limitations in effective communication because of interference with speech intelligibility and /or because they distract from effective ommunication of messages. Speech disorders may interfere with social participation, academic achievement, or occupational performance, individually or in any combination.Difficulties with speech production result in functional limitations in effective communication because of interference with speech intelligibility and /or because they distract from effective ommunication of messages. Speech disorders may interfere with social participation, academic achievement, or occupational performance, individually or in any combination. Specify: Speech Sound Disorder, Motor Speech disorders, childhood onset fluency disorder, Voice disorder, Resonance DisorderSpecify: Speech Sound Disorder, Motor Speech disorders, childhood onset fluency disorder, Voice disorder, Resonance Disorder

22. Social Communication Disorder Persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affects the development of social reciprocity and social relationships that cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability.Persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affects the development of social reciprocity and social relationships that cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability. Persistent difficulties in the acquisition and use of spoken language, written language, and other modalities of language (e.g., sign language) for narrative, expository and conversational discourse. Symptoms may affect comprehension, production, and awareness at a discourse level individually or in any combination that are likely to endure into adolescence and adulthood, although the symptoms, domains, and modalities involved may shift with age.Persistent difficulties in the acquisition and use of spoken language, written language, and other modalities of language (e.g., sign language) for narrative, expository and conversational discourse. Symptoms may affect comprehension, production, and awareness at a discourse level individually or in any combination that are likely to endure into adolescence and adulthood, although the symptoms, domains, and modalities involved may shift with age. Rule out Autism Spectrum Disorder. Autism Spectrum disorder by definition encompasses pragmatic communication problems, but also includes restricted, repetitive patterns of behavior, interests or activities as part of the autism spectrum. Therefore, Autism Spectrum Disorder needs to be ruled out for Social Communication Disorder to be diagnosed. Social Communication Disorder can occur as a primary impairment or co-exist with disorder other than Autism Spectrum Disorder (e.g., Speech disorders, Learning Disorder, IDD)Rule out Autism Spectrum Disorder. Autism Spectrum disorder by definition encompasses pragmatic communication problems, but also includes restricted, repetitive patterns of behavior, interests or activities as part of the autism spectrum. Therefore, Autism Spectrum Disorder needs to be ruled out for Social Communication Disorder to be diagnosed. Social Communication Disorder can occur as a primary impairment or co-exist with disorder other than Autism Spectrum Disorder (e.g., Speech disorders, Learning Disorder, IDD) Symptoms must be present in early childhoodSymptoms must be present in early childhood The low social communication abilities result in functional limitations in effective communication, social participation, academic achievement, or occupational performance, alone or in combination.The low social communication abilities result in functional limitations in effective communication, social participation, academic achievement, or occupational performance, alone or in combination.

23. Gender Dysphoria Members of the transgender community have complained that the current diagnostic categories of Gender Identity Disorder and Transvestite Feishism reflect disparaging attitudes toward gender diversity and have called for the assistance of more members from the transgendered community to assist in restructuring the criteriaMembers of the transgender community have complained that the current diagnostic categories of Gender Identity Disorder and Transvestite Feishism reflect disparaging attitudes toward gender diversity and have called for the assistance of more members from the transgendered community to assist in restructuring the criteria GID replaced by “Gender Incongruence”GID replaced by “Gender Incongruence” The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability**The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability**

24. Autism Spectrum Disorder Must meet Criteria A, B, C, D:Must meet Criteria A, B, C, D: A.Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following: 1.Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction 2.Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated verbal and nonverbal communication, through abnormalities I eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures. 3.Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people.

25. B.Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: 1)Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases). 2)Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes). 3)Highly restricted, fixated interests that are abnormal in intensity or focus; (strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4)Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of the environment (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects). C.Symptoms must be present in early childhood D.Symptoms together limit and impair everyday functioning

26. Rationale New name category, Autism Spectrum Disorder, which includes Autistic Disorder, Asperger’s disorder, Childhood Disintegrative disorder and Pervasive Developmental Disorder NOS Differentiation of autism spectrum disorder from typical development and other “nonspectrum” disorders is done reliably and with validity; while distinctions among disorders have been found to be inconsistent over time, variable across sites and often associated with severity, language level or intelligence rather than features of the disorder Because autism is defined by a common set of behaviors, it is best represented as a single diagnostic category that is adapted to the individual’s clinical presentation by inclusion of clinical specifiers (e.g., severity, verbal abilities and others) and associated features (e.g., known genetic disorders, epilepsy, IDD and others) A single spectrum disorder is a better reflection of the state of knowledge about pathology and clinical presentation; previously, the criteria were equivalent to trying to “cleave meatloaf at the joints”. Streamlining of criteria based on excessive weight on certain symptoms, merging of social and communication domains required a new approach to criteria

27. Attention Deficit/ Hyperactivity Disorder AD/HD consists of a pattern of behavior that is present in multiple settings where it gives rise to social, educational or work performance difficulties. A. Either (A1) and/or (A2). A1. Inattention : Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities. a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or reading lengthy writings). c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked; fails to finish schoolwork, household chores, or tasks in the workplace). e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized, work; poor time management; tends to fail to meet deadlines). f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers). g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones). h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). i. Is often forgetful in daily activities (e.g., chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

28. Attention Deficit/ Hyperactivity Disorder A2. Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities. a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, office or other workplace, or in other situations that require remaining seated). c. Often runs about or climbs in situations where it is inappropriate. (In adolescents or adults, may be limited to feeling restless). d. Often unable to play or engage in leisure activities quietly. d. Often unable to play or engage in leisure activities quietly. e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable or uncomfortable being still for an extended time, as in restaurants, meetings, etc; may be experienced by others as being restless and difficult to keep up with). f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences and “jumps the gun” in conversations, cannot wait for next turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission, adolescents or adults may intrude into or take over what others are doing).

29. Attention Deficit/ Hyperactivity Disorder B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12. C. Criteria for the disorder are met in two or more settings (e.g., at home, school or work, with friends or relatives, or in other activities). D. There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

30. Attention Deficit/ Hyperactivity Disorder Specify Based on Current PresentationSpecify Based on Current Presentation Combined Presentation: If both Criterion A1 (Inattention) and Criterion A2 (Hyperactivity-Impulsivity) are met for the past 6 months. Combined Presentation: If both Criterion A1 (Inattention) and Criterion A2 (Hyperactivity-Impulsivity) are met for the past 6 months. Predominantly Inattentive Presentation: If Criterion A1 (Inattention) is met but Criterion A2 (Hyperactivity-Impulsivity) is not met and 3 or more symptoms from Criterion A2 have been present for the past 6 months. Predominantly Inattentive Presentation: If Criterion A1 (Inattention) is met but Criterion A2 (Hyperactivity-Impulsivity) is not met and 3 or more symptoms from Criterion A2 have been present for the past 6 months. Inattentive Presentation (Restrictive): If Criterion A1 (Inattention) is met but no more than 2 symptoms from Criterion A2 (Hyperactivity-Impulsivity) have been present for the past 6 months. Inattentive Presentation (Restrictive): If Criterion A1 (Inattention) is met but no more than 2 symptoms from Criterion A2 (Hyperactivity-Impulsivity) have been present for the past 6 months. Predominantly Hyperactive/Impulsive Presentation: Predominantly Hyperactive/Impulsive Presentation:

31. Changes in ADD/ADHD Several potential problematic issues with DSM-IV ADHD criteria were not addressed due to lack of evidence based data and available resources/time to produce it. So, these issues are deferred to future revisions of the DSM. However, the work group felt comfortable with the level of evidence available to tackle some issues. The following changes are proposed for ADHD in DSM-5. 1) Change the age of onset from onset of impairing symptoms by age 7 to onset of symptoms by age 12, 2) Change the three subtypes to three current presentations; 3) Add a fourth presentation for restrictive inattentive; 4) Change the examples in the items, without changing the exact wording of the DSM-IV items, to accommodate a lifespan relevance of each symptom and to improve clarity. 4) Change the examples in the items, without changing the exact wording of the DSM-IV items, to accommodate a lifespan relevance of each symptom and to improve clarity. 6) Remove PDD from the exclusion criteria. 7) Modify the pre-amble A1 and A2 to indicate that information must be obtained from two different informants (parents and teachers for children and third part/significant other for adults) whenever possible. 8) Still under consideration: Adjust the cut point for diagnosis in adults.

32. Somatic Disorders Studies suggest that patients with hypochondriasis fall into two distinct subgroups. In one subgroup (75% of hypochondriasis patients), somatic symptoms predominate and form the patient’s primary concern. The other subgroup (25% of hypochondriacs) is composed of patients with minimal somatic symptoms but who are highly anxious about and suspicious of the presence of an undiagnosed, serious medical illness.Studies suggest that patients with hypochondriasis fall into two distinct subgroups. In one subgroup (75% of hypochondriasis patients), somatic symptoms predominate and form the patient’s primary concern. The other subgroup (25% of hypochondriacs) is composed of patients with minimal somatic symptoms but who are highly anxious about and suspicious of the presence of an undiagnosed, serious medical illness. In our proposal for DSM 5, the former subgroup of patients would be subsumed under the new diagnosis of Somatic Symptom Disorder (SSD), while the latter subgroup would now be subsumed under the proposed Illness Anxiety Disorder (IAD). IAD is closely related to other somatic symptom disorders, anxiety disorders, and depressive disorders, but it is included here because of its close relationship to the other somatic symptom disorders in clinical presentation, phenomenology, and in cognitive, affective and behavioral characteristics.In our proposal for DSM 5, the former subgroup of patients would be subsumed under the new diagnosis of Somatic Symptom Disorder (SSD), while the latter subgroup would now be subsumed under the proposed Illness Anxiety Disorder (IAD). IAD is closely related to other somatic symptom disorders, anxiety disorders, and depressive disorders, but it is included here because of its close relationship to the other somatic symptom disorders in clinical presentation, phenomenology, and in cognitive, affective and behavioral characteristics. Changes would likely increase the number of people diagnosed because fewer criteria required for the diagnosisChanges would likely increase the number of people diagnosed because fewer criteria required for the diagnosis

33. Feeding and eating disorders K 00 Pica K 00 Pica K 00 Pica K 00 Pica K 01 Rumination Disorder K 01 Rumination Disorder K 01 Rumination Disorder K 01 Rumination Disorder K 02 Avoidant/Restrictive Food Intake Disorder K 02 Avoidant/Restrictive Food Intake Disorder K 02 Avoidant/Restrictive Food Intake Disorder K 02 Avoidant/Restrictive Food Intake Disorder K 03 Anorexia Nervosa K 03 Anorexia Nervosa K 03 Anorexia Nervosa K 03 Anorexia Nervosa K 04 Bulimia Nervosa K 04 Bulimia Nervosa K 04 Bulimia Nervosa K 04 Bulimia Nervosa K05 Binge Eating Disorder (was in appendix of DSM IV) K05 Binge Eating Disorder (was in appendix of DSM IV) K05 Binge Eating Disorder K05 Binge Eating Disorder K 06 Feeding or Eating Disorder Not Elsewhere Classified K 06 Feeding or Eating Disorder Not Elsewhere Classified K 06 Feeding or Eating Disorder Not Elsewhere Classified K 06 Feeding or Eating Disorder Not Elsewhere Classified

34. Pedophilic Disorder Changes in the paraphilias was an attempt to determine if paraphilias are disorders. In explanation they state, “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 in the past. A paraphilia is a necessary but not a sufficient condition for having a Paraphilic Disorder, and a paraphilia by itself does not automatically justify or require clinical intervention.”Changes in the paraphilias was an attempt to determine if paraphilias are disorders. In explanation they state, “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 in the past. A paraphilia is a necessary but not a sufficient condition for having a Paraphilic Disorder, and a paraphilia by itself does not automatically justify or require clinical intervention.”

35. Pedophilic Disorder A. Over a period of at least 6 months, an equal or greater sexual arousal from prepubescent or early pubescent children than from physically mature persons, as manifested by fantasies, urges, or behaviors. B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or impairment in social, occupational, or other important areas of functioning. B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or impairment in social, occupational, or other important areas of functioning. C. The individual must be at least 18 years of age and at least 5 years older than the children in Criterion A. Type: Classic (attracted to prepubescent children); Hebephilic (Sexually attracted to early pubescent children; Pedohebephilic (sexually attracted to both) Type: Classic (attracted to prepubescent children); Hebephilic (Sexually attracted to early pubescent children; Pedohebephilic (sexually attracted to both) Specify: Sexually attracted to males, females or bothSpecify: Sexually attracted to males, females or both

36. Attenuated Psychosis Syndrome Listed in Section III of DSM 5 as a diagnosis for investigationListed in Section III of DSM 5 as a diagnosis for investigation This has been very controversialThis has been very controversial Intent is to help in early identification and intervention with pre-psychotic symptoms. The literature suggests that there is a high percentage of these individuals who develop full blown psychotic symptoms.Intent is to help in early identification and intervention with pre-psychotic symptoms. The literature suggests that there is a high percentage of these individuals who develop full blown psychotic symptoms.

37. Attenuated Psychosis Syndrome A. At least one of the following symptoms are present in attenuated form with relatively intact reality testing, but of sufficient severity and/or frequency to warrant clinical attention: 1. delusions/delusional ideas 1. delusions/delusional ideas 2. hallucinations/perceptional abnormalities 2. hallucinations/perceptional abnormalities 3. disorganized speech/communication 3. disorganized speech/communication B. Symptoms in Criterion A must be present at least once per week for the past month. C. Symptoms in Criterion A must have begun or worsened in the past year. D. Symptoms in Criterion A are sufficiently distressing and disabling to the individual and/or legal guardian to lead them to seek help. E. Symptoms in Criterion A are not better explained by any other DSM-5 diagnosis, including Substance-Related Disorders. F. Clinical criteria for a Psychotic Disorder have never been met.

38. Delusional Disorder No longer must the delusion be bizarre. There was no evidence that the type of delusion impacted the efficacy of treatment.No longer must the delusion be bizarre. There was no evidence that the type of delusion impacted the efficacy of treatment.

39. Personality Disorders Significant changes in the structure of PD section. These changes are partly tied to the lack of clear categorical differences among the personality disordersSignificant changes in the structure of PD section. These changes are partly tied to the lack of clear categorical differences among the personality disorders Research seems to suggest that there is no limited number of personality type. Instead, there is a model that personality varies continuously, emerging from various personality traits that forms a hierachical dimensional structure. The categorical approach was seen as problematic almost immediately after DSM III was published.Research seems to suggest that there is no limited number of personality type. Instead, there is a model that personality varies continuously, emerging from various personality traits that forms a hierachical dimensional structure. The categorical approach was seen as problematic almost immediately after DSM III was published. 1.Extensive co-occurrence among PDs. Since people only have one personality it does not make sense to have multiple PDs. This new model allows highlighting individual personalities with their unique set of trait dimensions that are maladaptive. Thus, fewer personality disorders defined by core impairments and pathological personality traints 2.Extreme heterogeneity among patients receiving the same diagnosis. (e.g., it is commonplace to say that there are 256 ways to meet criteria for BPD. So two people can have the same PD but have almost no features in common. Treatment for those two people may be extremely different as a result of those features being so unique between those two patients. 3.Lack of Synchrony with modern medical approaches to diagnostic thresholds. Use of severity dimensions in diagnosis is common in modern medicine (e.g., prehypertensive BP, three classes of obesity and multiple stages of cancer). In contrast, DSM IV-TR PD diagnosis uses dichotomous classification with thresholds set arbitrarily at simply half or more of the criteria. So for BPD, meeting 5/9 criteria was set arbitrarily because it was more than half, not because it met some empirical test.

40. Personality Disorders 4.Temporal Instability. The average short-term test-retest reliabilities of of.54 for specific PDs and.56 for any PD suggest poor dependability for structured interviews. Longer term test-retest reliabilities of.51 for any PD and.34 for specific PDs indicate diagnostic instability that is inconsistent with the relative stability of personality traits. By being trait based, it is thought that it will reduce temporal instability. 5.Poor coverage of personality psychopathology. A comprehensive meta-analysis documented that PD NOS is one of the most common PD diagnoses in research and the most frequent diagnosed PD in clinical settings. This diagnosis communicates no information about the personality dysfunction.

41. Personality Disorders 6.Poor convergent validity. Perhaps the most disturbing problem with current PD diagnosis is that there is low convergent validity across PD assessments. Meta- analytic convergence was.27 between structured interviews and personality questionnaires for specific PDs and.29 for any PD. So… are we even talking about the same thing? The 5 personality trait model is based on research of ½ century dating back to Catell (1946) and supported by Markon, et. Al. (2005). It has high convergent and discriminant validity across a wide range of measures (structured interviews and questionnaires)

42. Proposed Change in PD Diagnosis Two dimensional assessmentsTwo dimensional assessments 1.Personality Pathology Severity Scale, the Levels of Personality Functioning 2.A 5 domain/25 facet pathological personality trait assessment Combined they redefine the core features of a PD and provide information needed to rate the major diagnostic inclusion criteria for 6 specific PD categories and for a Personality Disorder, Trait Specified diagnosis to replace PDNOSCombined they redefine the core features of a PD and provide information needed to rate the major diagnostic inclusion criteria for 6 specific PD categories and for a Personality Disorder, Trait Specified diagnosis to replace PDNOS Revised general criteria for PD requires significant impairment in personality functioning (Criterion A) and the presence of pathological personality traits (Criterion B), that are relatively stable across time and situation. They are not in normal range for a person’s developmental stage or socio-cultural environment and not due to substance or a general medical condition. All specific PDs meet the general criteria.Revised general criteria for PD requires significant impairment in personality functioning (Criterion A) and the presence of pathological personality traits (Criterion B), that are relatively stable across time and situation. They are not in normal range for a person’s developmental stage or socio-cultural environment and not due to substance or a general medical condition. All specific PDs meet the general criteria.

43. Levels of Personality Functioning (4 pt likert scale) 1. 1.Self: Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of self- esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively. 2. 2. Interpersonal: Empathy: Comprehension and appreciation of others’ experiences and motivations; tolerance of differing perspectives; understanding of the effects of own behavior on others. Intimacy: Depth and duration of positive connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior.

44. Tied to Five Factor Model (FFM) Negative AffectivityNegative Affectivity DetachmentDetachment AntagonismAntagonism DisinhibitionDisinhibition PsychoticismPsychoticism There is a rating scale for each of these traits on a 4 point Likert scale (See dsm5.org for details)There is a rating scale for each of these traits on a 4 point Likert scale (See dsm5.org for details)

45. Six Personality Disorder Types + AntisocialAntisocial AvoidantAvoidant BorderlineBorderline NarcissisticNarcissistic Obsessive-CompulsiveObsessive-Compulsive SchizotypalSchizotypal Personality Disorder-Trait Specified (PD-TS)Personality Disorder-Trait Specified (PD-TS)

46. Example of BPD The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met: A. Significant impairments in personality functioning manifest by: 1. Impairments in self functioning (a or b): a. Identity: Markedly impoverished, poorly developed, or unstable self- image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress. a. Identity: Markedly impoverished, poorly developed, or unstable self- image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress. b. Self-direction: Instability in goals, aspirations, values, or career plans. AND

47. Bpd 2. Impairments in interpersonal functioning (a or b): a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities. b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.

48. Bpd Pathological personality traits in the following domains: 1. Negative Affectivity, characterized by: a. Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances. b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control. c. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy. d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior. 2. Disinhibition, characterized by: a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self- harming behavior under emotional distress. b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger. b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger. 3. Antagonism, characterized by: a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

49. Bpd C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations. D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment. E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

50. Rationale Lots of empirical evidence for validity of antisocial, borderline and schizotypal; virtually none for paranoid, schizoid and histrionic PDLots of empirical evidence for validity of antisocial, borderline and schizotypal; virtually none for paranoid, schizoid and histrionic PD Avoidant and O-C PDs are the most common in epidemiological and clinical samplesAvoidant and O-C PDs are the most common in epidemiological and clinical samples New criteria require relatively stable traits across time and consistent across situationsNew criteria require relatively stable traits across time and consistent across situations Eliminated requirement of Adolescent CD for Antisocial PDEliminated requirement of Adolescent CD for Antisocial PD Eliminated the Axis I disorder exclusion required for some PD diagnosesEliminated the Axis I disorder exclusion required for some PD diagnoses

51. Trauma Related Disorders G 00 Reactive Attachment Disorder G 00 Reactive Attachment DisorderG 00 Reactive Attachment DisorderG 00 Reactive Attachment Disorder G 01 Disinhibited Social Engagement Disorder G 01 Disinhibited Social Engagement Disorder G 01 Disinhibited Social Engagement Disorder G 01 Disinhibited Social Engagement Disorder G 02 Acute Stress Disorder G 02 Acute Stress Disorder G 02 Acute Stress Disorder G 02 Acute Stress Disorder G 03 Posttraumatic Stress Disorder G 03 Posttraumatic Stress Disorder G 03 Posttraumatic Stress Disorder G 03 Posttraumatic Stress Disorder G 04 Adjustment Disorders G 04 Adjustment Disorders G 04 Adjustment Disorders G 04 Adjustment Disorders G 05 Trauma- or Stressor- Related Disorder Not Elsewhere Classified G 05 Trauma- or Stressor- Related Disorder Not Elsewhere Classified G 05 Trauma- or Stressor- Related Disorder Not Elsewhere Classified G 05 Trauma- or Stressor- Related Disorder Not Elsewhere Classified

52. Ptsd Changes Revision of the definition of the traumatic eventRevision of the definition of the traumatic event Exposure to actual or threatened a) death, b) serious injury, or c) sexual violation, in one or more of the following ways:Exposure to actual or threatened a) death, b) serious injury, or c) sexual violation, in one or more of the following ways: 1. directly experiencing the traumatic event(s) 1. directly experiencing the traumatic event(s) 2. witnessing, in person, the traumatic event(s) as they occurred to others 3. learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental 4. experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.

53. PTsd Dividing DSM IV Criterion C into DSM 5 Criterion C and D C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by avoidance or efforts to avoid one or more of the following: 1. distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) 2. external reminders (i.e., people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about, or that are closely associated with, the traumatic event(s)

54. PTsd D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred), as evidenced by two or more of the following:D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred), as evidenced by two or more of the following: 1. inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia that is not due to head injury, alcohol, or drugs) 2. persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” "The world is completely dangerous"). (Alternatively, this might be expressed as, e.g., “I’ve lost my soul forever,” or “My whole nervous system is permanently ruined”). 2. persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” "The world is completely dangerous"). (Alternatively, this might be expressed as, e.g., “I’ve lost my soul forever,” or “My whole nervous system is permanently ruined”). 3. persistent, distorted blame of self or others about the cause or consequences of the traumatic event(s) 4. persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) 5. markedly diminished interest or participation in significant activities 6. feelings of detachment or estrangement from others 7. persistent inability to experience positive emotions (e.g., unable to have loving feelings, psychic numbing)

55. Subtype: Preschool PTSD A. In children (less than age 6 years), exposure to one or more of the following events: death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways: A. In children (less than age 6 years), exposure to one or more of the following events: death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways: 1. directly experiencing the event(s) 2. witnessing, in person, the event(s) as they occurred to others, especially primary caregivers (Note: Witnessing does not include events that are witnessed only in electronic media, television, movies or pictures.) 3. learning that the traumatic event(s) occurred to a parent or caregiving figure;

56. Subtype: Preschool PTSD B. Presence of one or more intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) (Note: spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment.) 2. recurrent distressing dreams in which the content and/or affect of the dream is related to the traumatic event(s) (Note: it may not be possible to ascertain that the frightening content is related to the traumatic event.) 3. dissociative reactions in which the child feels or acts as if the traumatic event(s) were recurring, (such reactions may occur on a continuum with the most extreme expression being a complete loss of awareness of present surroundings). Such trauma-specific re-enactment may occur in play. 4. intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) 5. marked physiological reactions to reminders of the traumatic event(s) 5. marked physiological reactions to reminders of the traumatic event(s)

57. Subtype: Preschool PTSD One item from criterion C or D below: C. Persistent avoidance of stimuli associated with the traumatic event, beginning after the traumatic event occurred, as evidenced by avoidance or efforts to avoid: 1. activities, places, or physical reminders that arouse recollections of the traumatic event 2. people, conversations, or interpersonal situations that arouse recollections of the traumatic event. D. Negative alterations in cognitions and mood associated with the traumatic event, beginning or worsening after the traumatic event occurred, as evidenced by one or more of the following: 1. markedly diminished interest or participation in significant activities, including constriction of play 2. socially withdrawn behavior 3. persistent reduction in expression of positive emotions

58. Subtype: Preschool PTSD E. Alterations in arousal and reactivity associated with the traumatic event, beginning or worsening after the traumatic event occurred, as evidenced by two or more of the following: 1. irritable, angry, or aggressive behavior, including extreme temper tantrums 2. hypervigilance 3. exaggerated startle response 4. problems with concentration 5. sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep)

59. PTSD With Prominent Dissociation Subtype The individual meets the diagnostic criteria for PTSD and in addition experiences persistent or recurrent symptoms of A1, A2, or both: The individual meets the diagnostic criteria for PTSD and in addition experiences persistent or recurrent symptoms of A1, A2, or both: A1. Depersonalization: Experiences of feeling detached from, and as if one is an outside observer of, one’s mental processes or body (e.g., feeling as though one is in a dream, sense of unreality of self or body, or time moving slowly. A1. Depersonalization: Experiences of feeling detached from, and as if one is an outside observer of, one’s mental processes or body (e.g., feeling as though one is in a dream, sense of unreality of self or body, or time moving slowly. A2. Derealization: Experiences of unreality of one’s surroundings (e.g., world around the person is experienced as unreal, dreamlike, distant, or distorted) B. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts, or behavior during alcohol intoxication), or another medical condition (e.g., complex partial seizures). B. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts, or behavior during alcohol intoxication), or another medical condition (e.g., complex partial seizures).

60. Nonsuicidal Self Injury A. In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body, of a sort likely to induce bleeding or bruising or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), for purposes not socially sanctioned (e.g., body piercing, tattooing, etc.), but performed with the expectation that the injury will lead to only minor or moderate physical harm. The behavior is not a common one, such as picking at a scab or nail biting.

61. Nonsuicidal Self Injury B. The intentional injury is associated with at least 2 of the following: 1. Psychological Precipitant: Interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act. 2. Urge: Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to resist. 3. Preoccupation: Thinking about self injury occurs frequently, even when it is not acted upon. 4. Contingent Response: The activity is engaged in with the expectation that it will relieve an interpersonal difficulty, or negative feeling or cognitive state, or that it will induce a positive feeling state, during the act or shortly afterwards.

62. Nonsuicidal Self Injury C. The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning. (This criterion is subject to final approval on the use of criteria that relate symptoms to impairment). D. The behavior does not occur exclusively during states of psychosis, delirium, or intoxication. In individuals with a developmental disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior cannot be accounted for by another mental or medical disorder (i.e., psychotic disorder, pervasive developmental disorder, mental retardation, Lesch-Nyhan Syndrome, stereotyped movement disorder with self-injury, or trichotillomania). E. The absence of suicidal intent has either been stated by the patient or can be inferred by repeated engagement in a behavior that the individual knows, or has learnt, is not likely to result in death.

63. Suicidal Behavior Disorder A. The individual has initiated a behavior in the expectation that it would lead to the individual’s own death within the last 24 months. B. The behavior did not meet criteria for non-suicidal self-injury—that is, it did not involve self-injury directed to the surface of the body undertaken to induce relief from a negative feeling/cognitive state or to achieve a positive mood state without risk of death. Having undertaken one or more acts of non-suicidal self-injury in the past is not incompatible with the diagnosis. C. The “time of initiation” is the time when the self-initiated behavior was undertaken by the individual who receives the diagnosis. The term “suicide attempt” can, therefore, apply to individuals who initiated the behavior and survived because of the timely interruption by a third party (sometimes known as an interrupted suicide) or because the individual changed his or her intent and decided to seek help (sometimes known as an aborted suicide). D. The act was not initiated during a confused or delirious state. However, attempts initiated during intoxication or while under the influence of a substance do not preclude this diagnosis. E. The act was not undertaken solely for a political or religious objective.

64. Cultural Formulation Interview Set of 14 questions that clinicians may use to obtain information during a mental health assessment about the impact of a patient’s culture on key aspects of care.Set of 14 questions that clinicians may use to obtain information during a mental health assessment about the impact of a patient’s culture on key aspects of care. Culture refers to the values, orientations and assumptions that individuals derive from membership in diverse social groups (ethnic, military, faith) which may conform or differ from medical explanationsCulture refers to the values, orientations and assumptions that individuals derive from membership in diverse social groups (ethnic, military, faith) which may conform or differ from medical explanations Culture also refers to aspects of a persons background that may affect his or her perspective, such as ethnicity, race, language or religion.Culture also refers to aspects of a persons background that may affect his or her perspective, such as ethnicity, race, language or religion. The Interview focuses on patient perspectives on the problem, the role others have in influencing the course of the problem, the impact of the patient’s cultural background, the patient’s help-seeking experiences, and current expectations about treatment. It is person centered to avoid stereotyping and understand how individuals vary from their cultural groups of origin.The Interview focuses on patient perspectives on the problem, the role others have in influencing the course of the problem, the impact of the patient’s cultural background, the patient’s help-seeking experiences, and current expectations about treatment. It is person centered to avoid stereotyping and understand how individuals vary from their cultural groups of origin. Four domains: Cultural Definition of the Problem; Cultural Perceptions of Cause, context and support; Cultural Factors Affecting Self coping and Past Help Seeking; Current Help SeekingFour domains: Cultural Definition of the Problem; Cultural Perceptions of Cause, context and support; Cultural Factors Affecting Self coping and Past Help Seeking; Current Help Seeking

65. Cultural Definition of the Problem 1.What problems or concerns bring you to the clinic (if patient only mentions symptoms, probe: Anything else?) 2.What troubles you most about the problem? 3.People often understand their problems in their own way which may be similar or different from how doctors explain the problem. How would you describe your problem to someone else? a.Sometimes people use particular words or phrases to talk about their problems. Is there a specific term or express that describes your problem? b.If yes, what is it?

66. Cultural Perceptions of cause, Context and support CausesCauses 4Why do you think this is happening to you? What do you think are the particular causes of your problem? (prompt further if required: Some people may explain their problem as the result of bad things that happen in their life, problems with others, a physical illness, a spiritual reason, or by some other cause) Stressors and supports:Stressors and supports: 5.What, if anything, makes your problem worse or makes it harder to cope with? If does not mention family/social network: What have your family, friends, and other people in your life done that may have made your problem worse?If does not mention family/social network: What have your family, friends, and other people in your life done that may have made your problem worse? 6.What, if anything, makes your problem better, or helps you cope with it more easily? If does not mention family/social network: What have your family, friends, and other people in your life done that may have made your problem better?If does not mention family/social network: What have your family, friends, and other people in your life done that may have made your problem better?

67. Role of Cultural Identity 7Is there anything about your background, for example your culture, race, ethnicity, religion or geographical origin that is causing problems for you in your current life situation? If yes, in what way? 8On the other hand, is there anything about your background that helps you to cope with your current life situation? If yes, In what way?

68. Cultural factors Affecting Self Coping and Past Help Seeking 9Sometimes people consider various ways of making themselves feel better. What you done on your own to cope with your problem? 10Often people also look for help from other individuals, groups, or institutions to help them feel better. In the past, what kind of treatment or help from other sources have you sought for your problem Sought help:Sought help: What type of help or treatment was most useful? Why? How?What type of help or treatment was most useful? Why? How? What type of help or treatment was not helpful? Why? How?What type of help or treatment was not helpful? Why? How? 11Has anything prevented you from getting the help you need-for example, cost or lack of insurance coverage, getting time off work or family responsibilities, concern about stigma or discrimination, or lack of services that understand your language or culture? If yes, what got in the way?

69. Clinician Patient Relationship 12Now let’s talk about the help you would be getting here. Is there anything about my own background that might make it difficult for me to understand or help you with your problem? In what way? Why not? 13How can I and others at our clinic be most helpful for you? 14What kind of help would you like from us now, as specialists in mental health?

70. How Do WE Help supervisees learn DSM 5?